Name: Minimally Invasive Bunion Correction
Uploaded: 2020-07-15T00:00:00Z
Channel: Arthrex
Description: Jorge I. Acevedo, MD (Jacksonville, FL), discusses tips and pearls for performing minimally invasive bunion surgery and provides technique overviews along with case examples.

<p>Jorge I. Acevedo, MD (Jacksonville, FL), discusses tips and pearls for performing minimally invasive bunion surgery and provides technique overviews along with case examples.</p>

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VID1-000750-en-US | B | Minimally Invasive Bunion Correction

Jorge I. Acevedo

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Chirurg:innen präsentieren einen oder mehrere klinische Fälle

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Minimally Invasive Bunion Correction

I'm doctor Jorge Acevedo. We're here talking about minimally invasive valgus correction. I'm going to give you a few case presentations and briefly go over the technique and the rationale behind the technique. So the indications are very similar to what we have for open procedures. You have a lower threshold because you're making smaller incisions. And basically it can be used more readily for primary and revision valgus surgery. Really your only limitation is the ability to shift that metatarsal head because it does allow for multi-planar correction. So if we look at the difference, you know, of the incisions, you can see the traditional open incision on the left and really the massive incisions that we used to do comparatively on the right where we have basically almost imperceptible incisions. But really, the take home here is that we're really using just smaller incisions, along with some specialized instruments to accomplish the same goals and results as we did for open surgery. And the goals are the same. We're trying to decrease pain, improve function, and correct the deformity as far as the equipment. This is not your typical bur. It's a high torque low velocity bur. So it's and you can control the speed. So that really decreases and avoids the potential for some of the earlier studies which showed bone and tissue necrosis, the burs typically are set at a 6000 rpms. And the nice thing about this equipment is that you have constant fluid flow. And that really cools down your cuts quite nicely, avoiding the bone and tissue necrosis. The typical burs that we use, there's basically shorter and longer Shannon burs. They're called they're in cutting burs. So they don't wrap up the tissue as readily as your regular burs. And then you have conical burs that we use. And I'll show you some examples of this to for the colectomy portion of of your procedure. Okay. So from an anatomic standpoint the group out of Spain with Magdalena and Mickey Dalmau have done an excellent job in defining the dorsal medial digital nerve and the dorsal lateral digital nerve and their location. Because you still have to respect your anatomy and be mindful of it, even more so when you're doing it minimally invasive. And what they've basically shown is that these nerves are typically found in the 10:00 and the 2:00 position, depending on whether you're on the right foot or the left foot. So they've done a beautiful job of defining this from an anatomic standpoint, and there are others, even in more recent studies that have shown clinical outcomes of minimally invasive surgery being equivalent to the open scarf osteotomy. So we can either do a minimally invasive chevron akin osteotomy, which is Amica, or a minimally invasive transverse akin osteotomy. And really, with the equipment I'm going to show you today, you can do either. So here's a typical 40 year old with a moderate valgus deformity that you would consider at least doing a chevron, if not a chevron akin osteotomy. So the bur here's the bur. You're going to penetrate the near cortex and the far cortex. And typically we use a transverse osteotomy or a pretty shallow chevron osteotomy. So this allows you to cut the superior surface as well as the inferior portion of the metatarsal So once you have made your cut, you can easily translate it. And I'll show you examples of this and put your fixation screws in. And then you're ready to go on to the akin osteotomy. And in a similar fashion, you don't want to penetrate the far cortex in the akin. And you make your basically typical akin osteotomy. We tend to do more of oblique osteotomy to give you a little bit more landscape to fire your screw in, and you'll see what I mean in a second. But basically, for the akin, we'd use a 2.5 headless screw for the chevron or the transverse osteotomy, we would use a 3.5 or 4.0 millimeter screw. You can then do your medial resection like you would do normally, and you could use any of the two small incisions that you've already made in order to accomplish this. So two things. You want to shave. You want to shave the medial overhang from your translation of your osteotomy. And you can also shave the medial eminence. And I'll show you. Here's a picture of shaving the medial eminence. And here I'm going through the my portal of my akin osteotomy in order to accomplish this. Here's four weeks post-op on that minimally invasive transverse aken patient that I showed you earlier. And you can see at four weeks how the swelling is decreased significantly. The incisions are basically almost completely healed. Here's one of my patients who I basically videoed just to show you that this is actually what patients are telling me. This is a patient who had six, six weeks post-op on the right, minimally invasive surgery versus ten years ago, an open surgery. And it's really dramatic, as you'll see in this testimonial, how their perception of the mis versus open. And I think this is some of my happiest patients are those that have had open on one side and then do the miss on the other, because they have that ability to compare and contrast the differences. She's six weeks out from Miss Chevron on the right, had open Chevron on the left ten years ago. And so how are you doing, Miss Bassett? I'm doing really well. I was able to wear a sneaker today. Walk on the beach. Very comfortable. No pain issues without the incision on the top. It's much better. So here I'm showing the bur being inserted through the near cortex and the far cortex initially. And I usually check that under fluoro to make sure that we've our trajectory is correct and that we're not shortening the osteotomy. You can see I'm angling it slightly towards the second metatarsal in order to avoid that that shortening. You can then place a guide wire, which will then help you maintain your shift so you can put either a small hemostat or a sayer elevator in order to accomplish the shift. And then you can pass this this wire intramedullary. And that will help hold your correction. But it's very important that you have this hand positioning where you're actually holding the toe over and making sure that the osteotomy does not displace inferiorly. As you can see, I'm quoting Doctor Redfern because this is his picture. And basically this is what you want to emulate when you're, when you're translating the osteotomy. So in this case example here you see moderate to severe valgus deformity and the kind of correction you can get with the minimally invasive chevron akin osteotomy. So what's our postoperative management? Well, basically you can wait for them as tolerated in the heel or lateral aspect of the foot immediately in a surgical shoe or a boot. I find in my patient population that they, they're feeling so well and, and the incisions are so small that they're kind of overdoing it. So I've kept them in a boot for the first six weeks, even though they can wait. Bear as tolerated in that boot. And basically the transition to the shoe is going to be edema dependent. So once the edema goes down, then they can go to a regular shoe. As far as the toe spacer, you really don't need much of a toe spacer, but you can maintain that there for six weeks. We expect light exercise at 8 to 10 weeks and impact sports as early as 10 to 12 weeks in some patients. So what are the pearls? The pearls of minimally invasive surgery is make sure that, you know this is this is no different than with open procedure. You have to preoperatively plan your site and location of the osteotomy. You know, implant accuracy is very important. So be patient, because when you're starting off, this is probably the most difficult task. Just a simple task like K-wires placement is extremely important. So this is where you need to allow extra time during the initial cases. Once you get good at it, this this becomes second nature, just like everything else we do in the operating room. But be mindful of the extra time involved in placing of the K-wires, as well as the extra time that that is required. So you may want to wear some lead initially when you're starting off. And remember that the basic principles have not changed. Have plan B and C, especially when you're starting, just in case you have to bail to an open procedure.