Why are we putting trimals in Arizona braces?
Because our group owns a DME shop with orthoti$t$... obviously.
I think a lot of the syndesmotic or trimall and trimall equivs get pretty bad issues. About 400% of pilons have issues. I tend to give them all an OTC brace at minimum - often upgrade to an Ariz shortly after PT if they continue to struggle awhile. It's not like they are all going to use the brace every single day indefinitely, but most cannot go straight out of the CAM boot and back to hiking hills and box jump cross-fit
But the procedure in question was performed on a completely asymptomatic and otherwise non-pathologic bone
...
I mean I’m not doing those things but there are certainly procedures with common associated procedures. The question is are those secondary procedures being done prophylactically? Or are they done at the same time as the primary procedure because they are addressing pathology (equinus for example) that is already present?
Yeah, I suppose it comes down to pre-op documentation and pt discussion. I kinda look at bunions as first MPJ pain, medial bump pain or shoe fit or crossover/abutting 1-2 toes, and central met pains. Hypermobility and OA of first MC are key but pt will barely ever complain of those. A lot have 2 or even 3 of those: bump/shoe pain, 1st MPJ joint issues, or 2nd ray issues. I document when they have 2nd MPJ capsule and met head pain or hammertoes; I'm pretty sure my bunion template has it by default unless I uncheck it. But yeah, I totally agree it'd be borderline to do a Weil with no documented pain there at 2nd, no hammertoe, no nothing besides that the Lapidus
might shorten the first ray.
For revision bunions, I think 2nd MPJ or general central forefoot pain might be the most common complaint. They usually had under-corrective osteotomy or just the bump shaved but sesamoid position or parabola is still out of whack and the first ray isn't doing propulsion well. If they had a 1st MPJ implant for a bunion, 2nd MPJ pain and callus is 99% the top problem.
If some patient ever said "fix the bunion but I don't want you to touch the 2nd met," then I'd probably say 'fine but be aware you might want a met pad or insole with a met pad in the long term' if they had a normal parabola. If they had a short first or long 2nd on XR or 2nd starting to hammer... or if it's revision, I'd tell them I don't believe they'd be happy without 2nd ray work and to go find another surgeon. The only exception I find is *some* first MPJ fusions... those can do well without Weils or a good parabola... probably because they get the first ray grabbing fairly well no matter what?
...A long second met is pathology.
There was actually a crazy study about that. It was a Euro study where they corrected met parabolas (surgically... across the board... to match some wacky hypothetical "ideal" met length goal) in mildly symptomatic or even asymptomatic (!!!) feet. It turned out it didn't significantly improve them. It also turned out they didn't hit the goal parabola in a lot of them. I couldn't find it just now, but it was one of the crazier modern papers you'd ever see; it was discussed in an ACFAS ASC lecture a couple years ago that's probably still on Acfas OnDemand.
As for a bunion painful enough for surgery, I think a long 2nd is pathology also. Long 2nd will cause PDS, pain, digit drift, problems... that's well researched. Lapidus causes shortening... no way around it besides plantar translating the met. Cartilage has thickness, subchondral plate has thickness... even if you don't use a saw (I sure do), you will still inevitably shorten. End of the day, it's all in the documentation of 2nd MPJ pain and just how you spin to the patient as to what will function best for them and tend to have a long term good outcome with minimal chance for re-op. Jmo
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