Puzzling Lapidus/McBride case

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I performed a McBride/Lapidus on a 48-year-old female runner approximately 10 weeks ago. She had a hypermobile,severe bunion, that was not amenable to a head procedure.
Intraoperatively, she had significant DJD at the plantar sesamoidal grooves however nothing more than I would normally see with this sort of deformity. Otherwise, nothing unusual was noted. Obviously, great care was taken intra-operatively due to her activity level.

Now at 10 weeks, the fusion site is doing very well however she has no sign of hallux extension. It appears the muscle is firing as I can see EHL tendon tensioning proximal to surgery site however the tendon" disappears" along the surgery site. It's acting like a transected tendon. Puzzling.

I have ordered an MRI and hope this will help clarify (although fixation may complicate this matter).

Has anyone had this experience and any suggestions as to the possible etiology?
Additionally, she has significant amount of first MTP stiffness and having difficulty recruiting the flexor hallucis tendon.

 

Foot Surg

Welcome to pod arena, and thanks for your interesting case study.

I am a general podiatrist and occassional surgical assistant and not a surgeon, however recently I observed a procedure that was to correct what ultrasonography diagnosed as an EHL tear after a distal met osteotomy (the original surgery was performed by a different surgeon; the revision was performed ~ 12 months post op from memory). It was similar to what you describe - tension of EHL occurred proximal to the 1st TMT/MC joint but no hallux dorsiflexion. Upon further exposure the EHL had multiple adhesions and we found that the ultrasound got it wrong, EHL was fully intact. It was hypothesised by the surgeon that the tendon had scarred up resulting in poor extensor recruitment. The patient had limited adipose and this was thought to have contributed to the adhesions.

Treatment involved tenoplasty and breaking up of adhesions with blunt dissection, then ensuring adequate adipose coverage to limit recurrence.

As I said I am not a surgeon, but this case sounds similar. The only thing is the time difference.

Furthermore the 2 surgeons I have observed in the past are dynamite on ensuring patient compliance with post-operative exercises/mobilisations to ensure adequate MTP range. Unsure if you typically incorporate this into your post-op protocol, but it may help with post-operative ROM.

Hope this helps

 

Thank you for the thoughtful reply. Do you recall whether or not this patient had any significant superficial scarring or dense tissue quality surrounding the perisurgical area upon examination? Did your patient have any significant post operative complications such as excessive swelling?

My first impression in my case was that in fact the EHL had scarred down somehow. However, I have never had it to this extent. There are usually some other signs such as significant postoperative swelling leading to superficial scarring.
Interestingly,you mentioned that your patient had very little adipose tissue and in fact this patient is a very thin, Caucasian female runner. Anything else you can add?
Anyone else have a similar problem?

 

Hi Foot surg

Unfortunately I cant shed much more light on that particular patient. I was not able to be involved in her post operative care, so unsure as to how she finished up.

With regards to post op swelling following the initial procedure I am unsure, it was performed by a different surgeon and we only got involved for a revision.

The lady from memory was a very thin Caucasian lady as well, so similar case...

Sorry I can't be of more assistance, keep us posted with the outcome :drinks

 

Thanks for the update

 

The patient should have good ROM and both tendons should be functional. If not, you really need to review what exactly was done during the surgery. If you do not do a lot of experience doing reconstructive surgery, you should always ask for someone more experienced than yourself to help as its in the patient's best interest.

Steven