Minimally invasive bunions

[CutsWithFury]

Anybody have any experience with any of the techniques out there on the market?

Original technique is Steinmann pin to move capital fragment over. Now there are certain cannulated screw techniques to skewer the the capital fragment and give a sturdier construct. Most recently there have plate designs where screws are going through the plate to fixate the capital fragment to the proximal residual first metatarsal.

If you have done the procedure have you had any complications. If so do you have any pearls for salvage.

I’ve been intrigued by the technique for quite some time. Just curious if anyone else out there has extensive experience and offer any advice, pearls, complications, etc

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[toe_tickler]

I have some experience utilizing the Bosch (sp?) procedure back in residency which would essentially involve a transverse cut in the neck. A pin would be inserted adjacent to the medial nail fold and directed down the 1st met shaft as fixation. The xrays always looked like a hackjob immediately post-op compared to a clean open Kalish/Austin but long term results look better. I am also curious about anyone's medium to longterm results with this (or similar) procedures.

 

[CutsWithFury]

Saw my first minimally invasive bunion today in clinic. Almost zero swelling. The transverse osteotomy is proximal to the metatarsal neck. Patient can freely move great toe with no pain whatsoever. I’m pretty impressed. Let’s see if it actually heals.

 

[ExperiencedDPM]

Saw my first minimally invasive bunion today in clinic. Almost zero swelling. The transverse osteotomy is proximal to the metatarsal neck. Patient can freely move great toe with no pain whatsoever. I’m pretty impressed. Let’s see if it actually heals.

I have been less than impressed by these cases. There was a doctor in my area who did MIS on anyone with a pulse and never used fixation. Needless to say, my surgical schedule was filled with his re-dos.

Putting in that 44 Shannon bur can do a lot of soft tissue damage. I’ve seen it destroy the medial nerves and vessels. It wasn’t pretty.

At this point I would not let anyone perform this procedure on my paws.

 

[CutsWithFury]

I have been less than impressed by these cases. There was a doctor in my area who did MIS on anyone with a pulse and never used fixation. Needless to say, my surgical schedule was filled with his re-dos.

Putting in that 44 Shannon bur can do a lot of soft tissue damage. I’ve seen it destroy the medial nerves and vessels. It wasn’t pretty.

At this point I would not let anyone perform this procedure on my paws.

I am using a plate construct with multiple screws. I don’t do anything without fixation.

 

[ExperiencedDPM]

I am using a plate construct with multiple screws. I don’t do anything without fixation.

Even neuromas!??

 

[CutsWithFury]

Even neuromas!??

I avoid neuroma surgery at all costs.

 

[ExperiencedDPM]

B

I avoid neuroma surgery at all costs.

Ah....a very wise man/woman. As I’ve told residents for many years, nerve surgery usually ends up with one of two results. 100% improved or 100% worse. Very few land in between.

And for those heros out there, when a failed tarsal tunnel surgery walks into your office and you believe you’re going to put on your loupes and be the hero, remember this post.

Being the hero on another provider’s failed tarsal tunnel surgery is a mistake you don’t want to make. These are prime candidates for CRPS and so on and so on.

 

[josebiwasabi]

I have been less than impressed by these cases. There was a doctor in my area who did MIS on anyone with a pulse and never used fixation. Needless to say, my surgical schedule was filled with his re-dos.

Putting in that 44 Shannon bur can do a lot of soft tissue damage. I’ve seen it destroy the medial nerves and vessels. It wasn’t pretty.

At this point I would not let anyone perform this procedure on my paws.

I'm not a big proponent of MIS procedures either. But one thing that they have improved upon is the technology. Old school MIS was via traditional high speed high torque power. Stryker and Arthrex (and maybe other companies?) now have low speed high torque burrs which are significantly less traumatic to surrounding soft tissues.

 

[DYK343]

I have been less than impressed by these cases. There was a doctor in my area who did MIS on anyone with a pulse and never used fixation. Needless to say, my surgical schedule was filled with his re-dos.

Putting in that 44 Shannon bur can do a lot of soft tissue damage. I’ve seen it destroy the medial nerves and vessels. It wasn’t pretty.

At this point I would not let anyone perform this procedure on my paws.

I am by no point experienced in or a proponent of MIS surgery. I have not had any other people's MIS surgery in my office but I also do not think anyone around here is doing it, though I could be wrong.

I am curious though. I know providers (podiatric and orthopedic) I would never allow touch my foot open. I bet the MIS world has the same issues with providers. Could this be why there were so many issues in your office? Or does it just suck.

And I just did a neuroma recently. Thought it went well and removed a large chunk of nerve. Traced the branches distally to each toe and the stump proximally. Resected cleanly. Yep, made her worse.

 

[ExperiencedDPM]

I am by no point experienced in or a proponent of MIS surgery. I have not had any other people's MIS surgery in my office but I also do not think anyone around here is doing it, though I could be wrong.

I am curious though. I know providers (podiatric and orthopedic) I would never allow touch my foot open. I bet the MIS world has the same issues with providers. Could this be why there were so many issues in your office? Or does it just suck.

And I just did a neuroma recently. Thought it went well and removed a large chunk of nerve. Traced the branches distally to each toe and the stump proximally. Resected cleanly. Yep, made her worse.

MIS has evolved. In the old days it was typically performed by those who had no surgical training. It was their way of performing surgery without hospital privileges. Of course there are exceptions, but my observation was as above.

Many of these doctors “buzzed” bunions and toes in the same room they were cutting nails 15 minutes earlier. Their “immobilization” was Coban or Elastoplast wrapped tightly. Post op xrays of these patients would make me crap myself if I was the surgeon. It was scary looking.

A popular procedure was sticking in a Shannon 44 and performing a lesser metatarsal osteotomy and letting the bone “seek” it’s own level. Remember, this burr often ripped the crap out of the capsule although they said it didn’t. As a result, the capsule of the joint often had no more integrity.

These patients would walk into my office with a large bump on the dorsal foot. That “bump” was the metatarsal head floating under the skin. There was no more capsule to confine the bone. If I made a dorsal incision I could literally see the head sticking out.

They did not use a C-arm very often back then and went by “feel”. Now they are at least using fluoroscopy and sometimes using fixation.

Do yourself a favor and go on the website of a provider who advertises a lot of MIS and look at the post op pictures and x-rays. I assure you that most of those pics would cause you to seek counseling if they were your patients and you had a conscience.

They’ve often compared MIS with arthroscopic or endoscopic surgery. That is not a valid comparison since a scope allows you to visualize what you’re doing.

But scopes are an ENTIRELY different subject. I can show you films of dozens of imcompetent arthroscopic surgeons and dozens of films of an iatrogenic talar dome lesion due to the poor skills of the surgeon.

 

[dtrack22]

The big difference between MIS then and MIS now is fixation. As well as newer burrs as someone mentioned. Though you can create the osteotomy with a smooth wire and an osteotome without even needing the burrs.

I don't mind it (in theory) with the newer screw constructs. The problem I have is the doctors pimping it either have plenty of cosmetically unappealing results, or they "never" have problems despite changing constructs over the years (which likely means some problems, hell AVN of the met head has been reported already), on top of the fact that when you shift the met head over 80-90% of the met width you've created a new deformity that makes future correction difficult/treatment options limited IMO.

 

[CutsWithFury]

on top of the fact that when you shift the met head over 80-90% of the met width you've created a new deformity that makes future correction difficult/treatment options limited IMO.

I disagree. If the 1st MTP joint developed arthritis in the future you could still fuse it without issue.

 

[dtrack22]

I disagree. If the 1st MTP joint developed arthritis in the future you could still fuse it without issue.

Right, you can fuse it. Like I said, your options are limited. And that’s of course assuming the met head is alive which some of the early adopters with Wright has issues with.

 

[CutsWithFury]

Right, you can fuse it. Like I said, your options are limited. And that’s of course assuming the met head is alive which some of the early adopters with Wright has issues with.

If bunion goes bad. Then it’s gone baby...gone

Unless you are one of those cartiva freaks

 

[dtrack22]

If bunion goes bad. Then it’s gone baby...gone

Unless you are one of those cartiva freaks

Bunions can go bad and still have perfectly healthy joint surfaces...

 

[Apolo106]

I recommend going next year to the MIS course in New Orleans due to the current outbreak of COVID 19 to learn more. A friend of mine uses Wright system with decent results. I have never done one myself outside of a cadaver. A lot of problem arises from lack of internal fixation and the instability from a transverse cut. I was told from the course to wait until you're certified with our board(s) and then do MIS since some older docs look down upon MIS. Also, at one time it was advertised as the "60 minutes" lunch time bunion surgery can done in the office. Does anyone have a recommendation for a MIS machine in office to do simple exostectomies? ie like where I can purchase one? I know Arthrex and Stryker has their own version but i'm not sure if we can purchase them to use in the office. There is definitely a learning curve and I would get comfortable with doing the standard open procedures before attempting to do MIS. I am not affiliated with Wright. Thank you.

Check this out,

PROstep™ Minimally Invasive Surgery Archives - Wright Medical Group

 

[CutsWithFury]

I recommend going next year to the MIS course in New Orleans due to the current outbreak of COVID 19 to learn more. A friend of mine uses Wright system with decent results. I have never done one myself outside of a cadaver. A lot of problem arises from lack of internal fixation and the instability from a transverse cut. I was told from the course to wait until you're certified with our board(s) and then do MIS since some older docs look down upon MIS. Also, at one time it was advertised as the "60 minutes" lunch time bunion surgery can done in the office. Does anyone have a recommendation for a MIS machine in office to do simple exostectomies? ie like where I can purchase one? I know Arthrex and Stryker has their own version but i'm not sure if we can purchase them to use in the office. There is definitely a learning curve and I would get comfortable with doing the standard open procedures before attempting to do MIS. I am not affiliated with Wright. Thank you.

Check this out,

PROstep™ Minimally Invasive Surgery Archives - Wright Medical Group

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[HaimFeldman]

We did them residency. Never used a burr for the cut. K-wires used as an osteomy guide for the tranverse cut with a saggital saw and lots of fluoro. We followed Laporta's technique: RI Vol. 7 - Issue 2 - Percutaneous Bunion Correction – Are you kidding me? Not Anymore…

Short term outcomes seemed to be good. Can only recall one complication where the capital fragment dorsiflexed. Need to reach out to that attending and see how they did long term and if he's still doing it.

Haven't done them in practice yet. Every patient i've discussed the option with balked at the idea of having a pin sticking out of their foot for 4-6 weeks. Sticking with Austins w or w/o Akins or Lapidus mostly.

 

[GreenHousePub]

Haven't done them in practice yet. Every patient i've discussed the option with balked at the idea of having a pin sticking out of their foot for 4-6 weeks. Sticking with Austins w or w/o Akins or Lapidus mostly.

I pretty much use exclusively cross k-wires and NWB after my austins/reverdins. I've done maybe 100 in the past 2 years using this method, only had symptomatic non-unions about twice. I really enjoy doing them this way.

It's all how you present it, if you do it confidently they seem to go along with it. Also not having retained metal is always a selling point.

 

[dtrack22]

Also not having retained metal is always a selling point.

ive had a few patients who, for whatever reason, don’t like the idea of screws/plates staying in their foot once things have healed. They are happy to have temporary k wires that get removed in clinic

 

[DYK343]

NWB after my austins/reverdins.

This is why I wouldnt do it.

1 screw and an incision that is healed in 2 weeks to be able to walk with a post op shoe? A lot of my patients go back to work at week 2 (sit down/office type patients. Not a factory worker).

4-6 weeks NWB for an Austin for the cool factor of minimally invasive seems like a stretch.

With that said I know pods walking them day #1 without fixation ("the bandage is your fixation") and claiming good results.

 

[dtrack22]

That's not very common though. The NWB part. Camasta uses 3 buried, closed k wires for 1st MPJ fusions and has them heel WB in a surgical shoe day one. I've never heard of an MIS bunion being kept NWB...even the people who don't use any fixation (that's pretty dang rare IMO as most are using screws and the rest use a pin/wire).

 

[GreenHousePub]

I'd never use pins/wires for 1st MPJ fusions. Far too many non-unions even with screws.

 

[CutsWithFury]

I'd never use pins/wires for 1st MPJ fusions. Far too many non-unions even with screws.

My patients would absolutely destroy k wire fixation for a 1st MTP fusion....DESTROY


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[sausagedigits]

I've been done about 20 MIS in residency so far. Definitely wouldn't call that extensive experience. We make incision size of sagital saw blade, make the transverse cut, and use Steinmann pin. First few cases we just used Steinmann for fixation bc in theroy that and capsule should hold it in place, but we have a very uncompliant patient base, so now we use Steinmann with stryker cross screw. Overall patients are happy, good correction of some pretty decent sized IM angles, and frontal plane sesamoids seem to reduce well.

I know a few people using Wright medical system and say they have good results. I just don't feel comfortable with the huge screws, and minimal purchase of bone to bone apposition.