From a brief review, I'd recommend semi-elliptical incision for the scar (1st MPJ)... Revision chevron, with screw fixation and possibly some bone matrix of chips at the site to promote healing.   The screw will keep the osteotomy from moving, but this looks as if the original osteotomy was a Youngswick.  A Youngswick with a wire is quite unstable and fails often.   Use a screw.  I usually use 3.0mm.  Then suture, little or no vicryl; and non absorbable, low reactive (nylon or prolene) mattress skin closure.   This will minimize the reactivity at the incision.

—RMS

A strong first step would include a bone scan to assess if there is vascular communication between the osteotomy, and a bone stimulator with strict non weight bearing until results are known. Bone scans can differentiate between a hypertrophic/elephant type (positive bone scan) and an atrophic/non-reactive type (neg.  bone scan) since it is relatively avascular. They cannot differentiate delayed vs. non unions.

Generally speaking, electrical bone growth stimulation is ineffective in the treatment of pseudoarthrosis, or if the gap between fracture fragments is greater than one half the diameter of the bone.

Educate the patient that she may require a revisional surgery, to include a debridement of non union bone fragments, with potential bone graft interpositioning. Assure her that she is not alone and that this complication may arise although infrequently in typical elective bunion surgery. Other surgical options could include external fixation bone transport with length determined after fibrous nonunion bony excision is performed, as well as eventual first MPJ fusion down the road depending on the extent of her articular joint involvement.

Ways to prevent this complication include using screw fixation for this procedure, as well as waiting 6 weeks to allow full weight bearing.

—Brian Timm, DPM

It looks like a hypertrophied delayed union.  Pt with h/o DM and smoking. No Hgba1c values are available, sensory neuropathy?  Looks like either an ant. tib. or ehl tendon repair.  How did that happen? Neuropathy ?? charcot foot considerations should be allotted.

Initially consider full nwb and bone stimulator. Patient not c/o metatarsalgia.

Since osteotomy position is acceptable, I would avoid orif.  Consideration for orif should be considered if conservative therapy fails.

—Simon Young DPM, NYC

Place her in a short leg fiberglass cast for 6 weeks non weight bearing. Then re-evaluate.

—Lawrence Jacowitz, DPM

1.  Obtain the patient's weight.   Plan surgery and recovery accordingly.  Consider weight management.

2.  Smoking cessation education.  Consider nicotine patch, Chantix, etc.

3.  Nutrition assessment and therapy.  Encourage glucose control.

4.  Full exam including ankle ROM, 1st ray ROM, pain, crepitus.  Address the tight posterior muculature if it exists.  Also, DJD is likely at the 1st M-C and N-C joints, consider 1st M-C fusion and/or debridement of osteophytes in the surgical plan.

5.  Include excision of hypertrophic scars x2 in surgery.  F/U with early pulsed dye laser at 95nm to prevent reoccurence during recovery period.

6.  Minimal dissection.  Debridement of non-union.  Assess 1st MPJ for DJD and treat as needed.  Include adjunct autologous platelet concentrate or tibial/calcaneal marrow aspirate mixed with bone graft substitute of your choice with fusion of site.  Internal and/or external fixation with screws, plates, mini-rail, etc.  Incorporate tricortical bone graft as needed if significant shortening is evident, although some shortening will help with her decreased 1st MPJ ROM.  Plantarflex the capital fragment as needed.

Example: TAL/gastroc recession(?).  Debridement.  Platelet concentrate or marrow with bone graft.  Headless compression lag screw (as a secondary form of fixation in the event of failed external fixation).  Mono-rail external fixator medially across fusion site(s) with articulating arm fixated to the hallux, for joint distraction and early ROM.

7.  Bone stimulator!

8.  Posterior splint.  Begin weight-bearing according to patient's weight, surgeon's preference, etc.  SubQ Lovenox.  Early ROM of 1st MPJ.  Physical therapy as needed.  Monitor/treat hypertrophic scars.

—Daniel J. Pero, DPM

Tell the patient. "Sorry but this has to be done again." I would redo and freshen the bone for the osteotomy. Then I would fixate with screws and a locking plate. Further, I would keep her non-wt. bearing with a steerable Roll-a-bout walker. If she does not stay off of the foot, she will have pain for the rest of her life.

—John & Leslie Cowden

I would place the patient on a bone stim., All WB with Cam Walker, And PT for 3 months, before I would consider add'l sx.

—Anon

Fig. 2: There is significant mobility noted in the capital fragment.

Fig. 3: K-wires mark the margins of the laterally based cortical window in the calcaneus which will be removed to allow access to cancellous autograft and bone marrow.

Fig. 4: The lateral body of the calcaneous following removal of the cortical window.

Fig. 5: Bone marrow and autogenous cancellous bone graft.

Fig. 6: The bone marrow and autogenous cancellous bone is mixed to create an injectable medium.

Fig. 7: Temporary stabilization of the capital fragment allows for placement of uni-cp locking plate. Autogenous autograft has been added to the nonunion site following curettage and removal of any interposing soft tissue.