Syndesmosis procedure

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Syndesmosis procedure
Painful hallux valgus.jpg
Fig. 8a. Painful hallux valgus and metatarsus primus varus deformity recurrence of left foot after osteotomy surgery
Specialty podiatry

Syndesmosis procedure is one of the more than twenty bunion surgeries currently being performed. While the majority of bunion surgeries involve the breaking and shifting of bones (osteotomy procedures), [1] syndesmosis procedure [2] is one of few surgical techniques that use a soft-tissue or non-osteotomy (non-bone-breaking) approach to afford the same correction. More than 130 different surgical techniques have been described for correction of one single condition of the foot: the bunion deformity.

Contents

Normal foot skeleton1.jpg
Fig 1a: Normal foot skeleton
First metatarsal bone has moved aside1.jpg
Fig. 1b: First metatarsal bone has moved aside

Purpose

Bunion (hallux valgus) deformity is actually part of a complex of anatomical derangements of protruding mass (bunion), buckling of big toe (hallux valgus) and the bone behind it (metatarsus primus varus), displaced sesamoid bones (detrimental to the important walking function of big toe), collapsed metatarsal arch and several other secondary changes that are the domino effects of metatarsal primus varus. Thus, metatarsus primus varus correction has become the primary objective of all bunion surgeries.[ citation needed ]

Primus varus deformity

Primus varus deformity is the leaning of the first metatarsal bone away from the second metatarsal and towards the opposite foot (Fig. 1). As it leans over, its head sticks out to form the bunion bump and it also widens the forefoot to cause shoes feeling too tight. Thus when bunion pain becomes unmanageable, surgical correction is to narrow the forefoot by repositioning of the first metatarsal head back to its normal position. This can be done by osteotomy (bone-breaking), soft tissue (non-osteotomy) or fusion techniques.[ citation needed ]

Cerclage bone sutures1.jpg
Fig. 2: Cerclage bone sutures
Fibrous connecting bridge to prevent recurrence1.jpg
Fig. 3: Fibrous connecting bridge to prevent recurrence

What causes the metatarsus primus varus deformity?

A first metatarsal bone would lean towards one side is because “the medial hood ligament is stretched” [3] and as it becomes weak and incompetent the first metatarsal would lose its support and then gradually shift out of place to form the metatarsus primus varus deformity.

What causes ligaments to fail?

Female hormone estrogen and genetic inheritance are the two primary factors behind the weak ligaments of bunion feet. Bunion deformity was found more common in people wearing shoes by a study in Hong Kong [4] and increased in Japan due to changing in footwear to Western style. [5] Aging, degeneration and trauma have also been attributed to weakening of the responsible ligaments.[ citation needed ]

Before syndesmosis surgery.jpg
Fig. 4a: Before surgery
2 years after syndesmosis surgery.jpg
Fig. 4b: 2 years after surgery

Technique

Syndesmosis procedure addresses specifically the two fundamental problems of metatarsus primus varus deformity that gives rise to the bunion deformity. They are leaning and instability of the first metatarsal bone . Syndesmosis procedure uprights the leaning first metatarsal bone with strong binding sutures between it and the second metatarsal bone (Fig. 2) and then also stabilizes it uniquely by creating a fibrous connecting bridge between these two bones (Fig. 3, 4). First metatarsal bone can be readily realigned because by definition of the metatarsus primus varus deformity its first metatarsal is abnormally loose and mobile.[ citation needed ]

Fig. 5 Stress fracture of the second metatarsal bone Stress fracture of the second metatarsal bone1.jpg
Fig. 5 Stress fracture of the second metatarsal bone

Advantages

  1. No breaking of bones (Less postoperative pain and swelling, Fewer possible complications, Technically simpler for surgeons)
  2. Single technique can be applied to almost all severities.
  3. Both feet can be done at same time.
  4. Immediate weight bearing is allowed and safe.
  5. Instability issue is specifically addressed to prevent recurrence.
  6. Function restoration has been proven by plantar pressure study.
  7. No special surgical instruments or implants are needed.
Left big toe joint shifted1.jpg
Fig. 6a: Left big toe joint shifted in sideway due to overcorrection
Left big toe joint shifted2.jpg
Fig. 6b: Left big toe joint shifted in sideway due to overcorrection

Specific cautions afterwards

  1. Restricted walking of no more than 5,000 steps a day for three months
  2. No sports or high heels for six months

Possible complications

  1. Wound infection
  2. Cutaneous nerve injury
  3. Cerclage suture breakage
  4. Big toe joint stiffness
  5. Second metatarsal stress fracture (Fig. 5)
  6. Over-correction (Fig. 6)

History

The surgical technique of syndesmosis procedure originated from the osteodesis procedure that was first described by Botteri in 1961. [6] It has since been studied and reported by Pagella in 1971, [7] Irwin in 1999 [8] and Wu in 2007. [2] Syndesmosis itself is a normal anatomical structure for the purpose of connecting two parallel long bones side by side, such as the tibia and fibula bones. The naming of syndesmosis procedure was thus to reflect the essence of the technique which is to create a “syndesmosis” mechanism to provide permanent stability to the first metatarsal to prevent recurrence. Both the bone-binding-sutures and syndesmosis-connection concepts are unique and revolutionary in a world of bunion surgery overwhelmingly dominated by osteotomy (bone-breaking) tradition.[ citation needed ]

Other options

  1. For severe bunion deformity correction (Fig. 7)
  1. For recurrence correction after osteotomy procedure (Fig. 8)

Late deformity recurrence can happen after osteotomy (bone-breaking) procedures because osteotomy surgeries do not specifically stabilize first metatarsal bone.

For recurrence correction after fusion procedure (Fig. 9) Metatarsus primus varus deformity and pain recurred 6 months after modified Lapidus procedure and it could also be again corrected by the syndesmosis procedure.

Related Research Articles

<span class="mw-page-title-main">Foot</span> Anatomical structure found in vertebrates

The foot is an anatomical structure found in many vertebrates. It is the terminal portion of a limb which bears weight and allows locomotion. In many animals with feet, the foot is a separate organ at the terminal part of the leg made up of one or more segments or bones, generally including claws and/or nails.

<span class="mw-page-title-main">Toe</span> Digit of a foot

Toes are the digits of the foot of a tetrapod. Animal species such as cats that walk on their toes are described as being digitigrade. Humans, and other animals that walk on the soles of their feet, are described as being plantigrade; unguligrade animals are those that walk on hooves at the tips of their toes.

<span class="mw-page-title-main">Bunion</span> Deformity characterized by lateral deviation of the big toe

A bunion, also known as hallux valgus, is a deformity of the joint connecting the big toe to the foot. The big toe often bends towards the other toes and the joint becomes red and painful. The onset of bunions is typically gradual. Complications may include bursitis or arthritis.

An osteotomy is a surgical operation whereby a bone is cut to shorten or lengthen it or to change its alignment. It is sometimes performed to correct a hallux valgus, or to straighten a bone that has healed crookedly following a fracture. It is also used to correct a coxa vara, genu valgum, and genu varum. The operation is done under a general anaesthetic.

<span class="mw-page-title-main">Coxa vara</span> Deformity of the hip

Coxa vara is a deformity of the hip, whereby the angle between the head and the shaft of the femur is reduced to less than 120 degrees. This results in the leg being shortened and the development of a limp. It may be congenital and is commonly caused by injury, such as a fracture. It can also occur when the bone tissue in the neck of the femur is softer than normal, causing it to bend under the weight of the body. This may either be congenital or the result of a bone disorder. The most common cause of coxa vara is either congenital or developmental. Other common causes include metabolic bone diseases, post-Perthes deformity, osteomyelitis, and post traumatic. Shepherd's Crook deformity is a severe form of coxa vara where the proximal femur is severely deformed with a reduction in the neck shaft angle beyond 90 degrees. It is most commonly a sequela of osteogenesis imperfecta, Paget's disease, osteomyelitis, tumour and tumour-like conditions.

<span class="mw-page-title-main">Clubfoot</span> Bone development disease

Clubfoot is a congenital or acquired defect where one or both feet are rotated inward and downward. Congenital clubfoot is the most common congenital malformation of the foot with an incidence of 1 per 1000 births. In approximately 50% of cases, clubfoot affects both feet, but it can present unilaterally causing one leg or foot to be shorter than the other. Most of the time, it is not associated with other problems. Without appropriate treatment, the foot deformity will persist and lead to pain and impaired ability to walk, which can have a dramatic impact on the quality of life.

<span class="mw-page-title-main">Pes cavus</span> Medical condition

Pes cavus, also known as high arch, is a human foot type in which the sole of the foot is distinctly hollow when bearing weight. That is, there is a fixed plantar flexion of the foot. A high arch is the opposite of a flat foot and is somewhat less common.

<span class="mw-page-title-main">Genu varum</span> Varus deformity marked by (outward) bowing at the knee

Genu varum is a varus deformity marked by (outward) bowing at the knee, which means that the lower leg is angled inward (medially) in relation to the thigh's axis, giving the limb overall the appearance of an archer's bow. Usually medial angulation of both lower limb bones is involved.

<span class="mw-page-title-main">Varus deformity</span> Deformity in which the bone near a joint is angled inward

A varus deformity is an excessive inward angulation of the distal segment of a bone or joint. The opposite of varus is called valgus.

<span class="mw-page-title-main">Valgus deformity</span> Deformity in which the bone near a joint is angled outward

A valgus deformity is a condition in which the bone segment distal to a joint is angled outward, that is, angled laterally, away from the body's midline. The opposite deformation, where the twist or angulation is directed medially, toward the center of the body, is called varus.

<span class="mw-page-title-main">Tailor's bunion</span> Medical condition

Tailor's bunion, also known as digitus quintus varus or bunionette, is a condition caused as a result of inflammation of the fifth metatarsal bone at the base of the little toe.

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The Ponseti method is a manipulative technique that corrects congenital clubfoot without invasive surgery. It was developed by Ignacio V. Ponseti of the University of Iowa Hospitals and Clinics, US, in the 1950s, and was repopularized in 2000 by John Herzenberg in the US and Europe and in Africa by NHS surgeon Steve Mannion. It is a standard treatment for clubfoot.

<span class="mw-page-title-main">Pigeon toe</span> Medical condition affecting the feet

Pigeon toe, also known as in-toeing, is a condition which causes the toes to point inward when walking. It is most common in infants and children under two years of age and, when not the result of simple muscle weakness, normally arises from underlying conditions, such as a twisted shin bone or an excessive anteversion resulting in the twisting of the thigh bone when the front part of a person's foot is turned in.

The forefoot is the anterior aspect of the foot, composed of the five metatarsal bones, the fourteen phalanges and associated soft tissue structures. It is a common site of pathology in podiatry, and is the anatomic region involved in such conditions as hallux valgus, hallux rigidus, and Morton's neuroma, among others. In cases of severe deformity, such as in Charcot joints seen with diabetic neuropathy, the forefoot can be reconstructed by arthroplasty.

<span class="mw-page-title-main">Index of trauma and orthopaedics articles</span>

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<span class="mw-page-title-main">Angular limb deformity</span> Medical condition

Angular limb deformity is a pathological deformity in the spatial alignment of any limb in quadrupedal animals. The term encompasses any condition in such an animal wherein a limb is not straight. It most commonly occurs in the carpal joint of the forelimbs, manifesting as the limb pointing outward or inward, deviating from normal development.

<span class="mw-page-title-main">Akin osteotomy</span> Surgery to correct hallux valgus

Akin osteotomy is a surgical procedure often used in the treatment of hallux valgus deformity, more commonly known as a bunion. A bunion is a bony bump that forms on the joint at the base of the big toe, often resulting in the toe pointing abnormally toward the second toe. Akin osteotomy is usually performed in conjunction with other procedures to correct the alignment of the toe and relieve associated symptoms. This procedure was first described by Akin in 1925.

References

  1. Coughlin MJ; Mann RA; Saltzman C. Surgery of the Foot and Ankle (Eighth Edition Vol 1 ed.). Mosby Elsevier. p. 233.
  2. 1 2 Wu, DY (2007). "19. Syndesmosis procedure: a non-osteotomy approach to metatarsus primus varus correction.". Foot Ankle Int. Column 2, Paragraph 2, Line 15.
  3. Haines RW, McDougall A (May 1954). "The anatomy of hallux valgus". J Bone Joint Surg Br. 36-B (36–B(2)): 289. doi:10.1302/0301-620X.36B2.272. PMID   13163115.
  4. Lam SF, Hodgson AR (1958). "A comparison of foot forms among the non-shoe and shoe-wearing Chinese population". J Bone Joint Surg Am. (40–A): 1061.
  5. Kato T, Watanabe S (1981). "The etiology of hallux valgus in Japan". Clin Orthop Relat Res. 157 (58): 78–81. doi:10.1097/00003086-198106000-00014. PMID   7249466.
  6. Botteri G.; Castellana A. "139. L'osteodesi distale dei due primi metatarsi nella curs dell'alluce valgo". La Clinica Ortopedica (13 ed.). p. 1961.
  7. Pagella P, Pierleon GP (1971). "LO Scalpello". Hallux Valgus and Its Correction. 1: 55–64.
  8. Irwin LR, Cape J (1999). "The Foot". Intermetatarsal Osteodesis: A Fresh Approach to Hallux Valgus. 2. 9: 93–98.