Hallux valgus (bunion) is the most common deformity of the forefoot. The etiology of this deformity is supposed to be hereditary however wearing high and narrow shoes is considered as accelerating factor. Females are commonly affected more than males. Hallux valgus means lateral deviation of the big toe. As the big toe drifts into valgus, a bump starts to develop on the inside of the big toe over the metatarsal bone (Fig-1) . This bony prominence is referred to as a bunion. Once a bunion is present the deformity of hallux valgus worsens slowly over time.

Fig-1
Right foot with hallux valgus deformity .Note the formation of the bump on the inner side and the lateral devaition of the big toe

Fig-2
Soft tissue release including the lateral capsule and adductor muscle of the big toe

Chevron Osteotomy (distal)

It is one of the most frequent osteotomy used to correct deformity of the hallux valgus with mild to moderate deformity. It is v-shaped bone cut performed at the distal end (subcapital) of the first metatarsal bone.

Fig-3
A chevron osteotomy fixed with one screw for a mild degree hallux valgus deformity

Fig-4
A scarf osteotomy for correction of moderate hallux deformity

Fig-5
A case of severe valgus deformity treated with fusion of the joint of the big toe

48 years old David Madeley from Australia has been suffering from chronic back pain for the past 15 years. He was never been given any diagnosis for his back problem. The back pain was a major obstacle in his day to day activities. He was suffering from acute pain causing him a lot of discomfort. Dave moved to Dubai 4 and half years back and is currently working as HR Manager at UPS. In the initial 5 years Dave was taking pain killers and anti inflammatory as a temporary relief major but after 5 years all medicines had stopped working on him. At that time the focus was only pain control and not the permanent remedy.

Once David moved to Dubai, the back problem had become worse over the period of time. He started visiting London Clinic and was being treated by a general physician; apart from regular pain Killers the doctor also advised acupuncture, homeopathy and physiotherapy. Out of which only physiotherapy worked for a short term. Looking at Dave’s case the doctor knew it was not a simple case it was high time that he needed to see an Orthopedic surgeon. That is the time when Dr. Bryan Moore suggested David to visit Dubai Bone and Joint Center. Dave was referred to Dr. Zbigniew Brodzinski, who diagnosed him with Iso Spondylitis; it was for the first time in 15 years that he was given a diagnosis. Immediate MRI and X-rays were done and surgery was suggested. The surgery was done with a new technique; in fact it was the first surgery done with this method in the Gulf region. What makes it different from the regular spine surgery is:

In David case the surgery period was divided into two parts, the 1st one was 10 hrs long and the second one was 12 hours. After the surgery he is doing exercise and is taking Physiotherapy. He will continue to be on pain medication for sometime. The fusion will start after 3 months and his recovery period is 8 to 12 weeks. If you ask him today how is he feeling, the answer is he is feeling great and can’t believe he is pain free after 15 years.

Symptomatic disc disease L3-L4, L4-L5, and L5-S1 with left-sided degenerative scoliosis and lateral olisthesis on the right side L3-L4 possible dynamic lumbar spinal stenosis L3-L4 and L4-L5.

Accordingly the very major surgery planned ( five major surgeries in one) ,all are Minimally Invasive surgeries and that is the interesting part.

The first two surgeries were DLIF (Direct Lateral Interbody Fusion) for two level (L2-L3 and L4-L5) — A Minimally Invasive Approach to Spinal Stabilization (accessing the spine through the patient's side, the Direct Lateral approach to interbody fusion offers surgeons and their patients a less invasive option for spine surgery) during the surgery the pt was under EMG ( Electromyography) monitoring in order to monitor the psoas muscle (One of the "unsung heroes" of the body, this important muscle extends along the length of the lower spine and is responsible for stability, flexion and range of motion in the lower back and hips).

For the third surgery, TLIF (Transforaminal Lumbar interbody Fusion) for the level L3-L4 and TILF one of the most advanced and highly skilled form of spine surgery for fusion of two or more vertebrae of the lumbar (lower back) spine.

The minimally invasive technique is best recommended for appropriately screened patients suffering from Degenerative spondylolisthesis, degenerative disc disease, lumbar canal stenosis, black disc, nerve compression with associated low back pain.

Comparing with the Posterior Lumbar Interbody Fusion (PLIF) involving large midline incisions for cutting of muscles, ligaments and bone in the lower back. this type of conventional surgery involves large incisions that could cause damage to important muscles, intraoperative bleeding followed by prolonged bed rest. Additionally, there is increased chance of nerve injury due to handling of nerve tissues during surgery – all of which could lead to Failed Back Surgery Syndrome.

And the fourth surgery was the correction of the scoliosis and stabilize the spine from L1 –L5 through the CD Horizon® Longitude™ Multi-level Percutaneous Fixation System : which is minimally invasive spinal surgery that require multiple levels of spinal fusion. The system’s free-hand inserter and reduction screw extenders are designed to allow a stabilizing rod to be passed through a small incision over numerous levels of vertebrae in the spine.

So intra-operative EMG used for the four mentioned surgeries to ensure the pt safety

The new scoliosis correction procedure has many benefits over traditional surgery. Traditional surgery requires a long incision and the stripping of muscle off the bone. With the newer procedure, percutaneous screws are placed through two or three tiny incisions, typically four to five centimeters in length. It spares muscle surrounding the spine, allowing for a faster recovery and less post-operative pain.

And the last part of the surgery was the most interesting part which is the Axial Lumbar Interbody Fusion (AxiaLIF) a percutaneous pre-sacral access route to the L5 - S1 vertebral bodies for spinal fusion and according to my information DBAJ is the first and only center for musculoskeletal treatment and research in the Middle East performed a minimally invasive spinal fusion surgery (MISS) using the Axial Lumbar Interbody Fusion (AxiaLIF) technique for the first time in the region.

Since AxiaLIF enables surgeons to perform lumbar fusion surgery without major dissections of the surrounding spinal soft tissue. In a short period of time, AxiaLIF has demonstrated a change in the way spinal fusion surgeries are performed while revolutionizing patient care by dramatically reducing recovery period.

The AxiaLIF System includes surgical instruments for creating a safe and reproducible pre-sacral access route to the L5 - S1 vertebral bodies.

The AxiaLIF technique features novel instrumentation to enable standard of care fusion principles, distraction and stabilization of the anterior lumbar column while mitigating the soft tissue trauma associated with traditional lumbar fusion through open surgical incisions.

The duration of surgery is less than an hour with AxiaLIF compared to the usual time that is four times longer. It also reduces the hospital stay dramatically, as patients can be released from the hospital a day after the surgery. Under normal course, this could run to three to four nights, followed by a one- to two-month recovery period.