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Should existing forefoot injuries be addressed with HAV surgery?

Discussion in 'Foot Surgery' started by RachWadd, Dec 21, 2019.

  1. RachWadd

    RachWadd Member

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    Hi all,

    I have a patient who is undergoing HAV surgery in March 2020 following many years of conservative management with orthoses, footwear adjustments and surgical advice.

    She is a 60YO fit and active female who has been compliant with all advice; worn her custom orthoses, got all the right footwear and managed her symptoms well up to this point. She is now looking at retiring from her very busy job and has finally decided to have the surgery.

    Along the way she has been diagnosed with all the regular accompanying forefoot injuries including at the last ultrasound examination performed on the Rfoot (most sypmptomatic foot) in 2017:

    - Full thickness, full width tear of the 2nd PPlate
    - 5.4mm neuroma with 19mm X 9mm bursitis of the 2nd webspace
    - IM bursitis of all other webspaces
    - Partial width degenerative tears of the 3rd and 4th PPlates

    She will have the surgery done by an orthopaedic surgeon who has advised her that the PPlate tears / neuroma won't be fixed / removed during the surgery as there is no need.

    I was surprised to hear this as I thought to aid and maintain forefoot stability and ongoing symptoms, both of these injuries would be addressed. Especially in a younger patient who has plans to continue her daily walking activities and traveling in her retirement.

    So I am curious to hear from some surgeons and any others with similar patients about what their processes would be in this situation.

    Thanks all for your time
    Have a safe and happy holiday

  2. Dr Rich Blake

    Dr Rich Blake Active Member

    Rachael, this is a real loaded question. First of all, the surgeon would have to be committed to do it all, and since apparently not, the patient would have to find another surgeon at this point. Secondly, it depends how stable the big toe joint area becomes over the 6-9 months post surgery. If the big toe joint can be stable again, then so much of the stress of motion will be back on the big toe joint and less on the lesser metatarsals. Could be a win win. Unfortunately, the big toe joint is normally straighter post surgery but very much weaker in the short term. Any surgical joint is weaker for a while. She will be putting more pressure on the lesser metatarsals at least temporarily and perhaps permanently. For one, I would not look at surgery to fix more than the bunion, hopefully in a slightly plantar flexed position and not leave her with met primus elevatus. I would be honest that this needs her full attention and she may be much less painful if only one side of her foot hurts. You can definitely strengthen the foot better if you can weight the lesser metatarsals more for a while. The bunion will take the longest to recover, generally 3 times longer than a surgeon says. The patient will have a lesser procedure 6-12 months from now at the earliest, one easier to heal from, if needed at all, in the worst case scenario. Finally, I am more concerned than most it seems about the blood supply to the toes when alot of surgery is done at once. Hope this helps some. Rich
  3. RachWadd

    RachWadd Member

    Thank you Rich, this has made the situation from a surgical point of view much clearer.

    Just to make sure I have your information correct before I speak with my patient, in summary:

    The bunion surgery, being the most significant in terms of procedure and recovery, should be focussed on initially:

    Best Case Scenario - with recovery an increase in functionality and stability of the 1st MPJ will mean less stress on the lesser mets and therefore less pain from the PPlate injuries, IM bursitis and neuroma which will mean no further surgery will be needed.

    Second Best Case Scenario - with recovery the 1st MPJ functionality and stability is not ideal, pressure over the lesser mets is still high and a second, more minor surgery can be done at a later date to address the PPlate injuries, IM bursitis and neuroma.

    Ultimately, blood supply to the distal foot could be compromised by attempting all surgeries at once.

    What can I, as the patient's podiatrist, do to ensure the best surgical outcome?

    Thanks again for your time.

  4. Dr Rich Blake

    Dr Rich Blake Active Member

    Could not have said it better Rachael. Evaluate the first ray range of motion and analyze if raising the first metatarsal in an osteotomy 5 mm on average would leave the patient with MPE. If so the patient has to talk to the surgeon about plantarflexory osteotomy. Analyze the pronation load on the first met for its role in a post op situation. At least pronation will be worse for a while. Will the patient need orthotics after, and if severe pronation is seen now, should other surgery like Lapidus be considered with its marked increase in rehab time! Then it comes to the rehab post surgery! Will they spend the typical 20-25 PT visits to rehab the entire leg! Begin her on an anti pronation muscle strengthening and flexibility program now including met doming, heel raises, pot tib and per longus, lat ham, gluts for hip ext rotation. The Achilles and hamstrings have to be stretched out to normal range. Then there are issues like no smoking, healthy diet, etc. Hope this helps. Rich

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