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12/20/2016    Keith L. Gurnick, DPM

The MIS Akin Osteotomy (Don Peacock, DPM)

Without addressing Dr. Peacock's use of the Katzen
Modified MIS Wilson procedure for HAV/Bunion
correction in general, I'd like to address his
pre- and post-surgery x-ray angle interpretation
from the x-rays he sent us to review. I can't
agree with his measurements of either the pre-op
and 6 week post-operative x-rays. I am not trying
to be critical, but to be honest here. Here is
what I measured from his x-rays sent in.

Pre-Op IM Angle
His measurement was 13 degrees
My measurement is 11 degrees

Pre-Op HA Angle
His measurement was 22 degrees
My measurement is 29 degrees

Post-Op IM Angle
His measurement was 8 degrees
My measurement is 10 degrees

Post-Op HA Angle
His measurement was 11 degrees
My measurement is 14 degrees

In all fairness, his post-op angle measurements,
regardless of his numbers or my numbers, do
indicate a nice correction, just not exactly as
dramatic as he states, but improved. But he did
not correct a 13 degree IM angle down to an 8

IM angle. There is only minimal improvement in the
fibular sesamoid position and the distance between
the lateral aspect of the 1st metatarsal head and
the medial aspect of the 2nd metatarsal head
reduced from 8 mm to 7 mm, so it is 1 mm closer. You can't achieve 5 degrees of IM angle reduction
with 1 mm reduction.

Also, this patient ends up with 4-5 mm of 1st
metatarsal length shortening which could become
problematic over time Without knowing
anything about this patient (age, sex, weight,
foot structure, ROM, activity, shoes used) I'd
watch for sub 2nd metatarsalgia down the road,
and consider foot orthotics post-op.

Also, in this surgical case presentation and many
others as well, I do not know why we are shown
only forefoot AP x-rays to interpret.

It is much more comprehensive to see the entire
foot on both the standing (weight-bearing) AP and
the lateral views for pre-op and post-op
evaluation of surgical results.

In this patient example, note there is also a
metatarsus adductus foot type (look at the
obliquity of the base of the 2nd
metatarsal), and the MIS 1st metatarsal osteotomy
is almost mid-shaft. Unless the laterally pulling
force of the extensor hallucis brevis was
addressed, one would expect to see lateral
deviation of the hallux over time. A 6 week post-
op x-ray view is still short term result.
Also could you please send a pre-op and post-op
lateral x-ray so we can examine for any post-op
elevatus of the 1st metatarsal head of your non-
fixated mid-shaft 1st metatarsal M.I.S. osteotomy.

Keith L. Gurnick, DPM, Los Angeles, CA

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