Reflecting on Forefoot Failures: Highlights from the ACFAS ASC

Key Takeaways

1. The Wrong Patient Can Equal the Wrong Outcome

Forefoot failures don’t always stem from poor technique—they may begin with patient selection. Limited preoperative time and insufficient understanding of patient goals can contribute to dissatisfaction, even when the procedure itself is appropriate.

2. Respect the Parabola to Prevent Recurrence

In revision bunion cases, recurrent deformity and transfer lesions often trace back to a disrupted metatarsal parabola. Attention to first ray length and appropriate adjunctive procedures (e.g., lesser metatarsal osteotomies) can help prevent failure.

3. In Revision Cases, Go Back to the Basics

Forefoot reconstruction can feel complex and anxiety-provoking, especially in failed cases. A return to fundamental principles of deformity correction often provides a clear and effective path forward.

Transcript

Jennifer Spector, DPM:
Hello and welcome back to Podiatry Today Podcasts. I'm Dr. Jennifer Spector, the Associate Editorial Director for Podiatry Today, and we bring you the latest in each of these episodes in foot and ankle medicine and surgery from leaders in the field. We're so excited to have back with us again today, Dr. Rachel Albright, a podiatrist, foot and ankle surgeon and researcher with Stanford Health to share with us more about another one of her sessions from the American College of Foot and Ankle Surgeons Annual Scientific Conference. Last time we spoke with her about patient expectations in hallux valgus surgery. And this time we're going to dive a little bit into some highlights on forefoot failures and what that means. So welcome back Dr. Albright. We're excited to speak with you some more today.

So when you're talking about forefoot failures, which I know is something we never like to think about, but are there particular decision points, whether it be preoperative procedure selection or post-op, where things most often go off track in your observation?

Rachel Albright, DPM:
So again, I think the preoperative visit is really important. One thing that is a challenge for me, and I'm sure others would agree, is sometimes you don't have a lot of time preoperatively with the patient. Many times patients are coming in for a consultation and they know that they want surgery for this, and that really does cut out a lot of the minutia that you have to talk to them about, but you don't get a lot of time to get to know them. And I have unfortunately had a couple experiences where I have done surgery on a patient and then I really regretted it, not because I felt that the procedure was the wrong procedure or anything like that, it's just that they weren't the right patient. But I didn't know that because I just didn't have a ton of time with them. And I think that that's challenging when you're doing reconstructive surgery. Reconstructive surgery is not totally benign, but oftentimes we're doing it when we don't have these long relationships with people. And I don't think it's wrong to do it without a long relationship. But I think that that's a challenge and I think that that's a risk we all take, I suppose though.

Jennifer Spector, DPM:
That's so true. And are you seeing any recurring patterns in your observation that suggest that we might want to rethink how we're approaching specific procedures or pathologies, sort of at what phase could we maybe be doing a different or a better job than what we're doing?

Rachel Albright, DPM:
Yeah, I think I agree with you. I think managing expectations is really key. I think you need to figure out what their goals are. If their goal is to run a marathon versus walk in a gym shoe, it's probably going to change your procedure selection a little bit. I think having a good understanding of their ambulatory status and functional status pre-op is really important, which I think, and most of the time everybody does, but I also think that sometimes the probably gets a little bit lost in translation. I've seen a couple times. So the biggest thing you see failure wise is bunion surgery. People come in, they had a bunion surgery done by another provider, now they have recurrence or they have transfer lesions or something like this, and they want something done to fix that. And the number one thing I see is that the parabola is a little dysfunctional. Yeah. So I think paying attention to that parabola, I mean shortening of the first ray, it happens to us all, but I think you need to do some shortening osteotomies, some whiles maybe to the second, maybe even the third if you need to. I think the parabola kind of gets lost in the shuffle, and that is a pattern I'm seeing more when I see bunions recur and patients that are not totally satisfied as the parabola was just not totally respected.

Jennifer Spector, DPM:
And so for surgeons attending the ASC, are there any mindset shifts that you hope that they take away from your lecture when it comes to dealing with and approaching those failed cases?

Rachel Albright, DPM:
I'm not sure there's a ton of mindset shift because I think that we, as foot and ankle surgeons do a really great job. I don't think our mindsets are necessarily off, but I guess one thing I hope people kind of take away is going back to the basics a little bit. Sometimes forfeit reconstruction, especially when you had a failure and you're doing a revision, can feel a little, it can cause some anxiety for the surgeon, but it doesn't have to. I think it's important to go back to the basics, and it really almost doesn't matter how dysfunctional it is because you can go back to the basics almost every time and be able to fix the deformity. Going back to the basics, and I'm going to go through that in the lecture, so I won't go through it now, but certainly that's something I'm going to go through in the lecture. And I'm hoping it'll ease some anxiety around some forefoot surgery.

Jennifer Spector, DPM:
Well, I am definitely sure that it will. Thank you so much for joining us for this episode and our previous episode and sharing some of the highlights from some of your ACFAS sessions. And thank you so much to the audience for joining us today too. Remember, you can find this episode and other episodes of Podiatry Today podcast on podiatry today.com, or you can go to SoundCloud, Spotify, apple Podcasts, or any of your favorite podcast platforms. We hope you will join us next time.