When can non-union of the second and third toes after bunionectomy (surgical removal of a bunion) be caused by breaches of the standards of care?

Non-Union of Second and Third Toes After Bunionectomy: Breaches of Standards of Care

Non-union of the second and third toes after bunionectomy is most commonly caused by breaches in standards of care related to improper surgical technique, inadequate fixation methods, and poor postoperative management.

Risk Factors for Non-Union After Bunionectomy

Surgical Technique Failures

• Improper fixation methods: Using a screw for third point of fixation has been shown to increase risk of complications (odds ratio = 3.01) 1
• Inadequate debridement: Failure to properly remove necrotic or infected bone tissue 2
• Excessive soft tissue release: Improper technique during first web space release can lead to instability 3
• Poor bone quality assessment: Failure to account for pre-existing bone conditions

Patient-Related Risk Factors That Require Special Attention

• Previous bunionectomy: Significantly increases odds of non-union (odds ratio = 3.957) 4
• Elevated BMI: Each unit increase in BMI raises non-union risk (odds ratio = 1.091) 4
• Increased preoperative hallux valgus angle: Higher angles correlate with greater non-union risk (odds ratio = 1.108) 4
• Female sex: Associated with higher rates of complications (odds ratio = 2.33 for hardware removal) 1

Standards of Care That Must Be Followed

Preoperative Assessment Standards

• Complete vascular assessment including pulse examination of dorsalis pedis and posterior tibial arteries 2
• Thorough neurological assessment using 10-g monofilament test with at least one other assessment tool (pinprick, temperature perception, or vibration testing) 2
• Comprehensive foot deformity evaluation to identify risk factors for poor healing 2
• Documentation of specific deformity characteristics and functional impact 5

Intraoperative Standards

• Proper surgical technique with appropriate fixation methods based on patient's specific anatomy 4
• Adequate debridement of necrotic tissue while preserving viable bone 2
• Appropriate antibiotic prophylaxis to prevent surgical site infection 2
• Careful soft tissue handling to prevent excessive trauma 3

Postoperative Management Standards

• Appropriate offloading of the surgical site 2
• Regular wound assessment and management 2
• Proper patient education regarding foot care and activity restrictions 2
• Timely recognition and intervention for complications 2

Common Breaches in Standards of Care Leading to Non-Union

1. Failure to identify and address infection: Surgical site infections are independently associated with increased risk of non-union, need for further surgery, and implant failure 2

2. Inadequate fixation: Poor choice of fixation method or improper placement of hardware can lead to instability and subsequent non-union 1, 4

3. Improper offloading: Failure to provide appropriate postoperative offloading increases mechanical stress on the surgical site 2

4. Insufficient debridement: Inadequate removal of necrotic or infected bone compromises healing potential 2

5. Poor patient selection: Failure to account for risk factors such as previous bunionectomy, elevated BMI, or severe preoperative deformity 4

Prevention and Management of Non-Union

• Early identification of patients at high risk for non-union based on preoperative risk factors 4
• Selection of appropriate surgical technique and fixation method based on patient-specific factors 1
• Meticulous surgical technique with proper soft tissue handling 3
• Regular postoperative monitoring with early intervention for complications 2
• Consider adjunctive treatments for difficult-to-heal wounds, such as negative pressure wound therapy for post-surgical wounds 2

Conclusion

Non-union of second and third toes after bunionectomy represents a serious complication that significantly impacts patient morbidity and quality of life. Breaches in standards of care at any stage—from preoperative assessment to postoperative management—can contribute to this adverse outcome. Surgeons must adhere to established guidelines for surgical technique, fixation methods, infection prevention, and postoperative care to minimize the risk of non-union.