Name: Multiplanar Bunion Correction
Uploaded: 2019-12-17T00:00:00Z
Channel: Arthrex
Description: Ryan B. Rigby, DPM (Logan, UT), describes the biomechanical and rotational aspects of bunion correction using the Arthrex Plantar Lapidus Plate.

<p>Ryan B. Rigby, DPM (Logan, UT), describes the biomechanical and rotational aspects of bunion correction using the Arthrex Plantar Lapidus Plate.</p>

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VID1-000774-en-US | A | Multiplanar Bunion Correction

Ryan B. Rigby

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Multiplanar Bunion Correction

I'm Ryan Rigby from Logan, Utah. Good to be with you guys. And I'll be speaking about Multi-planar bunion correction. I thought I'd start off a little bit differently. I want to start with a case example and a question. So there's a lot of experience in this room. How would you treat this x ray. This is an 18 year old female complaining of a bunion. What procedure would you do? Or perhaps the better question is, do you feel like there is a wrong procedure for this patient? Well, to answer that question, I think we need to dig a little bit deeper. Deeper. We need to find out how many planes are involved with this deformity. Well, we know the transverse plane is obviously affected. That's easy to see from an AP view. It's obvious. But what about the frontal plane? Can you tell that from an AP? I can't, so how do you find out if there's a frontal plane deformity for this 18 year old sesamoid? Axial views give you a lot of information. So for her she is sitting in a valgus. So does that change your procedure of choice. Would you do anything different if you get this view and you see that the sesamoids are sitting in this position? I like chevrons, I do a lot of chevrons, but if I try to slide this over towards the second metatarsal that capital fragment is going to run into the fibular sesamoid. It's going to be blocked. We've all been there. It doesn't reduce. It doesn't come over like we like it to. So we release the sesamoids. Slide it under. And now I've completely interrupted the metatarsal sesamoid complex and the relationship because I didn't address the metatarsal itself. So what if we ignore it? Does it really matter? Do we really need to do all of that and consider this and get all these axial views? When you see a patient with a recurrent bunion coming down the hall. We do the next logical thing. Like Costanza, we hide it in the desk. Right? We hate recurrent bunions. And that is exactly what happens if we completely ignore the frontal plane. We have an increased chance of recurrence. How do we know this? There's an interesting study that just came out last year from Shibuya, looking at over 200 bunions, all corrected without addressing the frontal plane, and they reported over 30% recurrence. Very high. Interestingly enough, they looked at factors that would predict recurrence. And if you ask yourself, well, you know, what do you think is going to predict a patient's bunion coming back? Is it potentially how bad it was to begin with? They found that actually didn't have anything to do with it, or at least didn't play didn't play into it statistically. How about the I am angle? Post-operatively you think I've got that dialed in? That should predict success, right? They found that didn't play into it statistically. The only thing they found that was a good, consistent predictor of success was the sesamoid position postoperative. And that caught my attention. If you look at how they broke this down and the percentages, if you have a sesamoid tibial sesamoid position number three or greater, you have a 40% chance of that bunion coming back or greater. Can I have an I am angle that's dialed in and have the sesamoid complex be off or not at a one or a two? Yes. Look at this x ray. The I am looks great, but the sesamoid complex is still not in position. So I know this patient has about a 40% chance of that bunion coming back, which is not a good thing. You know, if we if we just do single plane, transverse plane correction, we'll get it right. A good percentage of the time. It's very simple. You can do any procedure you want. Slide this over. It corrects the first MTP. The patient's happy. It's nice when that works. If you look at this from the top down looking at an AP view you look at the sesamoid complex and you say okay this tibial sesamoid is sitting in a position number five. I know what I need to do. I need to slide this over. Right. Get it in the right position. Get it in. Or 1 or 2. And then I've really cut down the chance of recurrence. But what if the sesamoid position is sitting like this? And you look at this from the top down and you think, oh, it's sitting in a position number five. If I try to slide that over, I'll struggle. Instead, I need to address the frontal plane and rotate this. The Sesamoids were not displaced. They were in the right position. It was the metatarsal in the whole complex that was displaced. And it needs to be rotated. You can see this clinically as you start to watch for this. You'll see there's a rotatory deformity here. Now does every bunion need to have a frontal plane correction. Do you need to do that on everybody. No I think we've all been there where we've just done transverse plane. Slide it over, get the sesamoids right and it works. So the question is how common is this frontal plane deformity or how often do I need to be rotating the whole complex. This came out. This is weight bearing CT from Kim in 2015 looking at over 160 bunion deformities. And they broke it down for us. So basically there's no rotation in about 12% of patients. There's about 70 over 70% where they do have transverse plane. We know that's a big part of part of it. That's a given. Interestingly enough, about just over 25% had frontal plane, only that just needed to be rotated. And then the rest is about 80% where it's a combined deformity. Really. Ultimately we're talking about a very simple technique. Put a wire in the base. Watch the sesamoid complex here. It's displaced by simply rotating only the frontal plane. What happens? The first MTP is improved. The sesamoid complex is put into a correct position. Everything is in a better alignment without even doing much to the transverse plane. Very powerful way to correct a bunion or valgus. So in combination with transverse plane, like I'm doing with the clamp and frontal plane, with that simple K-wires in conjunction with tension side fixation, like the planar lapidis plate, we give our patients the best chance of having success. Fixation is critical. We all understand that we like to put the plates and screws in. They have to be done right. I fully admit that if you put it on the medial or dorsal side and you let the patient's way very early, you run the risk of planar gapping and displacement of your fusion. I like to move the hardware to the planar side, the tension side, it's more mechanically strong. And if you let them weight bear earlier, you convert those forces into actual compression across the arthrodesis. And that's that's been a game changer for my practice. So let's circle back around. Let's get back to that 18 year old that we started with. Here's that valgus position doing multi plane bunion correction both transverse and frontal plane. I'm able to restore her to a sesamoid position number one. So when I look at X-rays now Postoperatively it was all about the first MTP and the I am. And that's all still important. That's good. And my fixation the fusion. But really I want to know where the sesamoids are sitting because that ensures that I provided long term success for that patient. So position number one, here's another patient, a 20 year old very hypermobile first rate got a sesamoid axial view. She's sitting in a valgus. I use tension side fixation or plantar fixation. I am is reduced, but more than anything the the sesamoids are sitting in a position. Number one. I'm happy with this postoperatively, which translates to a good clinical outcome for this patient. Elderly patients later 60s. Same thing. Valgus position using tension side fixation. This is the first week post-op early weight bearing. By week five it's fuzed and ready for regular shoes. But the most important thing is this sesamoid complex has been restored. Here's a 51 year old, and I'm able to let them weight bear it at one week and return to shoes at five weeks. Everything is stronger when the sesamoids are in the right position, starting distally and working proximally. Here's one where it's not. There's no frontal plane rotation. I wouldn't know that without the axial view. So in this particular patient I just did transverse plane. Slide them over to a position number one. And I've accomplished everything that I need to accomplish for this particular patient. Here's one where I did not. This was my own mistake. I made a mistake here and did not address multiple planes. I just did the transverse plane. I slid this over. I tried to reduce the intermetatarsal angle, I improved it, but look at the sesamoid complex. I have not improved that. That's not sitting in the right position. So here's an eight week post-op. It looks okay, but here's four months post-op. Sesamoids are not in a good position. It's at least a three maybe actually probably a four. And the metatarsal is rolling off the side again. Puts more strain on the inner Cartiform joint. I am opens back up. The patient has a bunion again. They're not happy. That's what happens if you ignore some of this. It's it's very powerful. What if it's extremely severe? Do I need a first MTP fusion on this patient? No. With multi-link correction you can restore the sesamoid complex and everything in alignment of the medial column. And the medial. The first Ray. What if it's severe frontal plane rotation? How far can you go? This is in a very rotated valgus position. Absolutely. And you don't know until you get the axial view where it's sitting. But moving this to a position number one ensures that I've given the patient the best chance of having success long term. Here's a couple. Just pop the top and bottom. It's mild rotation versus more severe. And once you see this pre-op which I think you really need to start obtaining, if you're not getting axial views you'll start to know interop. How much do I need to rotate. And you can over rotate these. I've done that myself. So this gives you an idea and you can plan ahead. So in summary if you want to insure your calves use Liberty Mutual. If you want to insure your bunion corrections, use Multi-plane correction techniques. Sesamoid axial views, I can't emphasize enough, are very critical. Not every bunion needs frontal plane rotation, but we need to be aware of it and not ignore it. Multi-plane correction, when indicated, is very powerful, and the sesamoid sesamoid position is the greatest predictor of long term success. Thank you.

Multiplanar Bunion Correction

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