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Syndesmosis Procedure for Hallux Valgus and Bunion Deformities Correction

Discussion in 'Foot Surgery' started by danielywu, Jan 15, 2014.

  1. danielywu

    danielywu Active Member


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    I have been doing possibly a predecessor technique to the Mini TightRope (MTR) procedure. I call it the syndesmosis procedure. It was originally an Italian effort called osteodesis procedure (Ref. 1). This technique has since been reported sporadically including myself (Ref. 2,3,4,5,6). I renamed it because I believe “syndesmosis” is a more appropriate name that surgeons are familiar with its anatomical meaning and it also accurately reflects the essence of the surgical concept. This procedure involves an ancient technique of using cerclage sutures to realign first metatarsal and then also maintains its corrected position with an intermetatarsal fibrous bonding between the first and second metatarsals.

    Syndesmosis procedure is not a commercialized technique (no special instruments or implants required) and thus probably still not popularized (no collateral profits to be made). But it can effectively and safely deliver the important surgical objectives of first metatarsal realignment and re-stabilization to correct and prevent metatarsus primus varus (MPV) and thus also hallux valgus without the downside of osteotomy or fusion. It differs critically from MTR procedure in its long term first metatarsal alignment maintenance by a biological instead of artificial material to connect the first metatarsal to the second metatarsal, as any artificial material can eventually fail. The surgical technique is described in each of the references provided below and it is important to take note that its temporary intermetatarsal suturing method is different from MTR to specifically facilitate induction of the essential fibrous connective tissue formation in the first intermetatarsal space.

    As to the concerns of first metatarsal reducibility without osteotomy, I have done more than 1,300 consecutive syndesmosis procedures without really one case where obstruction by first metatarsocuneiform joint contracture, the displaced fibular sesamoid in the first metatarsal space, os intermetatarsum or intermetatarsal facet has happened. No patient complained of early or late metatarsocuneiform joint problems either. There are good and simple explanations for that. I have also successfully corrected each of several recurrent cases after osteotomy and even modified Lapidus procedures with the same technique. There may never be a panacea bunion surgery but for me this soft tissue technique seemed pretty close to it.

    Stress fracture of the 2nd metatarsal can also happen after osteodesis procedure the same as MTR procedure but may not be as frequent. I believe I have this problem under very good control now.

    I regret that I have not had any luck in getting my work published again. To take advantage of the advancing information technology I have been submitting my past few studies with electronic raw material of images of all my study subjects. One of my rejected studies was to show that the syndesmosis bonding did work and there was statistically significant unchanged first intermetatarsal angle from six months after surgery onwards to the 2-year end point of the study period. The images of all these patients during this study period (including the excluded ones) are for free access at www.bunionregistry.com.

    Currently, I have one study under review by a journal and pray it will have better luck. It is a F-Scan study to show that the function of feet could be statistically and significantly improved after syndesmosis procedure. This functional effect was also clinically evident by the consistent disappearance of metatarsal calluses and metatarsalgia after surgery.

    I am genuinely convinced that most if not all metatarsus primus varus deformity of hallux valgus feet are acquired and can be corrected without osteotomy, and that the syndesmosis concept is effective in preventing MPV recurrence. Moreover, it has been proposed that intermetatarsal fibrosis was probably also the reason for the first metatarsal stability after osteotomy procedures.

    This non-osteotomy technique has been having a hard time in being accepted into the mainstream is probably because its results just sound “too good to be true”. This comment was actually and most unfortunately made in a rejection letter in the past.
    I appreciate any comments for discussion.

    Daniel

    References:
    1. Botteri G., Castellana A. L’osteodesi distale dei due primi metatarsi nella cura dell’alluce valgo. La Clinica Ortopedica, 1961; 13,139
    2. Pagella P, Pierleon GP. Hallux valgus and its correction. LO Scalpello, 1971; 1:55-64
    3. Stanley D, Smith TWD. Cerclage Techniques for the Treatment of Hallux Valgus, International Perspectives
    4. Shah A, Berkin CR. Sherman K.P. The Pagella procedure for hallux valgus: A critical review. The Foot, 1993; 3, 31-37
    5. Irwin LR, Cape J. Intermetatarsal osteodesis: a fresh approach to hallux valgus. The Foot, 1999; 9, 93 – 98
    6. Wu DY. Syndesmosis procedure: a non-osteotomy approach to metatarsus primus varus correction. Foot Ankle Int, 2007; 28(9):1000-6
     
  2. drsarbes

    drsarbes Well-Known Member

    Re: Syndesmosis Procedure

    Hi Daniel:
    I was only able to find summaries of the references.
    Can you briefly describe the procedure and materials used for cerclage.
    Also, how do you correct the PASA?

    Thank you
    Steve
     
  3. danielywu

    danielywu Active Member

    Re: Syndesmosis Procedure

    Hi Steve:
    Surgical approach for syndesmosis procedure is more or less the same as mini tightrope/suture button procedure. I pass a double-strand #1 PDS suture with a straight free needle through a 2mm drill hole in distal first metatarsal and then around the neck of the second metatarsal with a curved free needle to tie these two metatarsals together. I usually put in three of such sutures. My distal lateral release soft tissue release involves only lateral collateral and metatarsosesamoid ligaments. I prefer to preserve the adductor halluces tendon and fibula sesamoid. You have to fish-scale the opposing cortex for fibrous ingrowth. My second excisional incision over the bunion is made only after MPV correction so I can avoid excessive bunionectomy.
    Significant PASA or DMAA (distal metatarsal articular angle) is uncommon:
    1.Some may be real: but I would still like to regard it as a form of normal variance until it can be proven incompatible with normal function of the hallux and foot.
    2.Some may be apparent: due to pronation of the first metatarsal or x-ray angle.
    3.I feel picking the two articular reference points for its proper measurement can be difficult and inconsistent.
    4.I have not had much function issue with residual hallux valgus as long as IMA is normal and first metatarsal is no longer hypermobile.
    Daniel
     
  4. drsarbes

    drsarbes Well-Known Member

    Re: Syndesmosis Procedure

    Thank you daniel.
    I frequently find high PASA angles, particularly in younger patients with high IM angles. There needs to be attention drawn to this inorder to straighten the toe with a congruous joint.
    What are your criteria for this procedure?
    After care protocol?

    Thank you
    Steve
     
  5. danielywu

    danielywu Active Member

    Re: Syndesmosis Procedure

    Dear Steve:
    PASA/DMAA to me is still a big myth and I prefer to label it a normal variance. Why can’t PASAs (people) be different and the foot (person) is still normal. Attached case images belong to one (not an exception) of my high PASA patients and I can show you more if you wish. Unfortunately, it is normal human inclination to label things different from the majority, abnormal.

    To me, osteotomy is a means that is trying to look for the end (often cosmetics) for its justification. There has been absolutely no evidence that straighter big toes correlate with better function.

    My criteria for the more than 1,300 consecutive syndesmosis procedures that I have done was simply pain associated with MPV and/or hypermobile 1st metatarsal.

    My post-op protocol is to reduce forefoot stress with Orthowedge shoes by Darco and also to reduce walking in distance and pace for 3 months. Of course, immediate 1st MTPJ passive extension ROM exercises starting on the first post-operative day, usually within 24 hours for 3 minutes every half hour until 80 degrees of dorsiflexion is achieved in usually 2-7 days.

    Daniel
     

    Attached Files:

  6. drsarbes

    drsarbes Well-Known Member

    Re: Syndesmosis Procedure

    Very impressive.
    Well done. They look anatomic.
    Your cerclage is a tad more proximal then I was anticipating. Do you drill the 2nd or merely circle it? They appear to have some periosteal activity.

    The reason I questioned the PASA. I have had many patients in the under 30 year old range with high IM angles with the distal articular surface quite remodeled. The surface is not only very deviated laterally but often very small, oval in shape. This absolutely needs attention since correcting the IM angle deviates the surface even more.

    When do you get them back into a regular shoe?

    Thank you for sharing this information.

    Steve
     
  7. danielywu

    danielywu Active Member

    Re: Syndesmosis Procedure

    Dear Steve:

    You are quite observant of x-ray details and you can also find their clues in my brief description of the surgical technique on 1/16/14.

    I understand your concerns about severe PASAs but what I don’t understand is why do you (and possibly many others) judge PASA would undermine normal function of MTPJ (or just cosmetics) before it has ever even been proven so. This is what I was trying to ask on 1/17/14. We owe our patients evidence-based medicine. There is a big difference between truth and truthiness.

    Can you send me few exemplary x-rays to demonstrate your dilemma and I will try to find any matching cases from my file to ease your mind?

    Daniel
     
  8. drsarbes

    drsarbes Well-Known Member

    Re: Syndesmosis Procedure

    Hi Daniel
    Here is one that happens to be on my iPad (forgive ant errors, I can't type on this thing) Young girl, 20s. Once the IM was corrected her hallux was at around 45 degrees. You can't leave these like that. Not cosmetic.
     

    Attached Files:

  9. drsarbes

    drsarbes Well-Known Member

    Re: Syndesmosis Procedure

    The scan on the previous post, the articular surface was remodeled such that what you see in this X-Ray is articulating. There was no cartilage centrally. One could not merely align the proximal phalanx somehow and expect this joint to be mobile since the little cartilage she had on the meathead was pointing laterally.
    I'm not having success uploading the post op. I'll try again
    Steve
     

    Attached Files:

  10. danielywu

    danielywu Active Member

    Re: Syndesmosis Procedure

    Dear Steve:
    For a constructive and candid discussion, hope you don’t mind me making some interpretation and comments about your x-rays.
    Pre-op x-ray:
    1. Indeed severe hallux valgus for a 20sh person.
    a. Lat collat lig must be short and tight: congenital? doubt born like this, acquired? yes, due to severe MPV, also acquired due to weak 1st met stabilizing ST structures. Needs a good release.
    b. Lateral head of flexor hallucis brevis tendon prob short and contracted, nothing can be done but shorten the met for cosmesis but bad for function.
    c. Akin? no HV interphalangeus
    2. First metatarsal: Very short, be careful not to shorten it any further.
    3. PASA: Increased, can be apparent due to pronation or just normal anatomical variance.
    4. Lateral sesamoid: Completely dissociated from met head, minimal windlass power for toeing-off.
    5. Metatarsocuneiform joint: acute inclination can be exaggerated by pronation and x-ray direction also.

    Post-op x-ray:
    1. First ray alignment: Straight but forefoot not really narrowed; unchanged intermetatarsal space.
    2. Big toe: Straight but Akin?
    3. MTPJ: Congruent but disproportional
    4. PASA: Unchanged but not a problem anyway.
    5. Lateral sesamoid: poor position, forever a met walker with callus
    6. First met: further shortening, potential transfer metatarsalgia
    7. Metatarsocuneiform joint: Inclination increased by prox osteotomy.
    .
    Questions for every one: 1. Is PASA for real or even a proven problem? 2. Is osteotomy really necessary for most cases? please look through attached cases first.

    Daniel
     

    Attached Files:

  11. drsarbes

    drsarbes Well-Known Member

    Re: Syndesmosis Procedure

    Thank you for your impression.

    This particular patient actually did very well and is asymptomatic when I saw her last. No sesamoid issues.

    I did a rotaional neck osteotomy to bring what little articular surface she had into a more rectus position. I obviously did the akin as well since I have found (over literally thousands of these) that I get more ROM post op.

    The joint cartilage at the first metahead was approximately half normal size. The base of the proximal phalanx is quite large in comparison.

    I also did a closing wedge with absorbable screws rather than a Lap or Scarf. I knew the articular surface was paramount in giving this patient adequate ROM and alignment, which I could not do with the SCARF. As for the IM....Not sure what you see, this foot is probably an inch narrower than it was. I do not have a clinical photo.

    My point was... The syndesmosis procedure, in my opinion, cannot correct this type of small, remodeled, displaced articular surface. This type of congenital deformity requires osteotomies to attempt realignment. Of course this type of patient accounts for only a small percentage of hallux valgus patients.

    +++++++++++++++++++++++++++++++

    On another note: The soft tissue vs osteotomy debate is a long and storied one. When early podiatrists started performing bunion procedures many, if not all, were done in an office setting (since none had hospital privileges) thus soft tissue repairs (McBride for instance) became very popular.

    As podiatric surgeons became better trained, surgical equipment such as surgical saws and drills, became available to them. New procedures were developed as a consequence, particularly in light of the poor outcomes of the McBride or Silver or Mayo type procedures that under corrected. Here was also the MIS surgeons, those that perhaps were not privy to classical formal residency training but still did procedures (in the office with "minimal equipment" as well)

    The Soft tissue vs boney deformity argument commenced. The "you cannot repair a boney deformity with soft tissue procedures" prevailed and thus most bunionectomy procedure included osteotomies of some sort, whether open or MIS. Many also retained some soft tissue element.

    It was fairly common for some to suture the 1st and 2nd metaheads together for added correction. Why? Mainly for those that did not decrease the IM angle sufficiently with the osteotomy. They were looked down upon by "real" surgeons.

    Then the quick post operative stage. No longer was it all about the surgeon performing base wedges or Lapidus procedures that required casts or even non weight bearing. It was about the patient and quicker rehab. Austins were the thing. Quick, no fixation, good correction. MIS resurfaced.

    The pendulum has begun to swing again with added pendulums! Now we have various parts of the country (or world) promoting various procedures, some of which have already been tried and discarded, some improved, some requiring very long post op periods, some very little.

    Where are we? HArd to say. But I do need to say that your syndesmosis procedure (though it has some history) looks very good indeed.

    Steve
     
  12. danielywu

    danielywu Active Member

    Re: Syndesmosis Procedure

    Dear Steve:
    There are still debates indeed and also confusions as to what bunion surgeries need to achieve. I have been pleased with the syndesmosis procedure in correcting MPV and also most surprised by its beneficial effects on metatarsal callus, metatarsalgia and clawed toes. Never Weil’s needed. Of course I have shown you only the best examples. I had also less than satisfactory cases but rarely disasters. Fortunately or unfortunately, as a scientific endeavor based on evidence, even medicine behaves like a pendulum.
    Daniel
     
  13. Dieter Fellner

    Dieter Fellner Well-Known Member

    Re: Syndesmosis Procedure

    Dr Wu: we have privately corresponded extensively. You mention you have had some poor outcomes. Has this affected your selection criteria for the syndesmosis? Have you developed a sense of which patient might not be the best candidate? When the syndesmosis fails, what is your go to salvage option. How many syndesmosis require revision. What complications do you see? Are you still using the plaster cast after the operation, if so how is this made, and for how long is it used. How soon are your patients weight bearing, and what is the weight bearing status partial / full? Are you using gait aids?
     
  14. danielywu

    danielywu Active Member

    Re: Syndesmosis Procedure

    Dear Dieter:

    It’s nice to reconnect.
    I had less-than-satisfactory cases but seldom poor outcomes and rarely disasters. After all, how much damage can one do with limited surgical trauma like syndesmosis procedure.

    Less than satisfactory usually due to:
    1. Residual hallux valgus deformity (about MPA of 20°) due to
    a. Inadequate release of lateral collateral ligament
    b. Increased PASA/DMAA – inclined to believe it as a normal anatomical variance.
    c. Metatarsus adductus deformity – a normal variance like flat foot.
    d. Partial MPV recurrence due loosening of the cerclage sutures only during first 4 months after
    surgery usually.
    2. Second metatarsal stress fracture problem has been mostly resolved.
    3. Non-compliant patients
    a. Excessive walking to damage cerclage sutures before syndesmosis formation
    b. Self MPJ extension exercise
    c. Self-rehab exercises to re-educate hallux muscles to maximize first ray dominated walking.
    4. Inability to realign sesamoids adequately.
    5. Residual arthritis of MPJ: detected or undetected pre-op.
    6. Residual medial subluxation of MPJ from MPV over-correction.

    Poor outcomes:
    1. > 50% loss of initial IMA correction and final IMA ≥ 10° (~ 5% of cases, a disappointment but never a disaster) and often symptoms still satisfactorily improved

    Disasters:
    1. One and only deep infection and ended up damaging MPJ.

    Selection criteria:
    1. I have not needed to do any other procedures for the past >1,000 cases and do not expect
    any for my next 1,000 cases either.
    2. I combine syndesmosis with arthroplasty for HV with severe arthritic MPJ, but very uncommon.
    3. Syndesmosis procedure stands out the most for severe HV, MPV and hypermobile first met.

    Salvage procedures (≈ 1%):
    1. Complete cerclage suture rupture: syndesmosis procedure can always be repeated.
    2. MPV over-correction: cerclage suture release p.r.n.

    Post-op protocol: (same for unilateral and bilateral procedures)
    1. Tried forefoot slipper cast, foot cast-brace and Orthowedge. Now, prefer Orthowedge the most.
    2. Weight bearing as soon and as much as capable and as tolerated but no more than 5,000
    steps a day (guideline only) and must be at slow pace only.
    3. Crutches advisable for long distance walking.

    At last, I am collecting opinions as to what is the mechanism that osteotomy procedures provide in stabilizing first metatarsal and prevent MPV recurrence. What is yours?

    Daniel
     
  15. Dieter Fellner

    Dieter Fellner Well-Known Member

    Re: Syndesmosis Procedure

    Daniel:

    Thanks for the analysis. The syndesmosis is a procedure of limited surgical trauma. I was curious to know if at any time an osteotomy was required by way of secondary attempt. If so, the fibro-osseous bridge might be a problem from mechanical blockage limiting metatarsal translation. Of course this can be removed but might be a little 'messy'.

    The rationale underpinning syndesmosis: genetics, anatomy and estrogen is an incomplete explanation, so far. Genetics identifies risk but not cause, anatomy is identical for every walking human and estrogen is abundant. Mechanical factors are implicated and separate those who, do and those who do not develop HAV.

    HAV develops when the 1st metatarsal escapes the windlass mechanism. This occurs for mechanical reasons. The osteotomy works by decompression. When decompression is carefully matched with correct saggital alignment the outcome is very good.

    Dieter
     
  16. danielywu

    danielywu Active Member

    Re: Syndesmosis Procedure

    Dear Dieter:
    As foot surgeons we all appreciate and respect the amazing complexity, specificity and functionability of human foot anatomy. We can never reproduce or even reconstruct, but only possibly repair in some cases, a foot back to the cross-country running and sports normality. For bunion surgery I believe in “pathology specifics” and “less is more”. If hallux valgus is primarily a ligament (medial metatarsosesamoid) problem of first met instability and displacement, syndesmosis procedure is then to re-align and re-stabilize first met. Why deform (mostly) normal bones to compensate a ligament problem if a non-osteotomy procedure can do the job? I am afraid bone procedures may complicate the matter before we understand the condition better.

    One of my reasons for not feeling comfortable with osteotomy procedures yet is failing to understand how osteotomies can stabilize first metatarsal and prevent MPV recurrence.

    Daniel
     
  17. Dieter Fellner

    Dieter Fellner Well-Known Member

    Re: Syndesmosis Procedure

    Dear Daniel,

    I agree completely. The precise mechanism by which an osteotomy works is elusive. But it does. There is enough published work to know, experientially, the operation passes the test of time. It is why the osteotomy has become the accepted standard of care for many HAV cases.

    I am an advocate of the Barouk Scarf-Akin osteotomy, as you know. From my own experience, and that of many colleagues, when correctly executed the effect on medial column stabilization is impressive. The key is to balance correctly first metatarsal decompression, with transverse and saggital plane position of the first metatarsal. Although not a simple procedure, it has a steep learning curve, once mastered, the outcome is effective and reliable.

    The key question for the syndesmosis: if soft tissue failure is indeed the primary modus operandii, as you suggest, driven by estrogen / genetics, why would this factor be isolated to one small component of the 1st MTPJ capsulo-ligamentous complex. I doubt estrogen, which can be implicated and explain ligamentous laxity, can selectively compromise this structure. I do accept this can play a part, but in combination with mechanical factors. HAV is multi-factorial.

    The syndesmosis is an appealing concept, one that perhaps has to be experienced to be fully appreciated. Perhaps I can visit one day and see the execution and outcome first hand! This is also how I was seduced to accept, over a five year span of cynicism, that Scarf is the primary go-to procedure.

    Take care,

    Dieter
     
  18. danielywu

    danielywu Active Member

    Re: Syndesmosis Procedure

    Dear Dieter:

    Scarf osteotomy is the only osteotomy procedure that I know has been demonstrated to improve the hallux (first ray) function by plantar pressure study. I don’t do it but can imagine in good hands it has a greater multi-dimensional maneuverability and also stability than others.

    I would like to connect estrogen to women’s flexibility and HV (albeit all circumstantially) because estrogen shoots up during pregnancy to loosen up the pelvis for easier delivery and can also suddenly worsen HV deformity at the same time since it is a ligament loosening problem after all. This belief has also been strengthened by the fact that majority of my female Chinese patients never wore much high heels in their lives.

    Hong Kong is always worth everyone’s trip even without syndesmosis procedure. I have been told one of the obstacles/dilemma for syndemsosi procedure in the US is the insurance companies would only reimburse it as McBride procedure which is I understand almost 1/3 less than osteotomy procedures.

    Best wishes,

    Daniel
     
  19. Dieter Fellner

    Dieter Fellner Well-Known Member

    Re: Syndesmosis Procedure

    Ligamentous Laxity

    Mild ligamentous laxity is common in women with hallux valgus and has been reported in 70% of twenty patients with juvenile hallux valgus. Therefore, in conditions with generalized ligamentous laxity, such as Marfan syndrome, Ehlers-Danlos syndrome, and rheumatoid arthritis, hallux valgus is more common and more difficult to treat. It is interesting, although counterintuitive, that the only study assessing laxity with use of the Beighton scoring system failed to find any association between generalized ligamentous laxity and hallux valgus. Despite the fact that patients with laxity have a major risk for recurrence, little work has been done on this condition.

    J Bone Joint Surg Am. 2011;93:1650-61 The Pathogenesis Of Hallux Valgus
     
  20. danielywu

    danielywu Active Member

    Re: Syndesmosis Procedure

    I have read that the principal underlying pathology of hallux valgus is failure of the medial collateral ligament, and metatarsus primus varus is due to the failure of medial metatarsosesamoid ligament (Stainsby). It has also been found that these ligaments are made up of mostly weaker type III collagen in hallux valgus feet (Uchiyama). This explains why women wear regular shoes and also men can still develop hallux valgus. On the other hand, for feet with normal medial collateral and metatarsosesamoid ligaments, it would probably be less likely for abnormal shoes and hormones to cause these ligaments to fail. Again, for my practice, most patients are female and most of them never wore much high heels or any at all. I believe both general laxity (estrogen) and wrong shoes are aggravating factors but not necessarily pre-requisits.

    Reconstruction/Repair of these diseased/damaged ligaments has not been successful by any medial soft tissue procedures in the past. It has become obvious that another biological mechanism is required to help stabilize the first metatarsal against the deforming forces in carrying out normal daily activities and also sports. Syndesmosis procedure proposes therefore the concept of syndesmotic bonding. It has surprisingly and amazingly worked well in many different ways for my patients with not just cosmetically in bunion, hallux valgus, metatarsus primus correction but also functionally for collapsed metatarsal arch, metatarsalgia, clawed toes, bunionette pain and even collapsed medial longitudinal arch. I believe strongly that they all have to do with both proper realignment of the first ray and also preservation of its normal anatomical structures by the syndesmosis technique.

    Daniel
     
  21. drsarbes

    drsarbes Well-Known Member

    Re: Syndesmosis Procedure

    Hi Daniel:
    In my opinion, whether you are closing the IM angle by pulling the 1st Metatarsal closer to the second via "tight rope" type procedure, or whether you are performing this by osteotomy - the goal is the same....is it not?
    You are decreasing the IM angle.
    Period.
    WHY the first met has moved may be a topic of debate, but what the final deformity is is fairly straight forward.
    Steve
     
  22. Dieter Fellner

    Dieter Fellner Well-Known Member

    Re: Syndesmosis Procedure

    Steve,

    Daniel can answer for himself but I believe the argument is that in the absence of true deformity affecting bone (bone is misaligned not deformed), the osteotomy, although popular, is a blunt choice with several potential adverse sequela.

    Why the bone is misaligned is an important question that deserves an answer since this can direct the appropriate surgery. I am not yet convinced this has been adequately addressed. I am not familiar with the studies Daniel mentions and would like the complete reference to read the papers. The isolated collagen III anomaly needs closer scrutiny. I suspect this to be reactive to chronic, repetitive mechanical stress. Daniel seems to dismiss the importance of 1st ray mechanical dysfunction in the pathogenesis of HAV, yet most seem to accept this is a key component.

    Footwear does play a role also although the Framingham study suggests it's not high heels that are responsible. There are several studies linking shod populations with a higher incidence of operable HAV.

    Daniel may well have the answer. My problem, at this time, is independent outcome studies that can corroborate the claim. In other words, is the outcome reproducible. It might be, for example, the syndesmosis can work well but only in his hands. I would also like to see a detailed description of the surgical procedure, and a video would be amazing.
     
  23. drsarbes

    drsarbes Well-Known Member

    Re: Syndesmosis Procedure

    Hi Dieter:

    I see your point, however using terms such as "misaligned" and "deformity" are certainly open to interpretation. Also, I would suggest that a definitive understanding of an underlying etiology for a "bunion" "deformity" ( or an arthritic hip or fractured patella, on and on...) is not always REQUIRED for a successful treatment.

    Does it really matter if this patient wore heels or not?


    For something as straight forward as an increased IM angle....an osteotomy designed to reduce this gives very good, reproducible results.

    Of course for those of us performing these, there are a many details and case by case variations to take into consideration. However, I think it's safe to say that for the majority of HAVs, merely decreasing the IM angle, correcting the hallux valgus and not causing any iatrogenic problems is enough.
     
  24. Dieter Fellner

    Dieter Fellner Well-Known Member

    Re: Syndesmosis Procedure

    Steve,

    It matters, and it doesn't. It matters if you are interested to know what might be the ultimate answer to this ubiquitous complaint. This may well be a Utopian quest. I am in the bone cutting camp, my posts are clear. The results can be highly acceptable. Iatrogenic problems do occur, more so with the capital osteotomy, in the mid to long term. Iatrogenic problem may also occur with the syndesmosis but we have no long term outcome studies to know this yet.

    Does it matter if the patient wears high heels. Definitely. Aside from etiological considerations, this also provides insight into the patient's disposition and possible expectations.

    There is a BIG difference between misaligned and deformed. The osteotomy approach deliberately places deformity into normal bone to correct a misalignment. That should be a concern. The Lapidus does not create deformity but instead destroys a joint. Also a concern.

    There are those who have adopted the syndesmosis and it has become the go-to procedure. Podiatry has not yet embraced the concept.

    Take care!
     
  25. drsarbes

    drsarbes Well-Known Member

    Re: Syndesmosis Procedure

    Hi Dieter (again)

    Agree and don't agree.

    Does the etiology matter (for the patient lying on the table) - no.
    Does it matter for future patients if, in fact (big if) some etiological factors are discovered that directly effect choice of surgical procedures - yes.

    I understand what you (and probably I) define misalignment and deformity as...but these terms are not universally accepted nor defined.

    As far as "deforming" a misaligned bone via osteotomy.... this may appear "deformed" on an Xray, but it certainly does not clinically, and even radiographically this "deformity" certainly decreases dramatically over time. I've had occasion to view x rays on post osteotomies years after the fact and some are remarkably "normal" looking.

    Osteotomies work....usually very well (as you know). Because some podiatrists are not comfortable with the appearance of osteotomies radiographically does not mean they are not acceptable.

    Steve

    BTW: I require all my post op bunion patients to wear high heels, even the men.
     
  26. danielywu

    danielywu Active Member

    Re: Syndesmosis Procedure

    Dear Steve:

    Many studies have identify the connection between shod societies and bunion HV deformity but the notion of high heels worsen the situation has only been a conjecture without ever being studied in my knowledge. I believe feet with genetically weak medial collateral and metatarsosesamoid ligaments are the ones most vulnerable to shoe trauma and develop HV and MPV deformities.

    As Dieter said that first metatarsal is usually not deformed. How to realign it and without inadvertently deforming it is critical to the important functional wellbeing of the first ray since it contributes normally up to 80% of push-off power.

    Myerson has pointed out the uniqueness of metatarsocuneiform joint movement. When first metatarsal moves medially in MPV deformity it also moves dorsally in a diagonal direction. This is what results in the hypermobility of first metatarsal in the sagittal plane and of course also in the transverse plane. Conversely, when first metatarsal is pulled back towards the second metatarsal in one intact piece by intermetatarsal sutures, the first metatarsal head will also be moved plantar-ward by rightfully benefiting from the unique configuration of the metatarsocuneiform joint. This plantar realignment in sagittal plane can help restore both the metatarsal transverse and medial longitudinal arches. But if first metatarsal is osteotomized, its realignment will be mostly cosmetic not functional because the all-important guiding effect of the metatarsocuneiform joint in particularly the sagittal plane will be unfortunately lost.

    As far as I am concerned that if there are so many different osteotomy techniques practiced around the world and so many are required to manage different severities, then osteotomy concept has not yet really proven itself…. versus one single syndesmosis technique can correct all MPV severities at least in my hands.

    Finally and again, feet are created for function rather than for show. Plantar pressure studies have shown most osteotomy procedures, except Scarf procedure, have failed to improve function of the first ray. I have been using the Leaning Tower of Pisa as an analogy for the MPV deformity to advocate non-osteotomy means to preserve its anatomical and functional normality.

    Daniel
     
  27. drsarbes

    drsarbes Well-Known Member

    Re: Syndesmosis Procedure

    Hi Daniel:

    The high heels thing was a joke!
    haha

    As far as numerous osteotomies...these are not necessarily redundant procedures.

    As I'm sure you are aware, these are designed to correct various pathologies within the "bunion" diagnosis not just based on the "severity". Short first met, long first met, high PASA, overall met adductus, concomitant first metahead cyst, active individual, young, old, open epiphyses, hallux interphalangeous, first met-cuneiform arthritis, arthritic MTPJ, osteoporosis, remodeled metahead, on and on and on....

    I'm not sure why you suggest osteotomies have not proven themselves. As a surgeon, my basic criteria for surgical indication is pain. When we perform osteotomies and the patient is pain free afterwards, then it is successful. Various other measurable indices, as they relate to a surgical practice, are fairly irrelevant. Of course I need to remind everyone that on the patient side, they also want a "normal" looking foot.

    When you are in a private practice, not only are you getting paid to relieve the patients pain, but the foot should look cosmetically normal. Now, does straightening a hallux really add to the pain relief the procedure is offering? In some cases yes, in others possibly not, but certainly if a patient is going through a surgical correction for bunion pain shouldn't we straighten the toe as part of the procedure?

    I say...of course we should. They are asking us to "fix" their problem. They want a foot that does not hurt as well as one that looks normal. That's why we get the "big bucks!"


    Steve
     
  28. Dieter Fellner

    Dieter Fellner Well-Known Member

    Re: Syndesmosis Procedure

    Steve:

    For what it's worth, I got the joke. Daniel: the high heel issue has been looked at, I mentioned the Framingham study. High heels don't seem to be the culprit, but shoes in general do play a role.

    I have surgical skills that allow me to place the affected structures in any position I choose. How straight the segment will be after surgery is determined in part by what the patient wants. In general it is sensible to look closely at the preferred style of shoe the patient is likely to use. And, as a rule of thumb, the hallux should be aligned parallel to the lesser toes, unless there is severe concomitant lesser toe deformity. It's about symmetry in conjunction with the flare of the shoe. I have been impressed with the fact that some individuals can wear the silliest shoe and never develop a problem. Why is that? The metatarsal / digital parabola is the answer, in part. Reduced 1st stiffness is a further, if contentious, issue. Clinically, we can range the 1st ray and observe predominantly saggital plane motion, little if any transverse plane motion. A most recent study claims the primary defect is 1st metatarsal axial rotation. When this is corrected the sesamoids re-position spontaneously.

    That a syndesmosis can stabilize the 1st ray is logical. I am concerned about the lack of control over the position of the hallux, without adjunctive procedures. I am also concerned about the presence of an osseo-fibrous intermetatarsal bride. If the surgery fails, this can create a mechanical blockage to a revisional osteotomy.

    The second part that concerns me about the syndesmosis is the potential for 1st MTPJ stiffening. Daniel says this does not happen. I would like to see objective data 12-24 months after the surgery to know how well the joint functions. I believe the joint buckles, in part because the segment is long, in primary structure or function. Lengthening the segment is likely to return the mechanical stress causing HAV.
     
  29. danielywu

    danielywu Active Member

    Re: Syndesmosis Procedure

    Dear Steve:

    To me, most rationales for the osteotomy concept seem to be hindsight. Is it really abnormal to have longer or shorter metatarsal than usual? Why are the (abnormal) round metatarsal heads still round after osteotomy?

    I think we can put the normal anatomical variances behind us for now and focus more on the pathological ligaments again.

    Since I have never performed any osteotomy procedures, I can only rely on the function study results reported by others. (Read Attachment 1)

    BTW, I can bet you make much bigger bucks if you can perform the magic of correction without breaking bones.


    Dear Dieter:

    There are indeed many ways to skin a cat, but why break bones if they are not at fault. (See Attachment 2)

    Indeed, syndesmosis procedure desperately needs others to testify its results. Hopefully we will see someone stepping forward soon.

    Daniel
     
  30. drsarbes

    drsarbes Well-Known Member

    Re: Syndesmosis Procedure

    Hi Dan:

    Just a quick reply concerning the metaheads....I'm not referring to the shape of the head when I bring up that point, but the remodeling of the articular surface, it's misalignment relative to the long axis of the metatarsal and the, often, decrease in surface area.

    I think the pathologies associated with long or short first metatarsals are well documented and supported clinically.


    BTW: When I start factoring in my monetary reimbursement into my selection of a surgical procedure...that's when I'll quit.


    Steve
     
  31. Dieter Fellner

    Dieter Fellner Well-Known Member

    Re: Syndesmosis Procedure

    Daniel: I can see no convincing evidence to support the view we can dismiss out of hand abnormal metatarsal length and / or position. That will include metatarsal head curvature. HAV is multi-factorial. It is likely the sum total of the influence of the various factors combine to produce HAV. Each factor can provide an effect that in isolation will not make HAV but the net effect will cause HAV or make that individual susceptible to HAV. The relative individual contribution of the multiple factors likely vary among the individual.

    Ligamentuous laxity is but one factor. Isolated abnormality of part of the medial ligament complex is a red herring. It's an effect, not a cause of deformity. And there is no compelling evidence it is the only factor. Anatomical factors and patho-anatomy is one component, important when discussed in the context of pathomechanics. The latter will explain the former, not vice versa.

    There is a reason the overwhelming majority of the foot surgery profession will reach out for osteotomy: it works. Is there a risk of untoward sequela? Of course. There is a risk inherent to any surgical procedure. The syndesmosis is an unlikely exception to this rule.

    It is quite a revelation to know you have no experience of osteotomy! When all you have in the toolbox is a hammer, everything looks like a nail. I am curious to know why you have never attempted an osteotomy?

    As you know, I am planning to undertake an analysis of the syndesmosis in the next year or two.



    P.S. Your last post makes mention of attachments. There are none.
     
  32. danielywu

    danielywu Active Member

    Re: Syndesmosis Procedure

    Sorry for the glitch. They should be attached this time.

    Daniel
     

    Attached Files:

  33. Dieter Fellner

    Dieter Fellner Well-Known Member

    Re: Syndesmosis Procedure

    Daniel: no offense but the papers listed appear cherry picked - meaning to say, the findings corroborate the story you are looking to tell. You previously mentioned the Scarf can provide successful outcomes but your reference list does not include that study. Not sure if hallux pressure alone provides the clue, dispersion of pressure across the MTPJ across the forefoot is an important part of the analysis. Interesting, all the same.

    The XR of the failed osteotomy also is cherry picked. There are many, many successful osteotomy procedures. Like any other surgery, there is success and there is failure. If you search hard enough can you find an XR of a syndesmosis that failed magnificently?
     
  34. drsarbes

    drsarbes Well-Known Member

    Re: Syndesmosis Procedure

    I would suggest that we take a step back and look at what is being presented.
    A non osteotomy bunion procedure for correction of metatarsus primus adductus (varus).
    I don't think we should judge this procedure based on the outcomes (good or bad) of osteotomy procedures. It needs to stand on it's own, no pun intended.

    I'd still like to hear more about the procedure...post op protocol, what, besides the actual syndesmosis portion of the procedure is being done (distal work), how is the correction quantified intraoperatively, what are the surgical criteria/indications.

    If there is a better way, I'm all for it. I do think an Akin osteotomy along with the syndesmosis procedure would give better results without adding any rehab time.

    My major concern is actually with the ability of the syndesmosis suture (s) to stand up to physical activity above and beyond simple ambulation... sports activities, overweight patients, etc...


    Steve
     
  35. Dieter Fellner

    Dieter Fellner Well-Known Member

    Re: Syndesmosis Procedure

    Steve: I also would like a detailed account including the operative procedure. What is now the preferred incisional approach? What is Daniel's technique for placing the sutures. Is he using any special instrumentation? Is he now using biological adjuncts to encourage synthesis.
    Since no one procedure is likely to be appropriate for all cases of HAV, (the Barouk Scarf does come close to meeting this ideal) I want to know what selection criteria are put in place.

    What to do with the laterally deviated M1 cartilage. If the joint is maintained congruous it will not matter but the hallux abduction persists. If the joint is trackbound with significant PASA it is possible this may self correct in time but I would need to be convinced. In the flexible cases the hallux may well straighten secondarily to MPA / lateral release correction.

    As for the syndesmosis, the lasting correction will be from the osseo-fibrous band that forms, not the absorbable sutures placed only to provide initial approximation of M1/M2. During the consolidation period the foot is protected.
     
  36. drsarbes

    drsarbes Well-Known Member

    Re: Syndesmosis Procedure

    Hi DJ, and Daniel.

    "As for the syndesmosis, the lasting correction will be from the osseo-fibrous band that forms, not the absorbable sutures placed only to provide initial approximation of M1/M2."

    I'm at a bit of a loss of what exactly a fibrous band or osseous-fibrous band is and how it may form and how strong it is. Just because we have a suture or wire or fiberwire between two structures does not mean the body will react by reinforcing this, particularly with a gap as large as this one would be. In addition, if there remains "normal" first ray function post surgically would this independent first ray motion not preclude the formation of a "bonding" type of fibrosis?


    Steve
     
  37. Dieter Fellner

    Dieter Fellner Well-Known Member

    Re: Syndesmosis Procedure

    Steve: it's precisely this component of the procedure that makes it unique. The adjacent metatarsals are feathered with an osteotome. This generates an osseo-fibrous bridge stabilizing the 1st metatarsal that maintains the correction provided initially by the sutures.

    It's a very novel idea, and has gained popularity in Europe (UK, Italy) and Hong Kong. Probably other places also. So the premise here is that in the absence of firm ligamentous support the 1st ray can be displaced in the TP. In my minds eye (and most of our profession) the reason for this is entirely mechanical in origin, since in that respect all feet are anatomically the same. Ligamentuous laxity or ligamentuous anomaly is overplayed in an attempt to explain the displacement but that's a secondary concern. Same with "genetics' which explains everything and nothing. In the final analysis pathomechanics (for a variety of reasons) can exploit the anatomy to cause HAV syndrome. The biologic bridge provides a permanent stabilization to abnormal 1st metatarsal position and motion. As mentioned, the foot is protected during the period of synthesis. I suspect there will be some motion regardless and that is why it's a more fibrous union instead of a bony bridge. A bony bridge sometimes forms, when motion is tightly controlled (in my opinion), but this does not seem to cause problems.

    [​IMG]
     
  38. danielywu

    danielywu Active Member

    Re: Syndesmosis Procedure

    Dear Dieter and Steve:

    I am not surprised by your initial disbeliefs and skepticism of syndesmosis procedure just like about everyone else. I hope syndesmosis procedure is gaining popularity in UK and Italy but there have been only osteotomy procedures being reported from these places in the past 15 and 40 years respectively. It is still a very much denied concept worldwide that will probably take another 50 years to establish itself.

    To me, a soul-searching question to be answered is why there are still well over 10 different osteotomy procedures necessary for treating just one single condition. This number is unmatched by any other human surgical conditions at any one time. It may seem that I cherry-picked the papers but they were about all I could find. I wish someone who could cherry-pick other evidence to educate me.

    I agree that all your questions are reasonable and valid about a totally new and foreign surgical concept that is exactly opposite to what osteotomies preach. And yet I have also just about as many questions for the osteotomy concept.

    To understand syndesmosis approach, it is fundamental to believe that metatarsus primus varus is the epicenter of the whole HAV condition and ligaments are at fault of MPV, not bones. If we cannot come to term with this basic pathology, I don’t think our discussion can ever be fruitful.

    Syndesmosis procedure is to address specifically the two issues of MPV and they are instability and displacement of the first metatarsal. Once they are taken care of, but without traumatizing any innocent structures, then even other secondary deformities like the clawed toe I have shown you will often just correct themselves. It is actually not a magic !

    We can "talk" forever but I do not expect to do much good. I can only show you so much evidence of my own before turning you off completely. Maybe, only seeing is believing. You are welcome to come and observe and study all my cases, especially how I dealt with some of the complications.

    Good night,

    Daniel
     
  39. Dieter Fellner

    Dieter Fellner Well-Known Member

    Re: Syndesmosis Procedure

    Daniel: to the contrary, the community is open to possibilities. If you can, or want to, please provide a description of your surgical technique and post-op management for your patients.
     
  40. danielywu

    danielywu Active Member

    Re: Syndesmosis Procedure

    Dear Dieter:

    The surgical technique is well described in my article and Irwin’s that you have both already. We have discussed post-op care in the past and my latest regimen is in my website www.bunioncenter.com, from which I believe you took the illustration of syndesmosis procedure for your last mail.

    For anyone who would also like to be acquainted with the procedure and haven’t had a chance to visit my website, it gives a reasonably comprehensive introduction. Again, I will be happy to answer any specific questions to anyone after having gone through it first.

    Don’t try the surgery without proper training to avoid undesirable outcomes like the mini-tightrope procedure had to face. There is much more to any simplest surgery than what meets the eye so to speak.

    Daniel
     
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