General complications

        Infection: In elective surgeries such as done on Hallux Valgus (and excluding foot surgery on diabetic patients), this is extremely rare if there is no wire. With more than 2,500 surgeries performed, I had to drain an abcess twice only. There were 5 cases of mild cellulitis. ( those patients had a wire pin sticking out the skin ) All seven patients responded well to antibiotics. In the first week after Hallux Valgus surgery, the appearance of the toe may look to another physician as if it was infected: The foot is sore, swollen, red and warm, but these symptoms are the same for inflammation and inflammation is normal after surgery! Therefore it is better to go back to your own surgeon since he knows best what’s going on. Anyway, should your foot become infected, it would happen only four to five days after surgery in most cases.

        If a wire sticks out of your skin, there is more chance of infection (1 to 2%). If liquid seeps out or you feel a new kind of pain or the toe becomes even redder, go back to your surgeon who will remove the wire and put you on oral antibiotics. All these cases were treated successfully without infection to the bone. A bone infection can occur with diabetic patients, but is rare otherwise. If by mistake you caught the tip of the wire and it protudes more, do not push it back in! Let your surgeon know.

        Mal-Union (bone healing in the wrong position): This occurrence may vary, but this situation can happen when the osteotomy is not adequately fixed, or the patient is very osteoporotic

        Adhering scars: These happen from time to time in the proximal side of the incision where the skin is thinner. To free the tissues from one another, one could massage the scar daily with Vitamin E (squeezing open a 400U capsule and rubbing the oil on the scar).

        Stiffness (capsulitis): An articular stiffness in the first few months is usual. However, almost every patient have their big toe as mobile as before with appropriate after-surgery exercises. This is true mainly of patients who have had a light to moderate case of Hallux Valgus. Those with severe Hallux valgus often, had already lost part of their flexibility.

        However, 3 to 5% of patients might show a type of internal fibrosis with adhesions. They have too much internal scarring, so the joint takes much longer to be flexible again. Most of these patients will show a gradual improvement to an acceptable level if they are sent off to a physical therapist, and maybe also given one or two of cortisone injections. It is very unusual of that the joint stays locked permanently. ( Less than 1 :200). In this case, the injected synthetic cortisone serves to reduce fibrosis, since (outside of being anti-inflammatory) it will also ”break” the intertwined collagen fibers at the source of this “exaggerated” fibrosis. This is of utmost importance, because many patients are afraid of what they heard about the side effects of cortisone. Cortisone regularly ingested as a pill does have deleterious effects on bones, tendons, and all that, but when administered sparingly by a professional, its beneficial effects outweigh the risks. There is almost no risk at this location, as compared to shots in the area of major tendons.

        Hypertrophic Scars:  3 occurences only

This is very rare, and is not related to the surgical technic, but some people scar badly. Some body areas are more prone ( shoulders, presternal skin). Foot is rarely involve. Keloid scar is a more severe form of Hypertrophic scar. It occur more frequently ( as does hyperpigmented scar) in Black than in White people). If it occurs, it is treated with in-scar injection of Cortisone and some mecanical external pressure (Cicacare).
Most scars corresponding to the bunion (Hallux Valgus) becomes almost unnoticeable with time in most cases. Note that my incision is the Mid-dorso-plantar area, just over the bunion. Some surgeon prefer do their incision mostly on the dorsal skin. For me this is less cosmetic; specially for Latino and Black people who tend to have darker scars. During the first year after surgery, you should avoid exposing your scars to the sun or to the ultraviolet rays of tanning salons. It is essential to apply a total sunscreen the first year on these scars at that time, lest they become brownish and noticeable.
Metatarsalgia (pain at one or more metatarsal bone heads next to the 1st metatarsal): Any lenght reduction of the 1st metatarsal so it is shorter than those next to it can cause metatarsalgia. Thus when the 1st metatarsal is already short, care should be taken not to make it even shorter. In many cases of a severe grade of Hallux Valgus , the 2nd metatarsal already sags and metatarsalgia is present before surgery. It is therefore better to address the situation together with Hallux Valgus surgery..Otherwise even though the Hallux Valgus is corrected, metatarsalgia becomes worse. However, when the Hallux Valgus condition is well evaluated before proceeding to surgery, followed by appropriate surgery applicable to the case, there is less danger of worse metatarsalgia. There can also be occurrences of transitory metatarsalgia after surgery, but those can be treated with a metatarsal support.

Very important to note: Patient have to understand that the surgery can correct what is present at time of surgery. But in most patient with bunions, and some ligamentous laxity, with or whitout surgery, the foot might continue to change with years ie. other metatarsals may drop with time with latter hammer toes or morton's neuromma. So, having a surgery for Bunions ( Hallux Valgus) will not prevent other problems to occur in that foot. I repeat: having a surgery for bunions will not prevent other problems to occur in that foot...

Metatarsal support

        Haematoma / Bleeding / Wound Dehiscence: No case of haematoma that would have necessitated draining. However a small degree of bleeding happens a lot more often. This is never dangerous, but do not remove the dressing in the 48 hours after surgery. The bleeding will stop by itself if you keep the dressing on. (What you can do is to add more dressing on top of the existing one and put on a fresh elastic bandage.) If the dressing is taken off within 24 hours after surgery, especially for patients known as bruisers, some bleeding could start again. So I cannot advise you to take off the dressing you were sent home with until after 2 days. Patients who would have bled longer could have the dressing changed (by the nurse) before the ten-day post-surgery visit because the trapped humidity may macerate the skin, or the dried blood makes the gauze stiff and becomes the source of discomfort. The documentation you are sent home with gives you a pager number so you can call us anytime. We will advise you if your dressing needs to be changed before its due date, if you are in doubt.

        There are cases when we will delay the post-surgery visit to take out stitches to avoid dehiscence (opening) of the wound. This is a side effect in patients who take Prednisone (oral cortisone) to treat rheumatoid arthritis for instance. In any case, the stitches are replaced with wound-closing diachylons (steri-strips) which are kept on for a few days. The special-case patients (with a larger oedema or haematoma, or at risk for dehiscence after surgery or are undergoing a cortisone treatment) are told to keep their steri-strips on up to seven days rather than 3-4 days.

        Recurrence of Hallux Valgus with time:   This is most unusual considering the osteotomy procedures of nowadays. However, if a surgeon were to just “file down” the medial protuberance (the “bulge”) and put the capsule back on, the rate of recurrence is higher. This is also true if, faced with a severe Hallux Valgus case, the surgeon were to treat it as if it was a small case. Needless to say, treatment has to match the condition. In the case of “hammer toes”, some recurrence (a continuing MTP subluxation is more common because soft tissue“elastic memory” is harder to fight when the deformation is long-standing. You might say that this argues in favor of earlier-than-later treatment in case a Hallux Valgus comes together with a hammer toe.

        Deep Phlebitis: Extremely rare. There were 4 such cases on more than 2500 operations. These were patients who underwent surgery at the hospital under general (or spinal) aenesthesia and had thrombo-phlebitis under the knee. One patient already had had a previous deep phlebitis and the other was taking oral birth-control medication. In one instance, phlebitis occurred one month after surgery and it was not clear whether this was linked with the surgery. As all surgery at our clinic is now performed under local ( ankle block) aenesthesia, and all patients are walking immediately after the surgery, only one case occurred with this type of aenesthesia, when the patient stayed completely motionless for the three days following her operation. In fact, I mention in the pre-surgery documentation given to patients that, for safety’s sake, it is better not to take any oral birth-control medication for the month during which surgery will occur. Patients who have a significant history of such problem are given an (empiric) prophylaxis with a sub-cutaneous injection of  Fragmin (Sodium -Dalteparin) 5,000 Units once a day for seven days. In any case, the best way to avoid phlebitis is to move about and make use of the vein pumps moving toes and ankle.

        RSD (Reflex Sympathetic Dystrophy) = CRPS type I ( Complex Regional Pain Syndrom) This is an extremely rare complication which can happen after any kind of surgical procedure or even a minor trauma. This complication occurs more often in hand surgery than in foot surgery. It involved an area larger than the operated site and the whole area (foot-ankle, hand-wrist) becomes sensitive and painful, joints become stiff and there are circulatory issues as well: Abundant local perspiration, change in skin colour. There are all degrees and types of RSD cases and Capsulitis itself may be a milder form. I only had two patient with RSD (moderate to severe). One case went away with time; the other patient  remained mostly with stiffness.

        Skin Necrosis: Skin loss after surgery. One case only in more than 2500 operations. This was a man with no particular risk history. The sore was cut away and the wound healed without any skin transplant. Usually smoking is the main risk factor for flaps or cosmetic surgery.

This patient was a man with no particular risk factors. The wound ended up healing without need for a skin graft.

Conclusion on Potential Complications

   Complications are these years generally rather rare as long as you deal with an orthopaedic surgeon with experience in small bone fixation ).

        When they do occur, they are usually mild and do not last. Some could be attributable to the surgeon’s experience (because he can select the best procedure for that patient and know the technical details that make often the difference. Some are because '' patient factors'' (Fibrosis, for instance). Still others are unpredictable in spite of the best possible conditions and procedures.

        I could say that when the best procedure is carried out on the right patient, a meticulous evaluation is done of the whole foot before surgery, and finally the patient does not have unrealistic expectations, the rate of satisfaction after surgery is very high in spite of some rare complications. However, if the deformation is long-standing, affects other metatarsals, and is accompanied with hammer toes, results will not be as good. Even a good result will not give you back the foot you used to have when you were twenty years old. The frequent lack of best result comes from the patients not undergoing surgery in time. Too many of them wait too long before they see the doctor, so more extensive surgery has to be performed and thus results are not as ideal as if it was done before certain irreversible deformations had occurred.

SPECIFIC COMPLICATIONS

(This chapter is more technical and mostly to other surgeons.)

* Post-CHEVRON Osteotomy

1.    Avoiding an osteotomy which is going too  distal as the cut goes from medial to lateral      Not only is the bone difficult to reduce with that osteotomy, since it makes the 1st metatarsal longer, but it will tend to move itself back to its initial site. ( Unstable)
        So the osteotomy is done at right angle to the axis of the foot,( not the metatarsal axis). If it is   somewhat oriented proximally, from medial to lateral,  the shortening will be minimal and the head sliding will be easier with less chances of moving back to its initial site.
        Herewith: The trajectory of the osteotomy was too distally oriented, and it moved on its own after surgery. The line must be perpendicular with the axis of the foot rather than the axis of the 1st metatarsal. If this1st metatarsal is too long, it can even be shifted by a few caudal degrees. Then it is even easier to get a good placement of the head.

2.    Osteonecrosis of the metatarsal head
        Lack of arterial circulation to the metatarsal head, which may cause its partial destruction.   This very rare complication is mentioned in the books in the case of a disal metatarsal osteotomy associated with a simultaneous loosening of the adjoining soft tissues. Until the 1990’s, it was considered heretical to perform this double surgery. Since then, several studies showed that this condution was rare enough after disal oseotomy when combined with a lateral loosening, when this loosening is not extensive.
        Following these optimistic studies, I had rather regularly added a lateral loosening (limited to the area next to the 1st MTP), which allowed an extension of given distal osteotomies, without having to perform distal osteotomies. While using such procedure, there were no particular complications, except that, looking at X-rays, one would notice some speckled osteopenia which would then completely disappear with time. This, by the way, is corroborated in several recent studies. However, after about 300 Chevron surgeries associated with this lateral loosening, a good case of osteonecrosis of the metatarsal head happened one year after surgery. Therefore, I have come back to stricter standards in the last five years. This condition is rare but broad surgical standards are not worth the risk that this complication could happen. If a distal osteotomy (without lateral loosening) would not totally correct the Hallux Valgus, it is better to perform at once a proximal osteotomy (crescent, Ludloff or Scarf), which will allow a downright safe lateral loosening.

* Mitchell's Post-Osteotomy

        Mitchell post-osteotomy is the procedure which can give the most complications if all criteria are not present. It is safer to perform a proximal osteotomy if one does not yet master its various minute aspects.

1. Mal-Union – Dorsi-Flexion Displacement

        Notice that the 1st toes do not reach the ground.
        This young patient (see picture) had undergone the Mitchell procedure elsewhere. Both osteotomies ended in dorsi-flexion mal-union. She was in pain and had trouble finding shoes to fit her.
        So I had to perform a new dorsal open-bevel osteotomy with bone transplant on both feet. It is therefore better to prevent and correct those Mitchell osteotomies to avoid these complications.

2. Mal-Union – Plantar-Flexion Displacement

        In this case the displacement occurred the other way. This has caused an MTP hyper-extension, with secondary inter-phalangeal flexion.

3. Median Displacement

4. Delay in Mending

        In some atypical cases, mending after an osteotomy can take a little longer. An operation I did several years back resulted in spontaneous mending 11 weeks later.

5. Metatarsalgia

Metatatarsalgia happens particularly often, especially when a surgeon performs this procedure without regard to the length of the metatarsal. Consequently this (shortening) osteotomy should not be carried out on a metatarsal that is already short next to the others since, as is the case here, the patient experiences a lot of pain coming from the head of the 2nd metatarsal. In fact all the weight is transferred on it and it is too long a bone.

In this example, not only one must raise and shorten the 2nd metatarsal, but also the 3rd, itself somewhat too long next to the 4th, since otherwise the weight transfer would be on the 3rd metatarsal. Respecting the harmony in the lengths of the metatarsals is of utmost importance. For this, you need advance planning.

* Crescent Post-Osteotomy (Mann’s)

        Although Roger Mann’s crescent osteotomy allows a good correction of the condition, it is sometimes difficult to obtain a solid binding and a few cases of post-surgery displacements have occurred.

        In this instance, the inter-1-2 metatarsal angle was 20º before surgery. An angle of about 10º could be attained during the operation, but a limited displacement took place and it went back to 14º when healed.

        This is why I’d rather perform a Ludloff-Myerson osteotomy, because it will correct the situation just as nicely AND promote a harder mending.

[Haut de la page]