Minimally invasive percutaneous bunionectomy without fixation produces reliable and durable correction, functional improvement and decreased pain, according to a recent study in Foot and Ankle International.
Following 195 patients for nearly three years after they had the procedure, the study authors showed significant improvement in radiographic angles, pain scores, patient satisfaction and functional assessments. They noted that complications occurred in 9. 7 percent of the cases studied.
Neal Blitz, DPM, FACFAS relates his experience with minimally invasive bunion surgery is largely positive. He acknowledges it is not for every case and each method has advantages and disadvantages. Dr. Blitz cites improved cosmesis and structural results similar to that of an open bunionectomy.
“(Minimally invasive) techniques are easiest for the moderate bunion,” maintains Dr. Blitz, who is in private practice in New York City and Beverly Hills, Calif.
He says surgeons should strongly consider establishing their own radiographic guidelines to identify when they would feel comfortable utilizing a particular minimally invasive method.
Patrick DeHeer, DPM, FACFAS also relates positive results in his experience using a SERI (simple, effective, rapid, inexpensive)/Bosch minimal incision procedure in addition to a separate Lapidus/first MPJ arthrodesis/proximal triplanar osteotomy.
Dr. DeHeer explains his minimal incision procedure of choice is basically a Hohmann procedure, which allows for triplanar correction. While Dr.
DeHeer points out that this study did not evaluate multiplanar results, he says the transverse plane deformity correction is consistent with outcomes in his practice.
Dr. Blitz shares that complications due to lack of fixation likely caused these methods to fall out of favor in years past. He feels the complication rate in this study is encouraging but emphasizes an associated steep learning curve. In his experience, Dr.
Blitz feels that screw or plate fixation in minimally invasive bunionectomies is superior to K-wires.
Conversely, Dr. DeHeer says the lack of fixation would be problematic for long-term correction.
“I have significant concerns about the lack of fixation used in this (study) regarding the maintenance of correction for the frontal and sagittal planes, neither of which were quantified in this study,” notes Dr. DeHeer, who is in private practice in multiple locations in Indianapolis.
He states the SERI procedure utilizes a single 2. 0 mm (5/64 inch) pin, creating a tension-band type of fixation. He drives the pin into the navicular, locking the frontal and transverse planes past the first metatarsocuneiform joint. Dr. DeHeer also uses a bicortical 0.
062 inch K-wire from the dorsal lateral distal metatarsal head, plantar proximal and medially across the osteotomy site to lock the sagittal plane and avoid elevation.
Dr. Blitz points out that any bunion surgery method has associated complications which can include malunion, delayed/non-union, neuritis, hallux varus, metatarsalgia, fixation failure and recurrence.
Referring to this study, he feels that using fixation may lessen the malunion shifts in the metatarsal and possible metatarsalgia, but could also open the door to fixation-related complications.
Dr. DeHeer agrees that much of the complications noted in this study can be tied to lack of fixation but relates that overall complications with minimally invasive techniques can be low.
The most common complication in his experience is discomfort at the osteotomy site, which the authors also noted in the study.