Male Speaker: I'm going to talk to you about my go-to Bunion procedure, here's my concept on bunions. If you live in Atlanta, you're getting an Austin, if you live in Chicago you're getting a scarf, if you live in New England you're probably going to get a Mitchell, if you live in Pittsburgh or Seattle you're going to get a lapidus. So my conclusion is, as long as you do it well, doesn't matter what you do. All of these procedures are designed to reduce the IM angle and reposition the toe. Some deformities occur with rotation, some don't, so that determines what my approach is. I don't really do scarfs for no particular reason, but I will do distal osteotomies also do lapidus type procedures and I'll also do more proximal osteotomies. When I can, I do the procedure I'm going to show you. So we talked about this and what does do it well mean? Usually it means you're going to reduce the IM angle, you're going to reduce the elevation of the first metatarsal, you're going to reduce rotation if it exists because it doesn't always exist, you want to try and preserve the range of motion of the joint, you're going to use some type of internal fixation whatever that might be and then you're going to mobilize the joint as quickly as you can. My hypothesis after reading the literature was, that if I did a minimally invasive procedure, as a distal osteotomy, that I could provide equivalent results to more open procedures that I was trained on. But I thought that if I could do that, the range of motion would be better and that they could return to normal shoe gear quicker. So I had to ask a few questions while I was looking at that and the first one had a deal with hypermobility. If you read some literature, it'll say hallux valgus is caused by hypermobility. If you read the other half of the literature, it'll say hallux valgus causes hypermobility. So, which is which, I don't really know. All I do know is that every time I do an osteotomy I reduce hypermobility and if I do a lapidus, I can do away with it completely. Alright, so the key is how much hypermobility is present and how do I address it in order to reduce it as much as I can. Well first of all, a lot of the procedures we do don't even address where hypermobility occurs. We've done a number of the sections on cadavers with hypermobility and hallux valgus and guess what, the first metatarsal can you form joint looks pretty stable in all of these. Hypermobility occurs back at the navicular cuneiform, inter-cuneiform joint, we don't do anything back there to address hypermobility. Consequently, the reduction of hypermobility has to be a secondary result of our procedure. That's the joint where the hypermobility occurs. I get a kick out of certain people who say that they don't believe in hypermobility, well really? I mean what do you call this when you can move the first ray anywhere you want it, it’s like pornography, you can't define it, but you know it when you see it. Hypermobility does exist, okay? The question is, is it primary or secondary? We know the peroneus longus is situated in order to counteract hypermobility, it's at right angles to the first ray axis. What's more important to me is rotation, because I wasn't quite sure about this, there are a couple of articles that are confusing, Joe D'Amico's article says that, “When you start to get hypermobility, you get adduction, dorsiflexion and eversion of the metatarsal.” I said eversion, root said I got inversion what's that what's the scoop here? Well the scoop is you get both, it depends on when you get to see it.
At first you get eversion, because the ligaments in and around the first MTP joint won't let the first ray invert, but as those ligaments attenuate, as the tibial says more ligament stretches, then you get inversion. So, you may have to in some cases rotate the metatarsal in different directions in order to correct your hallux valgus. Here's a classic normal first MTP joint, this inner sesamoid ligament is there connecting the sesamoid, do you see the flexor is right between the sesamoids, the tibial sesamoid and fibular suspensory ligaments are exactly the same length. As you begin to get rotation as the metatarsal head rotates, you'll notice now that even though this head is rotated in eversion, the suspensory ligaments are still the same length, the sesamoids are still in their groove, this joint is stable. If you were in fact to de-rotate this as part of your bunion procedure, you'd have to invert the metatarsal in this case. In this particular case, you'll notice that there's a little bit of a difference. Now, the metatarsal is in fact still everted but look at the tibial sesamoid, it’s no longer its groove. The tibial sesamoid is in fact articulating with the crista. What's –how does this relate to your patient clinically? This is when your patient complains of pain, not just from the bump, but the joint hurts because the crista no longer is in the groove, it articulates with the crista of that joint and when you look at that, you see that the flexor instead of being right underneath the first metatarsal head is now lateral to the center point, okay. How many of you, show of hands, were taught in residency, when you're done with your bunion procedure, make sure the extensor tendon is centralized right in the middle of the joint? Most of you right? How many of you were taught, make sure your flexor tendon is right in the center of the joint? You were taught that? Where did you go?
Speaker 2: Northlake.
Male Speaker: Northlake? Chicago, Northlake? Very good, okay that doesn't surprise me. What's the reason for that? Why does the flexor tendon have to be centralized? When you're walking, you eccentrically lengthen the flexor. The extensor short as the joint dorsa flexes, the extensor has no deforming capability at all, the flexor does. So that means, you should make some attempt to make sure that your metatarsal head in your sesamoids are lined up after your bunion correction is done, I'm sorry I didn't recognize you ,I know who you are and I know you were at Northlake. So here's what the x-ray looks like, tibial sesamoids articulating with the crista, one or two things are going to happen. The metatarsal is going to continue now to invert okay? So what happened here, did the sesamoids get pulled lateral or is the metatarsal inverting away from the sesamoids? Well the sesamoids are exactly where they were before the bunion started, there are plenty of articles that show that. The sesamoids don't move, the metatarsal inverts away and if it does it slow enough it erodes the crista, if it does it fast enough, it pops right over the crista and the crista is still intact. That's what it looks like when you open the joint and the bump is usually where the tibial sesamoid ligament attaches to the metatarsal head. So is it enthuses, is it an enthesopathy? Could be ,it’s a traction periostitis on the medial dorsal aspect of the bump. Alright and then your rotational deformity continues, no need to belabor this, I just want to point out that rotation can be part of a lot of hallux valgus deformity. So, if you look at the literature going back quite a few years, there are a number of articles that tout doing minimally invasive surgery.
Used to be called minimal incision surgery, now it's minimally invasive, what's the big difference? Well, when I was president of the surgery board, minimal incision surgery was usually done in offices without the benefit of fluoroscopy and it was blind surgery. What used to impress me was that every now and then I saw a procedure that worked out perfect and I said, “How is that possible? You can't see what you're doing, you stick a burr in there and you blast everything to smithereens doing akin to straighten the toe, that can't possibly turn out well.” And guess what sometimes it did, so my interest in that kind of approach never really died and then I saw an article by Giannini, Sandro Giannini is an Italian orthopedist whom I've spent many times -- much time with at the Rizzoli institute in Bologna and what I like about this guy is that he is a very honest reporter. A very honest reporter any basis everything he does in biomechanics, sound familiar? Kind of like what we hope to do when we're addressing deformities and he did a simple effective procedure so-called serie from mild to moderate deformities, inter metatarsal angles no greater than 20 with instability and he did it in such a way that it was a minimally invasive approach. Many other articles followed, the number of procedures increased, everybody's technique was basically the same with small little modifications in what they did. The last article the Giannini published was on a thousand procedures, so in Europe and especially Italy, Giannini is the head orthopedist of the Bologna region. That means, unless you want to pay cash to have your bunion done, you're going to see him to have it done. Not a bad deal, alright? But, he published an article on a thousand procedures. This is not the Reverdin-Isham technique, which is in the literature frequently recently. Here you see in this technique, the bump is removed and a revertant type procedure obliqued from dorsal distal to plantar proximal is done, this is not that alright and I'm going to get to the procedure so that we don't waste time with this. This is what it looks like red one in monsieur procedure utilizing a Steinmann pin or K-wire for fixation. So, here's the percutaneous distal metatarsal osteotomy. A Steinmann pin is placed subcutaneously in the hallux not through bone, subcutaneously, down to the level of the bump. A K-wire is then drilled from medial to lateral at the location of your osteotomy. So you can place that K-wire neutrally if you don't want to affect length, you can angle it back if you want to shorten the metatarsal, you can angle it forward if you want to lengthen the metatarsal, that's your osteotomy guide. You can do the osteotomy in one of two ways, one of my former fellows likes to do the Wagner osteotomy technique multiple drill holes combination saw an osteotome, I just use this saw. We're comparing our results to see if there's any difference in the healing rates, but you do a complete through and through us osteotomy, why? That's the only way you can reduce rotation. If you don't have rotation you don't have to do this technique, if you do have rotation you have to do a through-and-through osteotomy and there it is and then use the osteotome to mobilize the capital fragment.
In this particular case, we place a hemostat down the medullary canal of the first metatarsal, that Steinmann pin that was originally put subcutaneously in the hallux is drilled and it bounces off the hemostat into the medullary canal of the metatarsal, all of this being done through a one or two centimeter incision. If you have a lot of hypermobility you can run the pin back into the cuneiform as you see here. What you expect is over a period of time, because of the lack of soft-tissue de section that you've done, you get quick and complete formation of periosteal proliferation healing the osteotomy and because your Steinmann pin overcorrected the hallux for the first four weeks, you stretch out all your soft tissue. Here are a couple of results, pretty much all look the same. Notice a couple of things, the head is over the sesamoids is that because I mobilized the sesamoids? Absolutely not I de-rotated it, I de-rotated the metatarsal head, so now as I de-rotate the metatarsal head that sesamoids move with the metatarsal head and end up underneath. Most important part of that is that your flexor is centralized. That's the incision, by the way is it necessary to drill that axis guide for your saw? I still think it is, because even as many of these as I've done, if you try to freehand this by sight, you end up cutting the metatarsal too far proximal. So the bump is an Illusion, most of these osteotomies have to start within the bump, not directly behind it, as soon as you’re directly behind it, you're in the shaft. Your incision goes down to bone, you take an elevator and lift the periosteum off the bone to make room for your saw, you then drill a K-wire across which is going to be the location of your osteotomy. See, notice it starting in the bump, that's where I think it has to start, there it is drilled across. Now in this particular case, I put this Steinmann pin in the toe afterwards, right now, I actually put it in not from the distal of the toe but through my incision. So I put it in through my incision, out distally and then retrograde it back into the metatarsal. There's the saw, it uses the pin as the osteotomy guide and then once the capital fragment is mobilized as you see here, the pins removed, a hemostat’s placed in the medullary canal, the Steinmann pin bounces off the hemostat into the medullary canal of the metatarsal. And then it's either drilled back into the cuneiform or hammered back. In the beginning, I didn't take off the bump, that ledge because both – the procedure as it's done in Italy, Giannini didn't. I've had one or two patients that complained about that. So now I just take it off either with a rongeur as you'll see on the movie, with a power saw. And that's the final product, alright? The Steinmann pin is back in the cuneiform. This patient walks in a flat surgical shoe immediately. Steinmann pin stays in place for weeks. And the first question is, what holds it in place? The Steinmann pin. There's no soft tissue.
The reason you need all of these screws, plates and everything else and a lot of these open bunions, is that you’ve detached every piece of soft tissue from the bone where you made your cut, something's got to hold it in place. In this particular case, the only thing that's been removed is the track for the saw, all the other soft tissue is in place as evidenced by the way it heals, you can see how the periosteum fills in right underneath where it's moved and there it is in place. Two centimeter incision, you overcorrect the hallux and then as soon as this Steinmann Pin comes out the hallux seeks its straight level. My hospital loves to see these on the schedule, I use a Steinmann pin and it takes about seven minutes. So they still charge for the hour and they're not using an eighteen hundred dollar locking plate for the bunion procedure, alright. There is what it looks like, looks great, patients love it, range of motion of the hallux is fantastic, absolutely fantastic range of motion. We got cute on a couple and said, “Well, maybe we can bury the pin.” It worked ok for the osteotomy but part of the procedure is that Steinmann Pin overcorrecting the hallux and stretching all the lateral structures around the first MTP joint, so I don't –as much as I can do it this way, I don't like to. I like this Steinmann Pin coming out the front of the toe. So my conclusions were that this procedure is minimally invasive, it gives me direct vision of everything I’m cutting, it's not done blind and we've cut the operating time down considerably in half, it used to take his 10 to 15 minutes takes about seven now. Minimal dissection, less disruption of the capsular structures which maintains the position in vascular supply the capital fragment with minimal fixation. High patient satisfaction, immediate return to weight bearing and obviously a less visible scar. I'm not going to get into mechanical axis planning, that's a lecture in itself, maybe we'll do that next year, but let's just say that there is an ideal position for each metatarsal following correction of a bunion deformity and there's an easy way to plot where that is. So as of date we have a hundred thirty-five procedures, one week to six year follow-up, two surgeons myself and Norman Siddiqui done with either a power saw or an osteotome, complication include two superficial infections at the entry site of the pin treated by antibiotics and cleared. Two dislocated capital fragments which did require return to the operating room to reduce it much like you would a fracture, we have since learned that the positioning of this time Steinmann Pin is responsible for that, one not painful, non-union and three delayed unions which took close to six months to heal. Here's the procedure and this procedure is done by a second-year resident. Periosteal elevator creates a groove for the saw just lift the soft tissue off, protects the extensor and flexor tendons, there's the 6-2 k-wire this is all being done and checked on fluoroscopy, then the Steinmann Pin from the incision out subcutaneously not through bone. Osteotomy with a saw through and through.
Capital fragment moves, K -wire removed, Steinmann pin is overcorrected, bounced off the hemostat into the metatarsal shaft checked on c-arm, overcorrected hallux, bend the pin, bandage, flat surgical shoe. There's that little ledge in this particular case removed with a power saw and then closure. So, whenever I have rotation as part of the deformity this is the procedure I do, very effective, patients are appreciative of the fact that they can bear weight immediately in a post-op shoe, they're all so appreciative of the fact believe it or not that there's no metal in there once you're done and remove the Steinmann Pin, Steinmann Pin is removed in the office, don't even need anesthesia 99.9 percent of the time to do it and it's a very satisfying…