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Evaluation of the McBride procedure for hallux valgus

Discussion in 'Foot Surgery' started by NewsBot, Jun 17, 2008.

  1. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1

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    Evaluation of follow-up results of McBride operative treatment for hallux valgus deformity.
    Orzechowski W, Dragan S, Romaszkiewicz P, Krawczyk A, Kulej M, Morasiewicz L.
    Ortop Traumatol Rehabil. 2008 Jun 30;10(3):261-73.
     
  2. drsarbes

    drsarbes Well-Known Member

    Re: Evaluation of the McBride procedure for allux valgus

    I believe the McBride was first described around 1880.

    I think it SHOULD have been LAST PERFORMED around 1890!

    Steve
     
  3. Dieter Fellner

    Dieter Fellner Well-Known Member

    Re: Evaluation of the McBride procedure for allux valgus

    :D

    Amen ... :drinks
     
  4. Stanley

    Stanley Well-Known Member

    Re: Evaluation of the McBride procedure for allux valgus

    I remember when there were four procedures that were performed by podiatrists: The Simple Bunionectomy, The McBride, the Keller, and the Silver Dollar Keller (discounting the Suppan CAP since it was done very locally in Ohio).
    Podiatrists were afraid to do more extensive osteotomies, and resorted to these "less invasive procedures".
    The McBride caused stiff joints in the majority of cases, as this moving the joint to a deviated position.

    Regards,

    Stanley
     
  5. drsarbes

    drsarbes Well-Known Member

    "The McBride caused stiff joints in the majority of cases, as this moving the joint to a deviated position"

    yesterday I had a patient with a severe Hallux Varus. The "Podiatric Surgeon" performed the procedure in his office 1.5 years ago. The x-ray showed an absent fibular sesamoid with a tibial sesamoid on the medial side of the metahead.

    hmmmmmmmm.........The McBride! Gotta love it.

    Steve
     
  6. Stanley

    Stanley Well-Known Member

    Is that 1.5 or 15 years ago? Since the McBride does not correct the IM angle, they had to take off a larger amount of the head. The rule was not to go beyond the sagittal groove.
    The McBride is a procedure you do when you do not know another. By the way, I just remembered what a modified McBride was. It was a McBride that does not remove the fibular sesmoid. (Is it any different than a Silver?) Why would anyone want to take out a fibular sesmoid (or for that manner the tibial sesmoid)?
    Hallux Varus is not limited to only McBrides. My roommates girlfriend had a bunionectomy with an oblique osteotomy (done by my roommates residency director) that ended up with a hallux varus.

    Regards,

    Stanley
     
  7. drsarbes

    drsarbes Well-Known Member

    Hey Stanley.

    1 point 5.

    The modified was for guys who had trouble getting the fibular sesamoid out through the interspace. The modification was to "release" the sesamoid so it wouldn't function, thus having the tibial sesamoid function "relatively" stronger - thus pulling the hallux into rectus.
    Hey, sounded good in 1881?

    You are SO RIGHT ON when you say it's for those who don't know any other procedure. This podiatrist in my area is notorious for McBrides with overzealous medial capsule work and spiked metatarsal heads OR spiked Silvers with MAXIMUM Akins.

    I've pretty much made a living redoing his work over the years!!!!

    Steve
     
  8. Stanley

    Stanley Well-Known Member

    Hi Steve,

    I'm sorry, it just seemed so unbelievable. I have never done one of those in my life, as I saw all the problems with them when I did my fellowship.
    Wow, I forgot that they released the sesmoid by cutting the adductor tendon.
    It was sounding good still in 1977.
    As far as the Akins, they were the first osteotomy done, and I remember one lecture (I won't mention the name of who lectured) who said that you could actually lower the IM angle, as the whole ray loosened. :wacko:

    Regards,

    Stanley
     
  9. drsarbes

    drsarbes Well-Known Member

    "As far as the Akins, they were the first osteotomy done, and I remember one lecture (I won't mention the name of who lectured) who said that you could actually lower the IM angle, as the whole ray loosened"

    Re; Akins - I also recall various lecturers telling us that you only take a "sliver" of bone out!!!!!
    How things have changed. I think most of the early surgeons were use to having a #313 blade in their hand shaving caloluses off, then wham......along came foot surgery!

    In all fairness, my most common bunion procedure is still the Austin/Akin. Of course Austin was a Podiatrist turned orthopedic Surgeon. Those early Austins were not fixated. I had quite a few of those "slip" back. Live and learn.

    Steve
     
  10. Stanley

    Stanley Well-Known Member

    I remember Dale Austin lecturing at Hershey. The trick was to impact the head on the shaft.
    I remember the biggest complication of the Akin was dehiscence. When I did my fellowship in biomechanics, I spent time rotating in some offices, and that was what I was told. I did my residency the following year, and then opened practice, and I never had that complication. Maybe they were using the #313 blade parallel to the skin to make the skin incision:wacko:
    I can talk about the guys that were starting open surgery (like Buchbinder in Connecticut who told the story of the first Phenol alcohol nail done in the state, and how the sweat was dripping into the wound or how Sy Frank would put down the instruments so he could tie the knots in the suture like you tie your laces) as there were also the Prober trained minimal incision guys. I had a second cousin that graduated in 1951. He left podiatry because he couldn't make any money, so he played the accordion in a band. When they started doing surgery, he went back into it. When he retired, he put the cash in the trunk of his Caddilac and went down to Florida. The story is that he was afraid to stop at a motel for the night, so they drove the 1500 miles straight through. I visited him once, and I would never go back. His office girl went to podiatry school, and she talked about the book she was given when she first started working for him. She said the first page talked about cleaning up after surgery, and how she had to remove the blood from the floor, walls and ceiling:craig:. The profession has come a long way. It is hard to believe we went through times like that.
    What year did you graduate, and from where?

    Regards,

    Stanley
     
  11. drsarbes

    drsarbes Well-Known Member

    Hey Stan:

    '77 from ICPM.

    Did my residency in foot surgery with Chuck Witt. What a great guy. I owe him a lot.

    Yes, we have come a long way; and it's surprising in how little time.

    When I first came to town here and wanted privileges for the Swanson hemi implant I had to make a presentation to the head of orthopedics!

    I think our problem is still in the training. We still have podiatrists under-trained for what they have a legal option to do. You can say what you want about orthopedics and foot surgery, but for the most part these guys have wonderful training. Podiatrist still have that spectrum with practitioners on both ends of the bell curve.

    Steve
     
  12. Stanley

    Stanley Well-Known Member

    I graduated NYCPM in 1976. I think as far as training goes, there are more residencies than ever before, and a much larger percentage of the graduates get residencies. There are also more second and third year residencies.
    A first year residency was sufficient to do forefoot surgery when we got out, and I can't see how that has changed.
    So I think our training is tons better than it was, and will be even better in the future.

    Regards,

    Stanley
     
  13. drsarbes

    drsarbes Well-Known Member

    Hi Stan:
    Well..I agreed with you before I disagreed with you!!

    I've had the opportunity to work with guys coming out of 2 year residencies (twice) and I was not impressed.

    Podiatry does things backwards. Anyone getting into school has the ability to do a surgical residency, regardless of hand/eye coordination (which in my humble opinion is incredibly under-appreciated) - In other areas of medicine, you need the "smarts" plus the hand skills to move on. I've seen podiatrists trying to perform surgery with very poor dexterity. You can have all the training you want but in the end surgery is still a technical skill.

    My 2 cents.

    Steve
     
  14. Stanley

    Stanley Well-Known Member

    Steve,

    I appreciate what you are saying.
    There is one thing you forget, and that is how good you have become. I remember when I was a resident I thought how amazing each of the attendings were. Years later, I had the opportunity to scrub with some of these "excellent" surgeons. I noticed the flaws in their technique, and how each one was not as good as I thought they were. Every year the better ones were coming down to my level.
    What happened was that I got better and learned by doing, seeing things I hadn't seen before, and improving on my techniques. I didn't realize it, as a "watched pot never boils".
    One day I did a surgery, and I did it at my usual speed, and being meticulous as ususual. At the end, the anesthesiologist said "you are the fasted foot surgeon I have ever seen". Trust me, I do not consider myself fast. Do you remember how long it took for you to do your first hammer toe as a student (30-45 minutes)? Now look at the time you do it in.
    So what I am saying is that these residents do not look like the residents you remember, because your skill level is so high, and you are comparing them with yourself.
    The residents you have questions about are better trained than we were and will be surgical leaders in our profession. I am more concerned about the lack of training in other areas, most notably biomechanics and podiatric medicine.

    Best regards,

    Stanley
     
  15. jwl1572

    jwl1572 Welcome New Poster

    Guys- Just came across these postings, good stuff... one question, are there any clinical scenarios where a modified mcbride (keep lateral sesamoid in place but do LTR/ capsule/ soft tissue adjustments) makes sense? thanks!
     
  16. I have seen an indication for the procedure in my 25 years of doing bunion surgery.
     
  17. drsarbes

    drsarbes Well-Known Member



    Hmmmmmmmmmmmmm.
    Let me think about that.
    aaaaaaaaaaa........

    No, never, unless Dr. McBride is standing over you with a gun pointed to your temple because he wants his name-sake procedure performed ONE MORE TIME.

    BTW: Silver's original procedure was described with a lateral capsulotomy.

    Steve
     
  18. Sorry.....this posting should have read "I have never seen an indication for the procedure in my 25 years of doing bunion surgery.
     
  19. rnunes

    rnunes Welcome New Poster

    I think some members are a bit too dogmatic about this issue.
    I will not refere to the original McBride procedure ( who wants to remove the fibular sesamoid? ) , but to soft tissue distal procedures without first metatarsal osteotomy.
    Just because these procedures are simpler than surgeries wich include osteotomies it doesn't mean they are NEVER indicated.
    Orthopaedic surgeons must know how to do procedures wich include bone surgery AND soft tissue procedures.
    In fact soft tissues distal procedures are indicated in about 5% of hallux valgus cases: young patients with an angle between the first and second metatarsals less than 15º, a metatarsophalangeal angle less than 30º and no degenerative changes at the metatarsophalangeal joint.
    Let' s not forget that good surgical technique includes lateral capsular release, release of the sesamoids and their realignment by means of a correct medial capsular plication.
    By the way, drsarbes must review his historical data: Dr McBride did not describe his procedure "around 1880" but in 1928 :
    McBride ED: A conservative approach for bunions. J Bone Joint Surgery:10:735-739,1928.
     
  20. drsarbes

    drsarbes Well-Known Member

    OK RNUNES:

    I can promise you this, if you do a "modified" McBride on a young healthy patient with an IM angle of - say- 13, she will be back in 10 years with a foot that looks like no procedure had ever been done.

    "In fact soft tissues distal procedures are indicated in about 5% of hallux valgus cases" !!!!!!!!!

    What does this mean exactly? I've performed literally thousands of bunionectomies and have NEVER seen an indication for "distal soft tissue procedures" to correct a bunion.

    One more thing; SIMPLE or DIFFICULT does not enter into this discussion.

    Steve
     
  21. rnunes

    rnunes Welcome New Poster

    Some type of osteotomy must be done in most hallux valgus cases.
    Nevertheless the modified McBride seems to have survived the test of time. For instance, the last edition of Coughlin and Mann's "Surgery of the foot and ankle" includes the procedure in their decision alghoritms for the treatment of bunions and describes the technique in detail. If such a "Bible" considers the procedure still useful I don't think there's much room left for discussion.
    The foot surgeon must be realistic about the possibilities of the McBride and do not try to correct this way a first intermetatarsal angle greater than 15º.
    The key to succeed with the procedure is to MOBILISE the first metatarsal. The surgeon must free the adhesions between the lateral deviated sesamoids and the head of the metatarsal - a sharp rongeur introduced right under the head of the metatarsal should do the trick. Then check if the intermetatarsal angle reduces. If it doesn't I always do an osteotomy. But if it does , a properly done medial capsulorraphy should suffice to maintain the reduction IN A LONG TERM BASIS.
    Professor Jean Lelièvre from France showed some decades ago the basic principles of this method. He called this the "cerclage fibreux" ( "fibrous cerclage" for those of you who need to have a brushup in french ).
     
  22. drsarbes

    drsarbes Well-Known Member

    RNUNES:

    If I could figure out how to get those cute little animated figures on a post I would insert the BEATING A DEAD HORSE here.

    Why perform a procedure designed prior to modern biomechanical understanding, especially when there are so many BETTER procedures out there? Just because textbooks document procedures for historical prospective does not mean the authors are justifying their continued use.

    I'm interested in how many of these you have done and for how long?
    I get the feeling we are a bit wanting in the experience department. Perhaps once you get your Modified McBride patients returning with complaints of "recurrence" of their bunion, you will stop doing them.

    Sesamoids, by and large, are not laterally deviated when a metatarsus primus adductus angle increases. Rather, the head of the metatarsal moves medially in relationship to them. The sesamoids are generally where they are suppose to be, it's the metatarsal that has migrated.

    The lateral sesamoid release was NEVER intended to reduce a the IM angle, but to decrease the hallux valgus. However, as an unforeseen consequence, the retrograde force on the metatarsal was sometimes (temporarily) reduced thus decreasing the IM angle (until, of course, the bunion progressed). The release, in realty, did little to realign the hallux which is why the Modified McBride was commonly done with the Akin osteotomy. Of course as you know, the original McBride was done with a removal of the fibular sesamoid in order to increase the varus pull of the medial sesamoid. The sesamoid "release" was popularized due to the fact that the fibular sesamoid was difficult to remove, especially in mild cases with low IM angles.

    The cerclage was a suture, nonobsorbable or wire, that tied the first and second metatarsal together (either truly around the meta necks or merely between the adjacent sides of the capsule.) The second approach, of course, doomed to failure upon weight bearing. The first somewhat rediscovered via the TightRope procedure (adopted from the TibioFibular diastasis procedure) and also not very well thought out.

    BTW: if you need to do medial capsule work after your osteotomy has been performed then you did not correct enough with the osteotomy.

    The bunionectomy osteotomies where devised and became popular for a very good reason, soft tissue bunionectomies just did not work.

    Steve
     
  23. rnunes

    rnunes Welcome New Poster

    drsarbes:

    I generally agree with your comments.
    Concerning the position of the sesamoids: in fact the incongruence between them and the head of the first metatarsal is mainly due to the medial deviation of the first metatarsal. However in more advanced cases the sesamoids can suffer a lateral deviation. Several factors play a role here: contracture of the tendon of the adductor halucis; erosion of the ridge on the plantar surface of the head of the first metatarsal (the crista, wich can be clearly seen in a sesamoid view of the first MTP join); and pronation of the hallux.
    In these cases a surgical gesture directed to pull the sesamoids medially can be beneficial.
     
  24. drsarbes

    drsarbes Well-Known Member

    Rnunes:
    Sorry, I just can't agree with you.
    Any force being applied to the sesamoids in a lateral direction is from the ever increasing 1st IM angle.
    Period.
    Again, the object of any met osteotomy for correction of met primus adductus is to "RE"locate the head of the metatarsal BACK over the sesamoids, not the other way around.

    Not much new here, let's not try to reinvent what is already known.

    Steve
     
  25. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Treatment of hallux valgus by modified McBride procedure: a 6-year follow-up Journal
    Istemi Yucel, Yuksel Tenekecioglu, Tahir Ogut and Hayrettin Kesmezacar
    Journal of Orthopaedics and Traumatology
     
  26. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Proximal First Metatarsal Osteotomy and Mc Bride Procedure in Hallux Valgus: 5-years results of 25 cases
    Ali Yeganeh et al
    Source
     
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