05/11/2013    Don Peacock, DPM

Overlapping 2nd Digit Status Post Bunionectomy

I wanted to show a nice correction I got on a
bunion deformity with the patient who I felt
uncomfortable with doing a 1st tmetatarsal
osteotomy on. In your case, you would have to
remove the fixation in the first metatarsal. This
can complicate the redo procedure for the
patient. On the elderly patient, I’m going to
show I performed a minimally invasive
bunionectomy and Akin through and through.

I used the same incision percutaneously to
perform the bunionectomy and the Akin. The
interesting result with her x-rays is that
despite the only osteotomy I performed was in the
hallux, the IM angle reduced.

If you look at the pre-op x-rays and compare them
to the post-op x-rays, you can see obvious
improvement in the 1stt met angle and in the
sesamoid position. Also, the joint, which was
deviated pre-operatively, is now in good
anatomical position. The same sort of pathology
exists in your patient. The hallux osteotomy can
work well because it realigns the first
metatarsal phalangeal joint by shifting the pull
of the FHL.

Your options for the second toe are not as easily
addressable.. If that fixation was not in place
this could easily be corrected with a transverse
osteotomy through minimally invasive correction
at the base of the proximal phalanx to realign
the second toe like In did in my patient. .
However, the fixation prevents this or at least
complicates this type of approach.

For the second toe, I would probably perform a
Johnson modified Weil osteotomy along with and
release of the medial structures in the second
metatarsal phalangeal joint.

Don Peacock, DPM, Whiteville, NC,
peacockdpm@gmail.com

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05/14/2013    Ed Cohen, DPM

Overlapping 2nd Digit Status Post Bunionectomy (Don Peacock, DPM)

If you have a 77 year old patient with painful
corns between the big toe and the second toe
along with a bunion (assuming the patient had
sufficient circulation), a great procedure would
be an MIS resection of bone from the medial PIPJ
of the second toe and an MIS resection of bone
from the lateral hallux distal hallux joint.

These procedures are very atraumatic and can
dramatically improve the quality of life in this
type of patient. My assumption is that this
patient would be a poor candidate for any bunion
surgery, even for a simple MIS modified McBride-
Akin bunionectomy, which could be done with two
stitches. The point is the goal of surgery is to
eliminate pain and not put the patient at risk.
This correction is not perfect but it could
dramatically increase the patients ability to
wear shoes and to ambulate.

Getting back to Dr. Peacock's case, he stated he
felt uncomfortable do an MIS first metatarsal
osteotomy on this patient. If we assume this to
be a fact, his correction was an excellent
surgery as seen by the pre and post-op x-rays.
Dr. Kittay raises a good point that there was
some distortion in the post op x-ray because
there was some supination in the foot when the x-
ray was taken.

It would be nice to see a photograph of this foot
after surgery and another x-ray where the foot is
not supinated. I am sure that Dr. Peacock will
provide the readers of PM News with this
information.

My contention is if this patient was not a good
candidate for a first metatarsal osteotomy, Dr.
Peacock performed a great surgery on this patient
and significantly improved the quality of her
life. I haven't seen the post-op picture and x-
ray without supination and my view could change ,
but I feel this was a very happy patient and Dr.
Peacock is extremely proud of this MIS surgery.

This brings me to my next point. If we assume
this patient was not a good candidate for an MIS
first metatarsal surgery, she certainly would not
be a good candidate for a Lapidus surgery. As to
the proposed Keller bunionectomy or fusion, I
would make the same argument. I have had too many
patients come into my office who have had Keller
bunionectomies where the big toe sticks up and
the big toe retracts.

I know the successful Keller bunionectomies
generally don't come into my office, but as in
this case, the 1st MPJ is fine and not painful
and it always better to preserve a major joint
than to destroy it. This is my same argument for
also not fusing the 1st MPJ.

Ed Cohen, DPM, Gulfport, MS, ECohen1344@aol.com