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I have been in practice for over 21 years and I still have problems
doing inter-space work in bunionectomies. I usually do the Austin
procedure with screw fixation, it looks good on the table but when
I see them for the first post-op visit, the toe is in mild abductus.
I usually do an adductor release, fibular sesamoid release and lateral
capsulotomy, ehb tenotomy. Somebody tell me what I am doing wrong
or what I am missing. Any tips would be greatly appreciated.

 

Consider a medial capsuloraphy with or without tacking the EHL tendon (sheath) back directly over the 1st MTP joint. This often maintains the rectus position of the hallux. Otherwise, it appears that you are addressing all other components.

Just one opinion.

 

One simple thing I do is to keep the patient in a "toe-spacer pad" between the hallux and 2nd digit for the first 3 months post-op. This seems to help maintain correction for a longer period and certainly makes good sense from a tissue healing/biomechanics standpoint.

The suggestion made by Mayres is good about medial capsuloraphy. It is probably best to hold the hallux in a little bit of an overcorrected position (increased hallux adduction) while measuring for the amount of medial capsule resection to make. In this way, when the cut ends of the medial capsule are coapted and sutured in place, the medial capsule will better resist hallux abduction when the medial capsule is placed under tensile loads during weightbearing,

Also, when I perform a lateral release, I do basically what you do but I also will manually palpate in the first intermetatarsal space to "feel" if any tight structures are left after I have made my initial release. I typically will transect the lateral half of the lateral sesamoidal tendon/ligaments proximally and distally to the sesamoid if I feel it needs further "loosening". I often also do a very aggressive lateral capsulotomy of the first MPJ.

Finally, and this is probably most important, I will always try to load the plantar metatarsals when I initially pin the first metatarsal osteotomy in place to see how the hallux lines up relative to the 2nd digit. If there is an abducted hallux alignment, or the hallux shifts into abduction with dorsiflexion of the hallux, I then try to shift the capital fragment more laterally and remove more PASA correction if possible and then repin it before I place my cannulated screw in place. I use a modified Reverdin type (i.e. horizontal L) osteotomy and the Osteomed cannulated screw system.

However, unless the correct surgical procedure is planned and performed optimally, so that the hallux abduction moments from the FHL and plantar intrinsics attaching to the sesamoids are effectively minimized, then even these above surgical modifications will be insufficient to optimize hallux positioning relative to the 2nd digit post-operatively.

Hope this helps.

 

DeFrank:
All things being equal, this normally works well for me.
I rarely do an Austin without an Akin, which obviously helps straighten the toe. I also "almost always" do the following;
I underscore the EHL tendon sheath and put a couple of horizontal matress sutures through it (medially) to the dorsomedial aspect of the joint capsule. This realigns the EHL to a more normal direction over the now displaced first metahead. At times I need to release some of the soft tissue attachments laterally at the sheath (but not the capsule) - It's my felling that if you do your osseous correction properly then the old lateral capsulotomy, lateral release is not needed. I'm also generous with my Akin and don't hesitate to do a Distal Akin instead of a Proximal one if the IPJ is abducted.
Hope this helps.
Dr. Steve