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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 degree
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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