The exam of the patient considering reoperation for recurrent hallux valgus mirrors the exam of an initial surgery patient with the addition of heightened thoroughness and inspection as to whether anything has changed or developed since the initial surgery. Within the PMH for example, has the patient become a diabetic or developed rheumatoid arthritis since the initial surgery? Of primary and utmost importance is the elicitation by the clinician of what exactly is the patient’s chief complaint. This should be obtained now, at the beginning of the overall exam, and then repeated at the end for comparison and confirmation by the clinician that they are focused squarely on resolving the issue at hand and physical limitation from the patient’s perspective and not myopically treating the X-rays solely or their own subjective and conditioned tendencies with hallux valgus surgery. The margin of error for a successful and pleasing result for the patient is much slimmer than an initial surgery. Is the chief complaint recurrence of the prominence of the first metatarsal head? Pressure and pain on the medial aspect of the second toe due to persistent hallux abductus? Is there metatarsal-sesamoid pain? Is hallux limitus or rigidus the primary complaint?

A full standing exam follows with careful evaluation for any torsional or suprastructural postural forces that may be impacting the foot. Does the patient have a valgus knee that may increase pronatory forces on the foot segment or have they had a proximal joint replacement from the ankle up that may affect favorably or negatively their mobility and functional demand? The standing foot-specific exam must identify the presence or absence of hindfoot and midfoot forces and dynamics that may have been undertreated or unrecognized with the initial surgery. Does the patient have a hindfoot valgus or adult-acquired flatfoot? Is there bowstringing of the extensor halluces tendon? Is there significant flexor substitution which may contribute to deforming pronatory and flexor forces? Is there metatarsus adductus present that contributes to lateralizing compensatory musculotendinous forces? The seated exam may begin distally at the foot segment and specifically the hallux. Is the hallux abnormally long relative to the second toe? This has been implicated as a causative factor in recurrent hallux valgus due to shoe pressure medially and may increase the vector forces of EHL and FHL on the first mtp joint in a lateral direction. Progressing proximally is evaluation of the first mtp joint and not only the quantity of range of motion but also the quality. Frequently the quantity is emphasized over the quality when in reality a lower yet painless total range of motion may be more tolerable by a patient versus larger yet painful excursions of the joint. Is there metatarsal-sesamoid pain along the medial plantar joint line signifying osteoarthritic changes as a part of the chief complaint? An overall assessment of the mobility of the first ray and reducibility of the deformity is critical here and determines the role of the first tarsometatarsal joint in later procedural correction. Was underlying hypermobility missed during the initial surgery? The reducibility or lack thereof of the deformity assists in determining if the residual effect of soft tissue deforming forces is primary or is it more the latent structural deformity of persistent metatarsus primus varus.

The X-rays must be studied thoroughly and correlated with the physical exam with an eye now toward procedural selection. It is an error to study the X-rays too early in the exam prior to a complete overview of the patient and the determination exactly of what is their chief complaint. A global view of the state of the first mtp joint is critical. Is the joint congruous, deviated, or subluxed? As the base of the phalanx deviates, do the sesamoids deviate as well? Are they grossly subluxed signifying resultant or recurrent soft tissue forces that must be neutralized? Again, is the proximal phalanx relatively longer than normal, and was there a previous phalangeal osteotomy performed that may have left an osseous deformity within the phalanx? Are there clear degenerative or erosive changes? Has the metatarsal head been excessively staked which may factor into the practicality of revisional osseous procedures. A rudimentary assessment of any articular set deviation of the metatarsal head cartilage is important with recognition that this must later be substantiated via intraoperative inspection. Next the metatarsal segment is studied. In the case of a previously performed metatarsal osteotomy, is there an identifiable apex of the recurrent deformity? Is there retained hardware that will need to be retrieved thereby affecting the consideration of revisional first metatarsal osteotomies? It is always wise to obtain either an MRI or a CT scan of the first mtp joint as part of the revisional surgery planning to ascertain the state of the cartilage of the metatarsal phalangeal joint as well as the metatarsal-sesamoid joint.

Procedural planning and procedural selection are best approached via an inventory checklist method that culls any findings from the physical and radiographic exam into a workable and viable suggested surgical approach that will effectively resolve the patient’s chief complaint. The inventory list of pertinent clinical and radiographic findings is now collated and assessed directly against a revisitation of the patient’s explicit chief complaint. Only now may procedural selection begin. The goal of revisional surgery in a general sense is similar to initial hallux valgus surgery, that is, a well-aligned first ray with reduction of metatarsus primus varus, a congruous first mtp joint, the metatarsal head displaced back directly over the sesamoids, and an aesthetically pleasing and functional alignment of the great toe in relation to the lesser toes. The surgeon must also play a social worker role during procedural selection to the extent that although some patients may be eager and desirous of complying completely with postoperative requirements, they may be situationally noncompliant in the sense that their living and daily arrangements and responsibilities simply do not allow them to comply with certain postoperative instructions.

The overriding goal of the procedural selection phase of the revisional surgical treatment is to err on the side of being aggressive and definitive. A one-stage lasting correction and an end to the frequently frustrating saga are the goal for the surgeon and the patient alike. A simple starting point is the determination of whether the first mtp joint can be saved or not. In the spirit of definitive treatment, if it cannot, a fusion may be considered immediately, and it is clearly understood that the first mtp fusion reliably corrects the intermetatarsal angle as well. If the first mtp joint can be saved, a definitive structural correction of the first ray deviation, intermetatarsal angle recurrence, and unrecognized hypermobility via the Lapidus fusion may be considered. An intermediary option between a fusion at the mtp joint or TMT joint is the performance of a first metatarsal osteotomy and especially if none was performed previously or a proximally based one if a distal one was performed previously. Lastly, deformities of the midfoot or hindfoot and even recessions of the gastrocnemius should be corrected when deemed influential in the cause of the recurrence. Although it may be attractive to go straight to the Lapidus as the treatment of choice for all recurrent cases, the author cautions that the principle of N = 1 dictates that factors such as surgeon skill, surgeon experience, technical execution, and patient desires and expectations allow for other creative and effective ways to resolve the recurrent hallux valgus dilemma for patients. The remainder of the chapter will illustrate all these options via case presentations and in several specific categories .

The first category is the non-salvageable first mtp joint addressed via first mtp joint fusion (Figs. 12.9, 12.10, and 12.11). The second is the salvageable first mtp joint addressed via a Lapidus fusion (Figs. 12.12, 12.13, and 12.14). The third is the use of basal osteotomies, either opening or closing wedge types for effective recurrent intermetatarsal angle correction, and occasionally a distal osteotomy (Figs. 12.15, 12.16, 12.17, 12.18, 12.19, 12.20, 12.21, and 12.22). Fourth is the manipulations of the scarf or Z-type diaphyseal osteotomy that allow more case-specific corrections of recurrent hallux valgus to be entertained (Figs. 12.23, 12.24, 12.25, 12.26, and 12.27). The fifth category is illustration of examples of cases where a pivotal portion of the revisional correction was the correction of a concomitant midfoot or hindfoot deformity or unrecognized structural issue (Figs. 12.28 and 12.29). Lastly, the sixth and final category embraces the concept of N = 1 and demonstrates cases in which careful analysis of all elements and variables in the outcome formula described at the outset of this chapter has allowed for very patient-specific procedural selection and combinations of traditional and less traditional approaches to still solve their chief complaint (Figs. 12.30, 12.31, 12.32, 12.33, 12.34, and 12.35).