CHAPTER 3

THE, AUSTIN BUNIONECTOMY REVISITE,D :

A Review of 59 Procedures

Clay Ballinger, DPM,Ricbard Greem, DPMNicbola.s DeSamtis, DPMDonald Green, DPl,t

INTRODUCTION

Ha1lux valgus is one of the most common disordersof the foot. Physicians treating clisorders of the footand ankle can choose from a variety of surgicalapproaches to treat this condition. According toKelikian, there have been more than 100 proceduresdocumented that describe diff-erent techniqr-ies intreating hallux valgus.' These surgical approachesrange from soft tissue procedures,2s to osteotomiesof the first metatarsal head','nle to metatarsal shaftprocedures,'0'6 to base procedures of the firstmetatarsa1,181e253; and to combinations of head andbase procedures.

One of the more widely accepted procedurestoday is the Austine bunionectomy. It is used to treatmild to moderate hallux valgus deformities,rt' andhas been reported to have good to excellentresu1ts.3"u The authors of this afiicle undefiook a

retrospective analysis of the Austin bunionectomy.The Austin was evaluated as to the technical resultsas set forth from radiographic angles. The subjectiveresults were determined from our patients and wasbasecl on their perception of pain, function,cosmesis, and overall success of the surgery. Themodified American Othopedic Foot and AnkleSociety Rating System for the hallux metatarsopha-langeal joint was employed to evaluate oursubjective results. The effectiveness of this tool as arating system fbr the Austin w'as also analyzed.Patient expectations were used to evaluate thesurgical outcomes.

MATERIALS AND METHODS

Questionnaires were mailed to a1l eighty-ninepatients who underwent an Austin bunionectomyfor painful ha1lux valgus deformity, between theyears 1997 to 2003, by three of the authors (DRG,

RMG, ND). Forty-five patients returned thequestionnaire. Three were removed because thequestionnaires were not completely filled outleaving forty-two patients. The medical records andradiographs, of the forty-two respondents werereviewed by LCB.

Of the 42 respondents, there were 37 womenand 5 men. The average age at the time of surgerywas 51 years (range, 1.5-84 years). The averagelength of follow-up was 2 years (range 6 months-6 years).77 patients had bilateral sLrrgery,15 patients had surgery on their right foot, and 10

patients had surgery on their left foot, for a total of59 Austin bunionectomy procedures performed.There were a total of 32 right foot procedures and27 left-fbot procedures.

A subjective clinical rating score was obtzrineclusing the modified American Orthopaedic Foot andAnkle Society Rating Scale (Table 1)'' from theresults of the subjective questionnaires. A total of100 points were awarded for the following arcrs;pain (0 to ,i0 points), ftrnction (0 to 40 points),alignment/cosmesis (0 to 5 points), and sr:ccess ofsurgery (0 to 15 points). A value of 90 to 100 pointswas an excellent result, 80 to 89 was a good result,70 to 79 was a fair result, ancl less than 70 was apoor result.

Thirteen patients for twenty procedures agreedto a fol1ow-up examination and an updatedradiographic evaluation. Appearance, edema,scarring, neurologic status, deformity, first metatar-sophalangeal joint range-of-motion, first rayrange-of-motion, pain, calluses, shoe gear limitationsand toe purchase were all evaluated by LCB Firstmetatarsophalangeal joint range-of-motion wasmeasured using a tractograph as described by Buel1et al.'2 First ray range-of-motion was measured byusing a segmometer as described by \ilhitney.'i3

Of the patients who responded to the

t2 CHAPTER 3

sublective questionnaire, preoperative ancl post-operative radiographs were compared. A11

radiographs of the patients were taken nhile weight-bearing. Mezrsurements of the radiogrzrphic anglesand calculalions were performed on dorsoplantar(DP) views. A11 measurements of the radiographicangles and calculations were performed by LCBusing a tractograph (mac1e by Allied OSI Labs), a

protractor and compass (made by Staecltler), and anultra fine Sharpie point marker which was used tomark out the angles. The radiographic angleslncluded: 1. Hallux Abductus Angle (HAA), 2. Tn-re

1-2 Intermetatarsal Angle, 3. Metatarsal ProtrusionDistance (MPD), and 4. Tibial Sesamoid Position(TSP). Radiographic measurements were performedas described hy others."

SURGICAL TECHNIQUE

The procedure begins with a dorsomedialcuruilinear incision macle medial to the extensorhallucis longus tendon along the contour of thedeformity extending frorn midshaft of the metatarsalto midshaft of the proximal phalanx. Anatomicaldissection in layers is deepened don n, taking care toretract the dorsomedial clrtaneous nenre which runsmeclial to the metatarsal and along the first metatar-sophalangeal joint. Attention is then directed to thefirst interspace where the conjoined tendon of theadductor hallucis is releasecl at its attachment to thebase of the proximal phalanx. The fibular sesamoiclis then freed of its sesamoicl metatarsalsuspensory ligament. A medial capsulotomy is thenperformed, and the capsule is reflected to a1lolvexposure of the flrst metatarsal head. Using pou-cr'instrr,rmentation the dorsomedial eminence is resectecl.

F'igure 1. Surgical Techniqr,re: Allstin V-Osteotom)r, V angled at 60degrees.

removing more bone dorsally than plantarly.A through and through V-osteotomy is

performed from meclial to lateral through the firstmetatarsal heurd. The apex of the V-osteotomy is

placed in the metatarsal head and the arms areangled at 60 degrees extending proximal-dorsal andproximal-plantar from the apex (Figure 1). Themetatarsal heacl is then clisplaced laterallyapproximately one-third the width of the metatarsalshaft. At this point, the capital segment is impactedonto the shaft of the metatarsal (Figure 2). Thecapital fragment is fkated to the metatarsal withabsorbable pins or kwires. The remaining rnedialbone shelf is then resected with power instrumenta-tion and the denuded edges are smoothed. Thewouncl is copiously irrigated and a standarcl layeredclosure of the soft tissues is performed. A betadinesoaked gauze postoperative dressing is then applied.Postoperative shoe is utilized to allow weightbearingas tolerated.

SUBJECTIVE RESULTS

A total of 42 patients having 59 proceduresresponcled to the aborre mentioned questionnaire.On a pain-rating scale of 0 to 10 (with 10 being theworst pain). an average preoperative pain score of 6(range, 0-10) rvas reported. Preoperatively, 39o/o ofthe patients repofied having limitations in their c1aily

actirrities. A limitation in sports activities srasreportecl by 51o/o of the patients, and 640/o of thepatients reported some type of limitations to the

rypes of shoes they were able to s,'ear. Twelvepercent of the patients repofied their joint(s) as verystlff; 440h reported their joint(s) as not very stiff; ancl

440/o repofied no stiffness at a1l preoperatively.

Figure 2. Sur-gical TecLrniciue : C:rpital fragrlcnt clisplacccl lateral1y

CHAPTER 3 r3

The reasons for the patients' decision to havesurgery were reported as foilows: bump pain36/42, a crooked toe 20/42, difficr-rlty wearing shoes

30/12, aL unsightly appearance of their foot/feet 78/42, calluses 6/42, response to their doctor'srecommendation L5/42, hammertoe of theirseconcl digit 6/42, and joint pain 22/42 (Tab1e 3).The types of conseryative therapies attemptedbefore surpaery inclr.rded 16 bunion shields, .12 widershoe(s) at the toe region, 10 toe spacers, 23

stretching their shoe(s), and 4 reportecl noconservative measures (Table 4).

All postoperative results were related to thenurnber of procedures(52). None to mild occasionalpain in the first metatarsophalangeal joint(s) u,-as

reportecl by 940/o of the patients. 6)0/o rcpotedrelieving all stiffness, ancl9B0/o resulted in no painfulcalluses on the side of the patients' hallux surgery.No swelling w-as reported Lry BB%, ancl 480/o reporteclno pain w'ith c1aily activities ; 460/o reported mild,occasional pain; and 6% reported moderate dailypain. In regards to the limitations of dai\, Iiving,92o/oof the patients reportecl no limitations post-operatively, while B% reported some limitations, andnone of the patients repofied severe limitations.A total of 81o/o of the patients are nos,r able toparticipate in spofis activities without pain. Thesespol-ting activities include walking, n:nning, step aer-obics, golfing, bowling, volleyball, weightlifting,kickboxing, swimming, karate, softball, dancing,yoga, sailing, cycling, rnountain hiking, zrnd tennis.

Patients were satisfied with their amount firstmetatarsophalangeal joint motion in 86% of theprocedures, 240/ct repofied the motion in theirjoint(s) hacl increased greatly, J2o/o reported a

somewhat increase in motion, 30% reported nochirnge in motion, end 740/o reported a decrease inmotion. Participation in sotne type of physicaltherapy w'as repofied by 29o/o of the patients, and7L0/o reported no physical therapy parlicipationat all.

Only 20/o of patients reported being able toreturn to wearing regular shoes within 2 weeks ofsulgery, 9%o were able to return to regular shoes in4 u,'eeks, L40/o rn 6 rveeks; and 75o/o returnecl toregular shoes in over 6 weeks. A total of 670/o of thepatients reported har-ing no restricrions to tl-ie typesof shoes they are now able to s'ear, 7% reportedbeing restricteci to n'ide shoes,/sneakerc, and 32o/o

reported being unable to wear many types of shoessuch as dress shoes/high heeled shoes.

Table 2

SUBJECTTVE RESUITS SCOREDON THE MODIFIED AMERICAN

ORTHOPAEDIC FOOT ANDANKLE SOCMTY RATING

SYSTEM FOR HALLI.IXMETATARS OPHAI-A.NGEAL JOINT

Result

ExcellentGoodFairPoor

Score (o/o) Number ofProcedures

90 - 100 3280-89 8

70-79 71<69 5

Table 3

REASON WIIY PATIENT CHOSE TOHAVE SI.IRGERY

ReasonBump painCrooked great toeDifficulty r,vearing shoesDid not like the appearanceof your footCallusesRecommendation of doctorHammertoe second digitJoint pain

# ofResponses3620

30

18

676

72

22

Table 4

TYPES OF CONSERVATTVETREATMENT THERAPIES TRIEDBEFORE GOING TO SURGERY

Conservative TreatmentBunion shieldsWider shoe rrl the toe regionToe spacersStretching your shoesNothing

# of Responses16

4210

234

CHAPTER 3 I5

on a series of measurements of the HAA, true IM1-2, TSq and MPD, which indicated satisfactorymeasurement reliability.

DISCUSSION

Austin, from his original study, believed that a

satisfactory bunion operation "shottld redirect thefirst metatarsal head to create a uniform contact at

the first metatarsophalangeal joint, that the halluxvalgus should be ful1y corrected, that most of thecorrection of primus vatts should be obtained,that rotation, or dorsiflexed attitude of the firstmetatarsophalangeal joint if present should becorrected, and that t1-re first metatarsal shouid not be

significantly shoftened."'This study intended to lookat these parameters set forth by Austin as well as

patient overall satisfaction to evaluate the V-osteotomy. The true 1-2 intermetatarsal angle was

found to have a mean change of 7 degrees, thehallux abductt-ts angle had a mean change of 74

degrees, the tibial sesamoid position changecl by a

mean of 3, ancl the metatarsal protrusion distance

had a mean change of 2.Jmm. The mean change ineach of these angles was statistically significant.These findings are consistent with the findings ofprevior-rsly reported studies (Table 5)."t' One woulclspeculate that the significant changes in theradiographic angles following an Austin bunionec-tomy would provide excellent results for thepatient's overall satisfaction.

Our results demonstrated the patient's painwas significantly diminished, they were able to get

back to activities of daily living as well as sportingactivities, patients were satisfied with the amount ofmotion in their first metatarsophalangeal joint, the

majority were able to get back to many types ofshoes, llreater than half were pleasecl with theappearance of their foot, and more than 70% wouldrecommend the surgical procedure to a familymember or a friend. \Vhen the results weretabulated utilizing the MAOFAS rating system forthe hallux metatarsophalangeal joint, we onlyreported 68zo good to excellent results. These

values from the rating system did not seem tocorrelate with our finclings from our patients.

Our results were then compared w-ith otherpreviously reportecl studies that evaluated the same

categories as our study but did not withe theI\L{OFAS rating system to evaluate their overallresults. Johnson et a13r repofied on 18 patients for 26

procedures and found 21 patients (-920/a) werecompletely satisfiecl with the results. Two u,'ere

satisfied with minor reselations secondary tocosmetic reasons. Hattrup et a138 repofied on 754

patients and 225 procedures. A total of 79,7o/o of thepatients (178) feet were completely satisfied withtheir results. Leventen'u repofted on a series of 90

patients for L20 procedures. His results found that

90o/o of the patients had complete pain relief. A totalof 770/o of the subjects were completely satisfiecl.

Trnka et a15t and Pochatko et alle repofied on 49

patients and 62 procedures and 30 patients ancl 42

procedures respectively. Trnka et al found 85.60/,t ofhis patients had good to excellent results, and

Pochatko et al for,rnd 910/o of his patients had goodto excellent results.

Based on the rating system MAOFAS,the results

of our study compared to others, appeared to be

significantly lower. Yet when looking at individualcomponents;95o/o were pleased with the results and

would recommend the procedure, 710/o would

Table 5

RADIOGRAPHIC CHANGES FOLLOWING THE AUSTIN BfII\IONECTOMY

StudyDr-rke (57)

Knecht and Van Pelt (67)

Pochatko et al (56)

Seiberg et al (58)

Steinbock and Hetherington (59)

Bryant and Singer (58)

This Study

HAA1710

74

27

15

7471

IM L.2B

2

5

8

7

5

7

TSPN/AN/AN/A

2

1

2

3

MPD5

N/AN/A

3

3

12

l6 CHAPTER 3

highly recommend to a family member or a friend,and 96o/o felt that more rhan 50% of their chiefcomplaint was resolr,ed. The patient satisfactionratings nere higher than what the IIAOFAS ratingsystem acturally allowed in its scoring. Looking closerat this rating system is where the discrepancybelween our stucly ancl others can be for,rnd.

The rating system does not rccount for apreoperative to postoperative evaluation of pain.For example, if the patient had severe pain pre-operatively and mild pain postoperativeiy then hewould only receive a score of 30 points. If thepatient l-racl mild pain preoperatively then severepain postoperatively, he would receive a scoreof 0. \[hy not a score ol -3OZ The incliviclual hasgone from good to worse. The rating system needsto correlate preoperative 1evels of pain to post-operative levels.

The functional aspect of the rating systelnevaluates the patient's perspective of activitylimitations, footwear reqr.rir enrents, range-of-motion,calluses and swe11ing. Of these subcategoriesfbotwear requirements seemed to be the mostsignificant factor for the female patient. Nmost everyfemale patient l-rad the expectation that followingthis procedure they would be able to ger inro highhee1s. Those that u,'ere unable to return to highheels, hacl their expectation unmet. This str_rdyclid not recorcl hou. many could not get into highheels preopelatit ely.

Patient expectations seemed to play a large rolein the success of the surgery. If the patient wasexpecting to return to a cefiain type of shoe and thisexpectation was not met then the success of thesurgery was not alwavs favorable. One other areathat seemed to be significant was cosmesis. A largenumber were pleased with the final appearance oftheir fcrot following the surgery but the ones withhypertrophic scars were displeased. This was asignificant factor in the overall success of thesu1gery. Upon or-rr clinical follow-up examinationand speaking with the patients, we found it tobe absolutely imperative to understand yoltrpatients' expectations.

\7hen analyzing the questionnaires using theMoclified Arnerican Orthopaedic Foot and AnkleSociety Rating System for Halltix Metatarso-phalangeal Joint, the overall findings were 68% withgood to excellent results. $rhen comparing theX,IAOFAS rating system findings wirh rhe patienr'sratings, the poor correlation leads the author toconclucle the Modified American Foot ancl AnkleSociety Rating System for the Hallux Metatarsao-phalangeal Joint may be too strict in its ratingsystem. For example, one patient that had somemild pain and limitation dropped 20 points on theRating System which alltomatically rated thatpatient's procedure zrs fair. However, that samepatient stated being highly satisfiec'l, or what wouldbe an excellent rating. How the scale rated theoutcome of the procedures did not always correlatewith the patients' overall perception of the or'ttcoflte.The parameters for the rating system scored thepatients' responses equally, rather than allowingfor indiviclualiry. When using this particular ratingsystem, one needs to be very certain the criteriabeing enterecl for rating precisely fits the strictiydesigned parameters of the scale and has no otherpossible interpretation.

CONCLUSION

The Austin bunionectomy f-ias been reported to havegood to ercellent results. This str-rdy showed thesame statistical significant results from a technicalstandpoint, as well as overall patient satisfaction.The Austin bunionectomy sti11 continues to be aneffective approach for treating hallux valgusdeformity. The r-rse of the MAOFAS Rating Systemmay not be the best in its current form. Aprospective system which compares the pre-operative signs and symptoms with the post-operative results appears to be more effective. Thepercentage of points may neecl to be revised morein the direction of patient satisfaction to bc more inline with the success of the olltcome.

CHAPTER 3 t7

1.

10

ti.

17

l5

19

21

24.

11

T2

13

74

15

REFERENCES

Kcl:iki:rn H. Hallr-rx valgus ancl Alliecl dcforn-rities of the Iroot andNletatarsalgia. Philaclelphia: ni/B Saunclers; i965. p. 163-201.N,IcBricle E. A consefl'.rti\.e operation firr bunions. J llone .Joi?ttSurg 7)28;70:7J5.NlcBridc E. Surgical treatment of hallr:r r,:rlgus(,rrri lOfO zizl tTll

NlcBride E. Sr,rrg;ic:r1 trcatment of halLux valgus

bunions. ,.1llz -/

. Arn -[ Ot'rbop7963;5:41-5.N4cBride E. Tl're X{cRricle bunjon he1lux valgus operation. J. }}one

.loiilt .\tn';.4//l lo('- l't l6-iSilver D. 'l'he operative treatmcnt of hallux vLtlg\rs. .l Bone JoitttSurg 19235:225.Lau,ton -J. Nlodifiecl NlcRricle bunio|tectom\,. -] Am Podi:1try Assoc7915$5:6f 0.N{:rnn R. Pf-effinger L. Halhrx valgus repair: Dr-LVries n'rodifiedMcRriclc procedttre. Cl irt Orth op 7997: 21 2:273-8.Austin D, Leventcn E A Nen' osteotoml' fol' Hallux valgus: AHorizontally Directecl "\i" Displaccrnent Osteot.xny of thel4etatal'sal Heaci fcrr I{al1ux ValgrLs end Pdmus Vt\rLrs. Clil1 Ot'tb.)P

Rel Res 1981:157 t2i-30.Kalish S, Spector J. The Kalish osteotomy: a revien' '.rnd

retrospective anal-vsis of 265 cases. J A111 Po.liah! Med Assoc

1994;84:237.Sh:rrpe D. Doublc flrst metatal-sxl osteotomies fbr a particul.'rr

type of fiallux abductlts clcformity. Arcb Pod Mecl. 1974;1:255.lleverclin.l. De 1:r cler-i:ttion en aleltors du gros orteil et clc sontr2r itenrent clrirrrrgic:rl, Tr h'l t e rn d t,l,I e.l C ongr 788 1 :2 : 108 - I?,.

Laircl P. Trvo Rer.c.tclin Lair(l osteotoln,v moclifications forcorrection of hallux abclucto \ 2lgus. .lAPlll A 1 988;78:'i03.N1itchell C. Osteotonl-v$unionectomv fbr hallur vaiglls. ./. Bore

Joint Su.tE Am 1958t:10:41.

.lohnson .J, Smith S. Irreliminary' 1'eport on derotational,:rngulational, transpositional osteotolnY: 2l ne\\' al)proach to 1u11ux

abducto valgus surgety..l Attt Potlirltl'A55(,c lo-r16+ 6()r-5.

Hohman G. Ulrcr hallux and Spreizfitss ihre entstehung uncl

physiologische behanclltu-rg. Arcb OrtboP unl:Lll-i:hir.1923:21:525-50.Peabody C. Surgical carc of hal1ux val.qrts. J Bc)ne .bint SLIB

1931;71:2i3.D:rl,v N. Nlodiflcation of thc crescentic osteotomv fbr hailuxvailalrs correction../ Artt Pctdicttlt Med Assrtc 1992:82:2.50.

Colren NI. "f he cre scentic sl'relf ostcotolrlY. J l'oot Sttrg1L)L)3322(\1.N'leyer NI. Eine neuc modifilation der trallux valgus oper:rtion ,4&/

Cbir 7L)26:53:3215.l4au C. Aluber H. Dic operativc behandllr'rng des hallur valgus(nachtrntersuchungen). Dtsch Z C:h ir' 1 926:791 : )63.Glickrnan S, Zahari D. Short "Z' br.Lnionectonv..lFocttAnkle Sntg

1986;25:30/+ 5.

Dnke H. Rotational SCARF (Z) osteotomv bllnioncctomy fo1'

correction of high intermctatal'se1 anlales. ./ Am Podi.tttl' MedAs s o c 191)2 ;82 : 3 52 -60.

Chang T. The invertecl SCAIIF bunionectolny. In LiF).;ldte 1992.

Reconsttuctiue Surgery- of the Foot and Leg. Tttcker (ClA): PodiatryInstiturer 7992. p. 265-70.Ralascescn J. Ur-r caz cle l'rallur v:rlgr.ts simetric. Rev Chir Orthop1903r7:128.Chapchal G. Zuc operati\rcn behancllung des hallux valgus.

Ztschr Ofih()p,qrenzgb 7)11:73-f 1:4f -60.

Jur.ara Ii. Nouvcar-r procedure pou 1a cr:re radicalc clu "halluxvallaus." Nctt.n Presse Med 7t)7t):10:)9i.

Juvara E. Cure raclicale dc 1'halirtx-r'al€ILLS per la resectioncllneifbfln dc lir portion n.Io,vennc dc la cliaphysc cllt metatarsien,sr-rivc de l osteosynthese des fragrnenis. Ly-ott Cbir 1926:23:429.

-ftrvara E. L'hallr-rr valgus: son traitment operatoire. Reu Chir1932:5:327.

30. Loison NI. Note sur- 1e trltjtment chirugicale c1u l'rallux valgus

d'apres i'etuclc r-acliographiquc de la defbrmation, llull Mem Soc(/1iy lt)t)t;Zf :528.

31. Trctltorvan I. Hallux L)al.a,LLS, 0t s.ystem of surget! \en' York.Hoeber: 1923.

32. Stamm 'l'. 1'he surgical trcatment rtf hallux Valgus. Gzryis 17os Rep

7977 ;706:213.33. Balascescu J. Un caz cie hallux valgtts simetric. Reu Chir Ofibrtp

1903;7:128.

31 Logt'oscino D. 11 tratLrllento chirttrgico clcll'aluce valgo Chirt )tlatt l/1,)t. lO4h:J-:hl.

35. Lapicllts P. 'fhe oper-etive correction of the trretlliJlsr-ts prilnLls

varlrs in halhrr r':r1gus. StLrg Gl.ttecci Obstet 1934:58:183

35 Coughlin X4. I{ellux valglls: an instrlrctional cor-Lrse lecture../-Bone

.[oint Sur,q Am 1996:78: 932 66.

37. Johnson IiA. Cofield RH, N{orrev BF. Chcvron ostcotomy fbthallux r':rlgus. Clirt Otbop 7c)l9:7/t2:41-7.

38 Ilattrllp SJ, -]ohnson KA. Cherron osteotomy; analysis of factors

in piLtients' dissatisf:rction. Foot .lrt.l Ankle 1985 5:327-32.

39. tlin'ensalo E. Rostmar O. Torntala P, Veinionp:ra S. Rokkanen P.

Chevron osteomly fkecl u,ith :tbsorllablc ol1'glycolide pins. FbolAnlale 79t)7;11:272 8.

10. Leventon EO. Tl'rc chevron proccclllre Othopedics 1oqu l-3 t)-.3-6.

4L. Kitaoka Hll. Clinical Ratirrg Systcms for thc Ankle-Hinclfbcx,N{iclfoot, F1:rlhrx, ancl Lesser Tocs. Fttttt Attkle Int 7991+;75,31')-i3.

42. Buell T. (lreen DR. Risser J. Nleasurcnlent of the FirstN4etatarsophal:rngeal Joint Range of \\otton .l Att Pa.li.ltry lled,'l-ssoc 1 988r78 :'139-l+8.

43. 1fi'tritney AK. \Xiiritney 14e.tsLf il1g DeL'ices "A Measure clf'

AccLu'ac.y"./t4. Green D. R:rdiology ancl tsiomechanical Foot 'I'ypes. l-"pd'.Lte

1998, The Proceedirtgs of'the Anruurl lleetin.g rtl the Podiatry-

Itlstitute. 'l'he Pocliatry Institlltc, Atlanta; 1998. p 292373.15. Gerbert J.'l'extbook of Bunior-r Surgery: Thircl Edition.

Philadelphi:r: WI) Saundcrs; 2001.

16. X{itchell CL. Flen'ring JL. A1len It, Glenne.v C, Senford GA.

Osteotomv l)unionectomv fbr hal1ux valgus / l3one .loirtL Surg

1958:'10:'11-60.47. Schneidcr W, Knahr K. Metatat'sophalngeal ancl Internetatrsal

Angle : Differcnt \':11Lles and interplctatron of postopcrative resllltsdepencicnt on the technique of nleasurcmerrl Foot dnd Al1kle Int1998;19:532-6.

48. Yu GV, DiN:rpoli R. Surgical managcment of hrllux abclucto

valgr:s with cOncomit:rnt rlfiatarsLls aclcluctus. f?econstt'LlcLiue

.9tLrge4t of tbe Fctot nnd Le.a, (.tpddte '89. Tucker (ClA)r lrodiatn'In.rirrrrc Prrl,lir' ing: lob'). D. 262-S.

49. Pochatko D.l, Schlehr FJ, Nlurphy X4D. IIarnilton.fJ. Distal chevronostcotonJ, \'lth latcral rclease tb1' trc'.1tment rlf trallur Valgus

d elbrmiq,-. ? @t .t tt.l A n k I e I n ten Lat ion al 799 I ;7 5 : 457 -61 .

50. Dr-rkc LIF. Rr-Lriecl Kirschner t'ire flxation of the Austinosteotomv-bunioncctomY: e prelilninal]v report ./ Fctot Sntg

7986:25:797.51. Seiberg N'1, Felson S, Colson JP, Barth A. Gt'een R, Green l)'

Closing b:rse u'cdge Ycrsus Austin br'lnionectomies tbr flletatarsus

prinrus aclductus. J Am Podidtn' Med Assoc 1994:8'1:i'18.

52 Steinbock G, Hetilerington \'J. Austin bunionectuln) transfositionxl ostcotomv of the first metatarsal fbr halh-rx valgus srLrgen-'

J Fctctt Surgety 198E;27:211.

53. Brt'ant A, Singer KP. llcvies- of Radiographic l'{e?rsrlrcments

Follorv:ing Austin tsunionectom\r' .[ An1 Podidhf' MecJ Assoc

1998;88:290-'i54 Trnka H-[. Hot'm:rnn S, Salzer Nl, Ritsch] P. Clinical ancl radiokrg-

ical results tLfter Austin bunionectomlr fbr tre:ltment of halh'rrr.:rlgus. ,4rcl: Otthc)p tr.tLtma Szrry 1996;115:171-i

55. Knccht JG. Van Pelt \,/L. Austin bunionecton.I,v witl] Kirschnerrvire fixrLtion../ Am Pocliatrv- A-ssoc 1981:71:139.

1B

20

22.

23

2i

26.

27

2ft.

'29