Focus on the First Ray: Highlights from the ACFAS ASC

Key Takeaways

1. The First Ray Drives Bunion Strategy

Successful HAV correction starts with understanding the biomechanics of the medial column. First ray stability, flatfoot, metatarsus adductus, and other associated deformities all influence both conservative and surgical decision-making.

2. Not All Bunions Are the Same

Treatment should be individualized—not formulaic. Age, activity level, instability, and overall foot structure matter. Identical radiographs in a 15-year-old and a 75-year-old do not equal identical surgical plans.

3. Surgeons Need More Than One Tool

Modern bunion surgery includes head procedures, Lapidus, MIS techniques, and more. No single approach fits every patient. A well-rounded surgeon evaluates anatomy carefully and selects the right procedure—not just the most popular one.

Transcript

I think the first ray is extremely important. We look at the foot from a biomechanical standpoint and that medial column, which is mostly that first ray, I think it's extremely important. And I think when we've gone into treating this and changing our treatment modalities for bunion deformities and first rate deformities, I think that that first ray is extremely important. Again, the entire biomechanical medial column portion of it's an important part of how we treat this conservatively, surgically, just the entire biomechanics of everything globally. Look at the foot. What kind of deformities am I dealing with? This is just a normal rectus foot with a bunion, or are there other associated issues like flatfoot, deformities, metatarsus adductus?

Those are the different things that we look at that changes how we may treat this bunion deformity. So I think we definitely look at that. And then along the lines of the flatfoot deformity, and again, getting back to biomechanics again, is there instability there? And is it pretty significant? I think we've looked at the first ray and as the Lapidus procedure was getting more popular years and years ago, we said "hypermobility," and we didn't know what that meant. And maybe we still don't. But I think we're getting a better idea about what is hypermobile, what needs to be addressed. And I think that that changes the whole path, the pathophysiology of this whole medial column. But that's what I look at, adjunctive issues, flatfoot met adductus deformities, all those things. And then just globally looking at the foot when they come in, see and sit down. Don't just look at the foot itself. I think that there's a trend and there's a change. I think before when I was training, you looked at things and we measured IM angles and hallux valgus angles, and we said, okay, that's a head procedure.

Or if it's a little bit heavier, a little more intense, we go, okay, that's a base procedure. Well, I don't know that we do base procedures much anymore. I'm sure there are people still doing it, but we don't talk about it a whole lot. We don't see it in the lectures. So now it's either, okay, it's a head procedure or it's a Lapidus procedure. Now we're changing a little bit more. And I think this is a good thing. The MIS stuff, I still think you can't just be a one trick pony. I think you have to have multiple things in your toolbox. You go back and if the only tool you have is a hammer, then everything's a nail. And when bunions come in, they're not all nails. Some of them are other things, and I don't think you can treat everybody in the same way.

I think you have to individualize the patient. There's different ages. A 15-year-old and a 75-year-old. They might have the same identical X-ray looking on the picture, but you're going to treat those differently. And then again, I think MIS is a great thing. I think it's coming on and we're going to have a lot of that stuff at our meeting in the next couple of weeks, but I think they got to have these other options available as well. So just have multiple tools in your toolbox. This session at ACFAS this year regarding hallux valgus and the first ray, what we've looked at is one, we're going to look at a little bit of the anatomy. We're going to go backwards and look at anatomy. Again, I think we've forgot about that, but I think some of the newer techniques, the MIS stuff, we need to understand the anatomy a little bit better even.

I think the second thing we're going to look at is we're going to look at a different, the not so typical bunion. So we're going to look at the bunion with flatfoot. We're going to look at the bunion with metatarsus adductus. So we're going to show a couple different approaches to that. Hopefully get into good debate about which one is better, or maybe they're both really good. It just depends on the patient. So I think it's just a better global look of that first ray and a better look at hallux valgus surgery and what kind of options we have available. Again, not everything's the same thing. I don't think you can go in with every bunion and plan onto the same surgical procedure. I think you got to have options available for the patient, depending on if they're young, old, if they're athletic, not athletic, all these different things. And I think that this panel that we have for this first ray pathology is going to be really good. They're varied, there's seasoned, there's not so seasoned, and there's MIS approaches and more traditional open approaches. So I think you're going to get a wide variety of opinions and strong personalities in this panel, and I think it's going to be great.