Minimally invasive bunions

Discussion in 'Podiatric Residents & Physicians' started by CutsWithFury, Feb 11, 2019.

  1. CutsWithFury

    CutsWithFury I like to cut
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    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
     
  2. toe_tickler

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    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.
     
  3. OP
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    CutsWithFury

    CutsWithFury I like to cut
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    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.
     
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  4. ExperiencedDPM

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    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.
     
  5. OP
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    CutsWithFury

    CutsWithFury I like to cut
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    I am using a plate construct with multiple screws. I don’t do anything without fixation.
     
  6. ExperiencedDPM

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    Even neuromas!??
     
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  7. OP
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    CutsWithFury

    CutsWithFury I like to cut
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    I avoid neuroma surgery at all costs.
     
  8. ExperiencedDPM

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    B
    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.
     
    #8 ExperiencedDPM, Feb 19, 2019 at 7:04 PM
    Last edited: Feb 19, 2019 at 7:09 PM
  9. josebiwasabi

    Physician 7+ Year Member

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    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.
     
  10. DYK343

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    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.
     
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  11. ExperiencedDPM

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    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.
     
  12. dtrack22

    Podiatrist 10+ Year Member

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    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.
     
  13. OP
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    CutsWithFury

    CutsWithFury I like to cut
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    I disagree. If the 1st MTP joint developed arthritis in the future you could still fuse it without issue.
     
  14. dtrack22

    Podiatrist 10+ Year Member

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    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.
     
  15. OP
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    CutsWithFury

    CutsWithFury I like to cut
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    If bunion goes bad. Then it’s gone baby...gone

    Unless you are one of those cartiva freaks

    IMG_2873.JPG
     
  16. dtrack22

    Podiatrist 10+ Year Member

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

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