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Avascular necrosis of the hallux metatarsal head is a possible complication after bunion surgery and can be further complicated by extensive bone loss. This would require a bone block arthrodesis to reconstruct the 1st ray length and avoid transfer metatarsalgia. Complications following hallux valgus surgery can lead to persistent pain and deformity of the operative extremity. Common complications include recurrence of hallux valgus, avascular necrosis, dorsal malunion with transfer metatarsalgia, hallux varus, and cock-up toe deformity. Avascular necrosis is a rare, but potentially severe complication, especially if there is extensive bone loss and collapse. Surgical treatment consists of bone block arthrodesis to reconstruct the ray length and stability. Shariff et al. performed a prospective study of avascular necrosis following chevron osteotomy for the treatment of hallux valgus in 39 patients. They reported 7.7% of patients developed abnormal bone scintigraphy findings at an average of 8.5 weeks post-op, but these cases did not develop signs of osteonecrosis. They concluded chevron osteotomies may lead to circulatory disturbances but do not pose a risk for avascular necrosis. Grimes and Coughlin performed a retrospective study of 29 patients treated with 1st MTP arthrodesis after failed hallux valgus surgery. They reported a 4 point improvement in average pain scores, 72% good-excellent patient satisfaction rate, and mean hallux valgus angle of 16 degrees. They concluded 1st MTP arthrodesis is a reliable treatment option for the treatment of failed hallux valgus surgery. Machacek et al. performed a prospective study of 46 patients with failed Keller resection arthroplasty treated with 1st MTP arthrodesis or repeat Keller procedure. They reported a higher patient satisfaction rate with arthrodesis but repeat arthrodesis was necessary for five patients due to malposition and pseudoarthrosis. They concluded arthrodesis is the preferred salvage procedure following failed Keller resection arthroplasty despite being a more technically challenging procedure. Figure A is an AP radiograph of bilateral feet with left hallux varus after a left proximal metatarsal osteotomy and soft tissue release. Figure B is an AP radiograph of the left foot with apparent nonunion of the proximal osteotomy site. Figure C is an oblique radiograph of the left foot with osteonecrosis of the hallux metatarsal head with significant collapse following a percutaneous distal metatarsal osteotomy. Figure D is a lateral radiograph of the right foot with a dorsiflexion malunion of the hallux metatarsal following a distal osteotomy. Figure E is a lateral radiograph of the right foot with a plantarflexion malunion of the hallux metatarsal following an osteotomy. Incorrect answers Answer 1: Hallux varus can be successfully treated with an MTP fusion using a standard technique without a structural bone graft. Answer 2: A nonunion after hallux valgus surgery can be treated with bone grafting and conversion to more rigid fixation, such as locked plating. Answer 4: Dorsiflexion malunion can be treated with osteotomy and correction. Answer 5: Plantarflexion malunion can be treated with revision osteotomy with or without MTP fusion.
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