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12/23/2016 Don Peacock, DPM
The MIS Akin Osteotomy (Keith Gurnick, DPM)
I agree with Dr. Gurnick's conclusion with regard to the necessity of weight-bearing lateral x-rays for appropriate assessment. In my original post, I included both AP and lateral x-rays pre and post. Only the AP x-rays were published.
This patient had a relatively small IM angle and our differing measurements may reflect some differences in how we are viewing the IM angle. Our measurements are not drastically different, and as Dr. Gurnick states good correction is noted. Also both of us are getting improved changes in the HA angle and IM post-operatively to within the normal range.
I have plenty of other cases showing stronger corrections in the IM for moderate to severe bunions using MIS protocols. For these patients, I use a procedure that I have published called the PRIBB procedure and I employ percutaneous fixation with this procedure. You can look up that publication and see more drastic IM angle corrections using this MIS surgical technique. I would be happy to post some of these as well.
There is some shortening and Dr Gurnick measures 4-5 mm shortening. That's actually good. The average shortening in a traditional Austin is 4-6 mm in studies published (Klosick, et al. ref in McGlamry). In this study an average of 6 mm shortening was seen after the Austin and only 5 patients out of the 85 complained of transfer metatarsalgia and the shortening did not correlate with symptoms. X- ray evaluation alone cannot predict transfer metatarsalgia except in excessive shortening cases. To combat the shortening seen using a burr I describe how to do this in the PRIBB technique.
Remember that studies show improvement of 1st ray stability after bunion correction even in the inevitable shortening we get with 1st ray head osteotomies. Dr Gurnick's post is a nice academic post and his points are all valid. Lateral x-rays are mandatory for true bunion surgery evaluation as he states and showing the whole foot x ray is important. All posts would be better evaluated if we show the laterals and APs of the entire foot.
Don Peacock, DPM, Whiteville, NC
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12/26/2016 Dieter J Fellner, DPM
The MIS Akin Osteotomy (Keith Gurnick, DPM)
On the question of the shortening of the first metatarsal S/P osteotomy: this is really not an issue, and might often be a desirable effect. With an osteotomy to decompress and reduce the mechanical forces on the joint, this results in the 'buckling' and displacement of the 1st MTPJ.
There are two important caveats:
First, the sesamoid apparatus must be positioned in the correct anatomical alignment, in relation to the first metatarsal head. There is very little tolerance to this rule, if a surgeon wants to optimize on outcome, a flexible 1st MTPJ and provide for a lasting correction. Secondly, the sagittal alignment of the first metatarsal must be balanced correctly with the lesser metatarsals. This requires of a surgeon a need to exercise due diligence, intra-operatively to evaluate and adjust, as required. This second requirement will take into account the position and flexibility of the segment and loading response - this is an acquired skill, one that requires good judgment.
If I have an issue with some of the minimally invasive bunion surgery techniques, it is the fact that a surgeon cannot always easily evaluate effectively, to make such an adjustment intra-operatively, when this is required. The SERI procedure is a notable exception.
When both criteria are satisfactorily met, the 1st metatarsal will correctly engage the Windlass mechanism to allow for correct function and weight distribution, in gait. In such a circumstance, the absolute length of the first metatarsal is almost irrelevant - or at least a secondary concern. A short metatarsal will not, then, automatically expose a patient to the risk of transfer metatarsalgia, or related issues.
Dieter J Fellner, DPM, NY, NY
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