04/29/2023    Richard Jaffe, DPM

MIS Using a Shannon Burr For HAV Surgery: A Systematic Review

I have been watching the movement to MIS foot
procedures for well over 40 years. I always hoped
that I could rationalize the negatives and include
the technique in my list of available procedures.
Now that we have a serious study to help evaluate
the efficacy of the technique, I am as steadfastly
opposed to it as ever. Twice the complication rate?
Twice the rate of a second surgical procedure? And
for what? Has it eluded our practitioners that
recovery from foot surgery takes much longer for
bone than for soft tissue? Pain and swelling come
from bone healing, and not much from skin. And the
sum of 3 small incisions is almost as long as a
scarf incision. So, what are the advantages of MIS?

In the early years, it took only a few minutes to
perform the procedure. Indeed, I noticed the first
comments made by orthopedists who tried it always
seemed to begin with a wondrous exclamation that it
was so fast that they could perform large numbers
of them in a day. But the real advantage of MIS is
that patients are usually misled by the surgeon to
believe that it will heal faster and with less pain
than conventional procedures. They are misled to
believe it’s all about the skin incision instead of
the bone work when the opposite is true. Assertions
that post op x-rays “weren’t always pretty” is a
thinly veiled misrepresentation of the fact that
they were unacceptable by standard criteria of
evaluation. It is this kind of obfuscation to which
I object.

I also did not find in this study any evaluation of
1st ray elevatus or shortening (difficult to
control with a Shannon). These are significant
problems that may become apparent over a period of
time much longer than the data presented in the
study.

After having performed over 2,500 Scarf-Akin
procedures over the years, I had less than 2%
hardware removal and less than 2% re-operations.
Most cases were bilateral, ambulatory and strong
pain medication beyond NSAID was never necessary.
So, it seems obvious to me that the advantages of
MIS are much more in favor of the surgeon than of
the patient. Less operative and post-operative time
required and a great way to attract new patients. I
cannot help feeling that there is a vein of
dishonesty running through the profession that
demands further investigation.

Richard Jaffe, DPM, Jerusalem, Israel

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04/26/2023    Keith L. Gurnick, DPM

MIS Using a Shannon Burr For HAV Surgery: A Systematic Review

A total of 911 subjects were included, and 1088 MIS
procedures were performed. The average follow-up
was 23.8 months. All used the Shannon burr,
performed distal metatarsal osteotomies, and had to
have screw fixation.

This review found a 16.6% complication rate with
MIS hallux valgus correction, which is higher than
that reported in the literature for open procedures
of 7% to 8%. Many reasons for this increase in
complication rate with MIS hallux valgus surgery
can be considered. The hardware removal rate
accounted for almost 40% of all complications as is
likely due to screw prominence after swelling
resolves given the entry point on the medial border
of the first ray.

1) The review of 17 studies on MIS bunion using a
Shannon 44 burr and screw fixation showed twice the
complication rate of non-MIS bunionectomies.
2) Hardware removal in 40% required a second
surgery, also with predictable and associated
complication rates, and the costs (financial, pain,
time off work or activities) associated with a
second procedure. Is the 40% hardware removal "by
design of the surgeon" to get a second surgery
later, or it just happens sometimes due to the
angle of the screw placement with a small incision
and the protuberance of the screw head (which
becomes a pressure issue after the swelling
subsides and the patient returns to normal
footwear)?

3) Quoted HAV bunion recurrence rate with an
average study length of only 24 months is really
way too soon to determine recurrence and this
number is very likely under-representative of the
true number that would show up in a longer term
study.

So please can someone explain to me, why do a MIS
procedure (with screw fixation) for a bunion
correction vs. a more open procedure?

Keith L. Gurnick, DPM, Los Angeles, CA