12/20/2016    Michael M. Rosenblatt, DPM

MIS Metatarsal Osteotomy Surgery vs. Akin Osteotomy on Elderly Patients

There are complications from pressure under the
2nd Metatarsal head post-surgery. Any 1st
metatarsal osteotomy to correct a bunion
deformity, whether it is held by internal
fixation or not, is subject to leaving the 2nd
metatarsal structurally "elongated." This can
easily result in a painful plantar lesion and
capsulitis under the 2nd metatarsal head.

This is why it is so important for
biomechanical examination to be part of patient
evaluation. If the patient has
forefoot/gastrocnemius equinus and/or a short
Achilles tendon, they will be putting a great
deal more pressure on their forefoot during
gait cycle. This will exacerbate pain under the
2nd metatarsal head. If the patient has
hammertoes, this will even be worse. Even with
internal fixation, elevation of the first
metatarsal head can occur. Without internal
fixation, after MIS surgery, it is
"guaranteed."

However, if you "plan" for this exigency, you
can do much to alleviate painful post-operative
ambulation. You can start your patient on
Achilles stretching exercises as soon as the
bone is healed. If they can stretch their
posterior leg muscles without weight bearing,
perhaps sooner. You can prepare and make
orthotics and advise rigid shoe gear to try to
make the forefoot more "rigid" during gait, so
that ALL of forefoot weight bearing is not
directed against the "forlorn" 2nd metatarsal
head. You can also have them stick felt
adhesive pads just behind the 2nd metatarsal
head.

If you are well prepared, you can prevent a lot
of post-operative complaints and angry
patients. The gastrocnemius recession is the
"ideal" treatment, but you might not be able to
do it for various reasons on patients selected
for MIS surgery. By dealing with this common
complication ahead of time, your patients will
more likely be happy and refer more friends and
family to you for the same surgery.

Michael M. Rosenblatt, DPM, San Jose, CA

Other messages in this thread:

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12/26/2016    Don Peacock, DPM, MS

RE: MIS Metatarsal Osteotomy Surgery vs. Akin Osteotomy on Elderly Patients (Dieter J Fellner, DPM)

Dr. Fellner you are exactly right. This
procedure has not been subjected to scientific
evaluation. A modification of the Wilson has
been performed MIS and it is in the literature.
This particular modification has not been.

In order for us to truly back up what we are
saying about this procedure, we are going to
need to publish it. I would not go as far as to
calling it a sound-bite because we do have some
case presentations that have been published in
non-peer-reviewed journal articles. However,
from a purely academic standpoint we will need
to back up what we are saying with scientific
data.

I have performed 10 of these procedures. We
have a collective process going on now where we
are planning to retrieve the data and try to
publish our results. Clinically, the results
have been promising so far. More cases and more
studying is required before the procedure
should be considered by physicians outside of
the study group.

Admittedly, it's premature for us to be singing
the praises of this procedure until more is
known about the postoperative course and the
actual results we are getting long term. That
being said there is nothing wrong with showing
what we are trying to accomplish and the good
results we're getting on a case-by-case basis.
The procedure does follow standard of care
practices and this is an osteotomy style that
has plenty of back-up in the literature. This
is merely a mild modification of a known and
well documented procedure.

Check out "Modifications of the Wilson
Bunionectomy, Clinics of Podiatric Medicine and
Surgery - Vol 8, No 1, Jan 1991 page 95. by
Dennis White, DPM. He performed a retrospective
study on 119 patients utilizing MIS modified
Wilson osteotomy. There were no non-unions.
Only 11 patients were fixated. A few patients
experienced transfer metatarsalgia with only
one patient requiring additional surgery.
Eight patients displayed mild dorsiflexion of
the first metatarsal head that did not receive
fixation.

Don Peacock, DPM, MS, Whiteville, NC

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12/21/2016    Don Peacock, DPM

MIS Metatarsal Osteotomy Surgery vs. Akin Osteotomy on Elderly Patients (Michael M. Rosenblatt, DPM)

I agree with most of the post Dr. Rosenblatt
has eloquently described. It is essential that
surgeons address gastrocnemius equinus when the
deformity presents. It’s equally vital that we
incorporate bio-mechanical exams in our
surgical endeavors.

I do take some exception with his conclusion
that performing a MIS bunion correction without
fixation will always lead to second metatarsal
transfer pain. The research in this area
contradicts this statement. Non-fixated first
metatarsal osteotomies such as the landmark
research Dr. Dale Austin gave us is a good
example of that fact. He did not fixate his
osteotomy.

As with all bunion surgery complications
certainly do exist with respect to the
probability of transfer second metatarsalgia.
Legitimate concerns over first metatarsal
instability after MIS bunion correction has
been raised and has led to augmentation of
osteotomy angles and percutaneous fixation in
some MIS surgical circles.

One quality we sometimes forget to remember is
the etiology of what causes first metatarsal
instability. We know from clinical experience
that stabilizing the rear foot via correcting
equinus, stabilizing the STJ, stabilizing the
1st met-cuneiform and other techniques leads to
stabilization of the first ray. As an example,
correcting gastrocnemius equinus results in
less need for compensatory pronation giving
mechanical advantage to the peroneal longus
tendon in his effort to plantar-flex and
stabilize the first ray. The peroneal longus
pulls in a more transverse plane in a pronatory
foot and more plantar in a rectus foot.

We often and wrongly assume that first ray
instability is the cause of the bunion
deformity. However, it can also be viewed in
the exact opposite. The bunion deformity in
fact has an effect on the instability of the
first. Research has shown that by correcting
the bunion deformity the first ray stabilizes
when examining it from a biomechanical
standpoint. Presumably, this is achieved by
realigning the tendon structures of the 1st
metatarsal thereby increasing stability.

The truth is instability of the first ray in
the presence of a bunion deformity has its
etiology in both the rear foot and forefoot in
many cases. With all of this information it is
easy to see that a blanket statement about MIS
bunion techniques leading to undesirable 2nd
metatarsal issues is not accurate.

Dr. Rosenblatt is on target with most of his
post and we agree with 99% of it. We do not
agree with the conclusion that non-fixated MIS
bunion correction will always lead to transfer
2nd pain. The research in this area backs us up
on this disagreement.

Don Peacock, DPM, Whiteville, NC