Are you on the MIBS train?

[DogSnoot]

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Minimally invasive bunion surgery, especially the newer 4th-generation techniques, is still relatively early in terms of long-term data, particularly beyond the 2-year mark. There are definitely some surgeons in the community who are strong advocates. It’ll be interesting to see how the longer-term studies play out.

Have you made the switch to MIBS yet? What’s your experience been like?

 

[Feli]

No, these are industry-created "solutions"... they "answer" a problem that does not exist (fuse MPJ, fuse MCJ, open met osteotomy with much smaller hardware all works fine). Less than 10% (probably less than 5%) of bunion repairs I'd do were met osteotomies before MIS came to market... so why do more met osteotomies now? It doesn't compute in my book. Lapidus is a much harder procedure to get right, but it is a lot more solid long term (or MPJ fusion in older ppl).

These MIS make so little sense that I only did one course... see no need for it (much like Tweece for Lapidus that already had 20 ways to fixate it).
I don't really understand MIS osteotomies as open met osteotomies are proven pretty poor long term, but I am also old. 🙂
We are all plagued with many failed Austins coming in for options (I see them about weekly)... yet we now choose to do MIS DMO? Huh?

Wait until the revisions are pouring in on these, just like open met osteotomies (recur, hwr and then met fractured, first MPJ OA, etc). Good luck with those. That big MIS hardware in the met and very little actual metatarsal healing is going to be a problem for revising to fusion, revising undercorrection, etc.

There is always a lag period between any new procedure (silastic, opening base wedge, cartiva, peroneals to rebuild lat ankle, arthroeresis, etc etc) and seeing how bad it crashes and burns long term.

 

[josebiwasabi]

Yes, I am doing it for the majority of my bunions (the rest are a mix of 1st MTP fusion or Lapidus). Most patients tend to be very happy with the result postoperatively. The biggest difference that I've noticed compared to traditional open is the lack of stiffness at the 1st MTP postoperatively.

The learning curve is overstated, assuming you have good foundational surgical skills. I think initial papers reported needing to do ~50 cases. It only took me about 15 to feel very comfortable and to deal with intraop issues. Doing an MIS DMO+Akin including skin closure now takes me about 45 minutes.

 

[air bud]

90 plus percent retro can be done MIS. Opens new doors for patients in 70s that would. Benefit but worried about soft tissue envelope.

I still stand by wife gets a lapidous mom gets an MIS bunion. Middle-ish '50s is cut off for lapitus for me these days anybody younger I think they do better long-term with a lapitus I still wait bear them at 2 weeks. Anybody older I do MIS and they can walk right away in a boot as a general rule

 

[air bud]

Yes, I am doing it for the majority of my bunions (the rest are a mix of 1st MTP fusion or Lapidus). Most patients tend to be very happy with the result postoperatively. The biggest difference that I've noticed compared to traditional open is the lack of stiffness at the 1st MTP postoperatively.

The learning curve is overstated, assuming you have good foundational surgical skills. I think initial papers reported needing to do ~50 cases. It only took me about 15 to feel very comfortable and to deal with intraop issues. Doing an MIS DMO+Akin including skin closure now takes me about 45 minutes.

Agree.... Still takes me a little bit longer. I use Stryker most of the time and I hate their jig. Treace jig is awesome. Correct joint is never stiff.

 

[Aresnebula]

Yes, I am doing it for the majority of my bunions (the rest are a mix of 1st MTP fusion or Lapidus). Most patients tend to be very happy with the result postoperatively. The biggest difference that I've noticed compared to traditional open is the lack of stiffness at the 1st MTP postoperatively.

The learning curve is overstated, assuming you have good foundational surgical skills. I think initial papers reported needing to do ~50 cases. It only took me about 15 to feel very comfortable and to deal with intraop issues. Doing an MIS DMO+Akin including skin closure now takes me about 45 minutes.

Did you have someone (pod, ortho F&A, etc.) with you in the OR when you were first doing MISB out of residency?

 

[Stormblest]

Doing one in a few weeks for the first time and can report back

 

[josebiwasabi]

Did you have someone (pod, ortho F&A, etc.) with you in the OR when you were first doing MISB out of residency?

Nope, was just me and the rep and I did zero of these in residency or fellowship.

I use the Stryker system for my MIS bunions. Prior to doing my first one on a real patient, I attended a Stryker training course in SLC, did a local cadaver lab, and had my rep bring the MIS console and a burr to my office and practiced making the cut on saw bones a couple times.

I am very meticulous with my surgery prep if I am doing a new procedure, using a new product, or just doing something I haven't done in a while. I talked to other surgeons about common issues requiring intraop troubleshooting and had plan B, C, D etc in case a real complication occured. Although it's ok to rely on the jig (that's what it's there for) you need to be able to do it freehand if something isn't working or something dumb happens like dropping the jig.

Prior to doing it on elective cases, I did quite a few cases for diabetic offloading (float mets, etc), which helps familiarize yourself with the tactile feedback when cutting with a burr.

One thing that I would recommend is that if you work with residents: do not let your resident do the actual osteotomy until you've done a lot of these. It is difficult to see if they are slightly off axis while making the cut and it is much harder to fix a poorly angled/performed cut compared to an open procedure.

 

[Feli]

... Doing an MIS DMO+Akin including skin closure now takes me about 45 minutes.

Agree.... Still takes me a little bit longer. I use Stryker most of the time and I hate their jig. Treace jig is awesome. Correct joint is never stiff.

Correct, but open Austin Akin or MPJ fusion is 30-40mins... or Lapidus Akin maybe 45-60mins?

I don't get rocketing the cost, making revision super hard due to monster screws... for what? Effectively same procedure (still a met osteotomy). Lapidus more of a learn curve but has proven maintain of the IMA, doesn't burn the bridge to MPJ fusion down the line.

[yes yes, I know air bud will say... steak dinner and doing the "latest technique," yes] 🙂

 

[Stormblest]

Anyone try the Arthrex system?

 

[air bud]

Anyone try the Arthrex system?

It's the same as Stryker. Paragon and Treace both have proximal stabilization via k wires along with frontal plane rotation. Teresa's by far the best it's reproducible.... The Stryker one half the time you don't even use it to throw the second screw and then the other two-thirds of the time you just bail on it and freehand the screws.

 

[Stormblest]

The reps told me most people just freehand the kwires. Have not practiced with the Treace system.

 

[Boba Foot]

Correct, but open Austin Akin or MPJ fusion is 30-40mins... or Lapidus Akin maybe 45-60mins?

I don't get rocketing the cost, making revision super hard due to monster screws... for what? Effectively same procedure (still a met osteotomy).

Intracapsular open osteotomy =/= extracapsular MIS osteotomy. Very different, not the same.

 

[Mia McBhul]

I've personally had 3 MIS bunions done by others come into my office this past year. One was a non-union, in the other two the bunion returned after 2-3 years...makes me very wary to be jumping onboard the MIS train. I suspect over the next few years we will all be seeing a recurrence of a lot of these MIS bunions just as we see with Austin osteotomies.

 

[Boba Foot]

I suspect over the next few years we will all be seeing a recurrence of a lot of these MIS bunions just as we see with Austin osteotomies.

I’ve heard people saying this since I was in residency. So for 7 years now. Haven’t come across any MIS bunion recurrences yet. I’ve seen many botched Lapiduses (Lapidi?) though. I think as long as you’re not doing MIS with significant hyper mobility, you should be OK.

 

[Feli]

Intracapsular open osteotomy =/= extracapsular MIS osteotomy. Very different, not the same.

Uh, sure... but both met osteotomy (make a straight bone into a curved one).

How are they very different with regard to the adductor, EHL/FHL, IM increase by age, etc?

...they will all be prone to recurrence. We've seen it for decades and decades that IM increases, HAV angle recurs with Austin (and many variations, CBWO, crescenteric, scarf, Mau/Ludloff, now MIS, etc... yet we still do the dumb stuff. Ditto for first MPJ implants (fail, fail, fail... yet keep trying).

As soon as there is MIS Lapidus and MPJ fusion, lmk. 🙂

 

[Toenail]

I've personally had 3 MIS bunions done by others come into my office this past year. One was a non-union, in the other two the bunion returned after 2-3 years...makes me very wary to be jumping onboard the MIS train. I suspect over the next few years we will all be seeing a recurrence of a lot of these MIS bunions just as we see with Austin osteotomies.

Nope. Think about how many mm a chevron is shifting the met head compared to an MIS osteotomy. It’s practically double the shift with none of the intra articular scarring. Whoever did those MIS bunions that you came across simply sucked at this procedure.

 

[Boba Foot]

Uh, sure... but both met osteotomy (make a straight bone into a curved one).

By this logic, a lap appy is the same as an open appy (make an appendix go bye bye). Don't think you'll get a lot of surgeons to agree with you on that one.

The difference, though I think you know this, is that you don't **** with the capsule and you can get double the correction plus not having to worry about varus complications. The difference in pain between a Lapidus post-op and MIS post-op is significant, and that was the biggest factor that converted me over. Do you have data or just vibes that recurrence in newer generation MIS is significant? Here's a study that shows MIS and Lapidus at essentially the same recurrence rate. Do you have issue with higher non-union rates in Lapidus? A return to OR is a return to OR, regardless of whether its recurrence or to fix a non-union, no?

 

[Feli]

.... Do you have data or just vibes that recurrence in newer generation MIS is significant? Here's a study that shows MIS and Lapidus at essentially the same recurrence rate. Do you have issue with higher non-union rates in Lapidus? A return to OR is a return to OR, regardless of whether its recurrence or to fix a non-union, no?

There is no way to know recurrence rates on "newer" mis osteotomy... that f/u is not back yet. It will be. Follow-up is the enemy of "good" surgery. Mpj implants and many things look ok for a bit.... but there is reason they keep being on newer "generation " ones, just like MIS. A study talking 5 months follow up is not useful... interesting, but that's just a poster, not anything useful with 8.1 months average follow. Those people aren't even fully healed... much less years more walking on it. That's a preliminary only (and they appropriately title it "early").

Lapidus issue is not non-union (assuming decent joint prep, good plate fixation, and non-turd candidates medically. Its downside is hardware removal (plate) or sometimes undercorrection, but that hwr is not a big deal as the fused joint then holds the IMA well long term... proven long term better than any met osteotomy. I would also question the study a bit when they're doing 2 screw Lapidus and taking 89min average (90min would be a very bad one... huge Ima, osteoporosis, bad OR team or much teaching, etc).

But their pain was less on Lapidus vs MIS... maybe NWB, who knows (and not significantly less).

It will end up that way for MIS also: higher recur. It's just the anatomy, pathology. You will have a lot of 'Figure 3' below when this is used for young people, hypermobile, big bunions... and this is not even a year post op. Wait 5, 10, 20 years... it's going to be just like other metatarsal osteotomy results.

 

[deleted1218629]

Like all other bunion surgeries, if the sesamoids are reduced and the hallux valgus angle is normal you probably have a good chance of lasting correction. If not, i agree with Feli they will have recurrence. it's possible recurrence shows more slowly due to the larger shift.

but you do need both - the sesamoids need to be reduced AND the hallux needs to be straight.

 

[DYK343]

Like all other bunion surgeries, if the sesamoids are reduced and the hallux valgus angle is normal you probably have a good chance of lasting correction. If not, i agree with Feli they will have recurrence. it's possible recurrence shows more slowly due to the larger shift.

but you do need both - the sesamoids need to be reduced AND the hallux needs to be straight.

I agree. That photo on the left is not a true AP/looks non weightbearing. Despite angled/poor radiograph it appears the sesamoids were never corrected via frontal plane. Which can be done with MIS bunionectomies. I never understood the "chevron" for this MIS procedure. Should be straight osteotomy to reduce frontal plane deformity. These can work but not with hypermobility.

That said im with Feli. I dont do these. I am lapidus or 1st MPJ fusion or bust. I would say 80% of my bunion surgery is open lapidus.

As soon as there is MIS Lapidus and MPJ fusion, lmk. 🙂

Stryker has a MIS lapidus. Im sure other companies do too. Ive never done it.

- -
Edit: I just watched the youtube animation for MIS lapidus. Thats a lot of steps. Cant imagine the cost of that system

 

[wakaflocka88]

I agree. That photo on the left is not a true AP/looks non weightbearing. Despite angled/poor radiograph it appears the sesamoids were never corrected via frontal plane. Which can be done with MIS bunionectomies. I never understood the "chevron" for this MIS procedure. Should be straight osteotomy to reduce frontal plane deformity. These can work but not with hypermobility.

That said im with Feli. I dont do these. I am lapidus or 1st MPJ fusion or bust. I would say 80% of my bunion surgery is open lapidus.

Stryker has a MIS lapidus. Im sure other companies do too. Ive never done it.

- -
Edit: I just watched the youtube animation for MIS lapidus. Thats a lot of steps. Cant imagine the cost of that system

Can do a mini open Lapidus. A few CM incision at TMTJ and use a burr to angle the cuts/prep joints. Perc home run wire at distal met and second point of fixation with a large staple at the TMTJ. no need for the Stryker system. Unless the cuneiform is really angled and weird shaped, this is what I’ve been doing for majority of Lapidus. No need for a big ass incision when majority of correction can be done at TMTJ and if need be, small incision for lateral release.

 

[DYK343]

Can do a mini open Lapidus. A few CM incision at TMTJ and use a burr to angle the cuts/prep joints. Perc home run wire at distal met and second point of fixation with a large staple at the TMTJ. no need for the Stryker system. Unless the cuneiform is really angled and weird shaped, this is what I’ve been doing for majority of Lapidus. No need for a big ass incision when majority of correction can be done at TMTJ and if need be, small incision for lateral release.

Whats your post op weightbearing status?

 

[Retrograde_Nail]

Did zero MIS in residency. Did two different courses and then a cadaver lab with rep. I've been doing MIS bunionectomies ever since. One screw or two screws. I've done both. I used to do them freehand. Getting the sesamoids perfect and advancing your wires is challenging freehand but can be done. The newer jigs out there make this very simple. I've used the Artemis jig from Vilex and felt it worked like a charm. It held my reduction/translation perfect while locking the sesamoids in anatomic position. Throw the screws perfectly through the jig. Nice system

For very large bunions without arthritis at the 1st MTP joint I've done combination of lapidus and MIS osteotomies with good success. Next time I am in that situation I will probably attempt MIS lapidus first and if its undercorrected can open or just do additional MIS osteotomies distally.

Sesamoids most be anatomic

You must translate almost 90% to get enough correction. Use a jig its way easier than freehand.

If the great toe still touches the 2nd toe even though it looks straight do the MIS akin. You won't regret it

Biggest pros of the surgery are no joint stiffness at 1st MTP joint, no nerve pain, and in general most patients state they hardly felt any pain from the bunion surgery when done MIS

Surgeons botch bunion surgery all the time when done open. Open bunion surgeries have significant risks such as nerve pain, permanent stiffness, etc. These risks do not exist with MIS in my experience. If the bunion is a little undercorrected patient's still tolerate it well because they hardly suffered during the recovery process. My two cents

 

[Retrograde_Nail]

I've seen far more botched MIS bunions in the last 3 years than I've seen botched open bunions in 24 years.

IMHO, if you can't do a clean open bunion as a podiatric surgeon, you have no business in the OR. Also, what percentage of that "significant risk" is patient non compliance? Care to show me where you get the data for this "significant risk" you're talking about?

"These risks do not exist" in your experience? Then either you haven't done enough of them, your complications are going elsewhere, or, you're lying.

Classic response from someone who does not do any MIS surgery. Talking to podiatrists from generations ago is pointless.

Open bunion surgery carries typical risks such as wound dehiscence, infection, scar tissue formation, joint stiffness, nerve injury. These are obvious complications. You don't need a research article to tell you that. It's experience. MIS bunionectomies almost completely eliminate all of these issues. You still can get an infection but the other risks are mitigated by the MIS technique. If you can't comprehend that then you have never done an MIS bunion.

I do hundreds of procedures a year, on pace for 13500 RVUs this year and generate 3 million in gross revenue for the level 1 trauma center I work for. I promise you I do more surgery than 99.9999% of podiatrists.

 

[wakaflocka88]

Whats your post op weightbearing status?

2 week splint
Boot for 6 weeks
I’ve had quite a few over the years ditch the boot at week 5-6 and still fuse

I do make sure my home run screw is close to 46-50mm as I feel that working length provides more stability. Usually 5.0mm partial thread.


I’ve also unfortunately had some loss of correction with this method or with a larger incision. Also still not sure if every lapidus should get an intercuneiform screw but I’ve been doing it for every case lately to reduce risk of the metatarsal trying to drift again. I do not bill for this.

it’s still a tough procedure sometimes trying to get it as perfect as possible.
Maybe I should jump on the Treace bandwagon because it sounds like it’s a perfect reduction every time.

 

[DYK343]

2 week splint
Boot for 6 weeks
I’ve had quite a few over the years ditch the boot at week 5-6 and still fuse

I do make sure my home run screw is close to 46-50mm as I feel that working length provides more stability. Usually 5.0mm partial thread.


I’ve also unfortunately had some loss of correction with this method or with a larger incision. Also still not sure if every lapidus should get an intercuneiform screw but I’ve been doing it for every case lately to reduce risk of the metatarsal trying to drift again. I do not bill for this.

it’s still a tough procedure sometimes trying to get it as perfect as possible.
Maybe I should jump on the Treace bandwagon because it sounds like it’s a perfect reduction every time.

Benefit of open is use of a plate. I weightbear day 1 to tolerance.

I use stryker lapifuse. Rock solid construct. Not going anywhere. 100% union rate. The screw through the plate into base 2nd met is solid.

Its also very fast system. Im done usually in 30ish minutes.

 

[wakaflocka88]

Benefit of open is use of a plate. I weightbear day 1 to tolerance.

I use stryker lapifuse. Rock solid construct. Not going anywhere. 100% union rate. The screw through the plate into base 2nd met is solid.

Its also very fast system. Im done usually in 30ish minutes.

Yes I still use the Lapfisue system minus the jig - just the screw and their plate if open approach.

AirBud is not sold on the construct