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Anyone using the mini-tight rope/bunionectomy procedure?

Discussion in 'Foot Surgery' started by dennis l berger dpm, Oct 22, 2007.


  1. Members do not see these Ads. Sign Up.
    I am curious as to how many foot surgeons are utilzing the mini-tight rope/bunionectomy procedure and what their results have been including patient satisfaction and post-operative results.Your response is appreciated.
    dennis l berger dpm dlbdpm
  2. drsarbes

    drsarbes Well-Known Member

    Good question Dennis. I too would be interested.
    I've seen it performed, but to be quite honest, was not impressed with it.
    Whether or not this is accurate, it seemed to me one of those procedures that was developed backwards, i.e., what procedure can we develop that will utilize something we can supply and sell?
    I'd be curious as to how "comfortable" it is to have the first and second mets basically tied together and jamming the met/cun joints. Also the long term effects of the "buttons" on the shafts.
  3. Steve,
    I have used it 9 times.And I have a complication rate of more than 50%.While it is technically easy to perform, I have fractured the 2nd MT,lost correction by loosening of the fiber wire,and had the brackets not maintain compression intra-operatively.The learning curve is depressing me.However, the positive results are most impressive.This is a classic no brainer for a short 1st MT with high IM angle and hypermobile !st ray
    I was hoping to find others that would be using the device.While I believe the 1st MT transverse plane deformity is addressed,the saggital plane motion is not stabilized adequately with the procedure.Currently a second point of fixation was utilized.I'll see how that goes.
    Dennis dlbdpm@yahoo.com
  4. Bruce Williams

    Bruce Williams Well-Known Member

    I've used it 3 times. Twice on the same patient for bilateral HAV w/ a 24 and 18 degree IM respectively. I used an Austin w/ a screw fixation as well as the mini-TR.

    the closure of the IM is at least an extra 4-6 degrees. I find that very good. I am only about 3 months post-op on the first one, but patient is back into shoe and still has a mild bunion deformity. She knew this would be the case but is still pleased to not have to go into a cast post-op.

    I had one pull-through on another osteoporotic patient with eventual fx of teh 2nd met. She's doing well and healing uneventfully.

    I think it is ok. I agree no sagital plane restriction, but patient ambulate very quickly. I've not tried it on a smaller bunion so far.
  5. Nat

    Nat Active Member

    I've done close to 20, and our group practice has done close to 30 total. Those numbers include one tailor's bunion and one juvenile bunion.

    When it works, it works great. There is less down-time than with a Lapidus or base wedge. There is also generally less edema and pain. Patients appreciate not having to be non-weightbearing. Since there's no osteotomy, there is no methead AVN or capital fragment displacement as one would risk with a head procedure. You also gain more correction and 1st ray linearity than with a head procedure. Biggest pre-op IMA was 19 degrees.

    We've had four cases of 2nd metatarsal fracture or implant failure. In one case the 2nd met drill hole was too dorsal (I think). In two cases the patients were osteopenic. In the fourth case I haven't yet deduced what happened.

    I think the biggest complication people are experiencing is 2nd met fracture. My hunch is that there is too much force concentrated at the small 2nd met button, and it causes a stress fracture leading to frank fracture in certain patients. I think we still need to clarify patient selection. I will no longer use it on patients with osteopenia. We need to figure out maximum patient weight limit.

    Steve, we have had zero complaints of met-cun joint discomfort. I was concerned about that possibility too, but it has not been an issue.

    Dennis, I have noticed a significant reduction in sagittal plane mobility, yet it allows a "normal" ROM, but I'm curios as to what was your second point of fixation that you mentioned?


    Edit: Overall patient satisfaction has been outstanding except in the cases of failure. In those cases you can guess their satisfaction level.
    Last edited: Oct 25, 2007
  6. Nat,
    You are correct,when it works well,it is excellent.Failure causes a pain in the posterior.My feeling is the transverse plane is well controlled,but the saggital plane of the 1st mt is not--at least until adequate consolidation of the holes around the fiber wire has been attained.The second point of fixation was a 5/64 steinman pin driven transversely from mt1 through mt2&3.That puppy was rigid.I also figured the patient coulg continue to walk(with assistance) in the post-op shoe.I also incorporated a small posterior splint (3x12" by 3MMM).Currently there is no problem,the pin will stay 6-8 weeks,ROM will be unimpeded.

  7. Nat

    Nat Active Member

    I just saw a post-op this morning with a 2nd met fx. It is indeed a pain. I have started incorporating a plate beneath the lateral button such that it acts as a buttress against the 2nd met. I hope that the plate disperses the forces away from the button across more of the bone.
  8. Bruce Williams

    Bruce Williams Well-Known Member

    at what point does utilizing a mini-TR and plate become as troublesome as just doint an Austing w/ a screw?

    I still have not done one in a smaller IM, though I am contemplating it. BTW, my pull through did finally fx at the 2nd. She's healing well though.

    Bruce Williams
  9. Nat

    Nat Active Member

    I can't recall how you ended up fixating the 2nd. Did you use a pin or plate?

    I actually prefer using the TR for a smaller IMA (i.e., those folks for whom I would've done an Austin). They get a great reduction and I don't need as much tension in the suture to hold the reduction. My Austins all seem to need an awful lot of post-op PT to avoid ROM-limiting scar tissue. Even with PT, many patients end up with limited ROM. The TR's all seem to have great p/o ROM with less swelling and pain.

    For me the debate is more TR v. Lapidus.

    I caught a lecture at a conference last week during which the speaker was discussing "1st ray co-linearity." The topic discussed the alignment of not just the 1st met but also the soft tissues around the 1st ray. He felt that by addressing the bunion at the point of deformity (the 1st TMTJ) there was better alignment of all structures. It seemed logical even though he had no evidence. The TR and Lapidus gives better "co-linearity" than a head procedure. If only we could figure out how to reduce the 2nd met complications, this procedure would excel.
  10. Nat

    Nat Active Member

    Further thoughts:

    You know what I'd like to see? I'd like some type of semi-flexible rod that would cross the 1st TMTJ. The rod would hold the 1st met in an adequately reduced position, yet would have enough elasticity to allow physiologic ROM of that joint. Picture a leaf spring of some sort. It would have to be able to withstand practically infinite cycles prior to fatigue, rather than breaking like a K-wire or S-pin. One would not have to do an osteotomy or joint fusion. One would just reduce the deformity then insert the rod to hold things in place. Wouldn't that be nifty?

  11. Nat

    Nat Active Member

    Nice timing, just this morning I had a mini-TR on the schedule but decided against it and did the good ol' Austin instead. She is 80 and has questionable bone stock. I didn't feel like fixing a 2nd met fracture in 4 weeks!
  12. Nat

    Nat Active Member

    I did not think of it while this thread was fresh, but one of yesterday's cases reminded me to post here about another option. In the case of excessive 1st ray dorsiflexion one can also do a Cotton procedure to plantarflex the ray. We used an allograft plus OsStaple.

  13. Recent utilization of a second point of fixation has proven currently successful.It is my impression that the concept of the mini tight rope is excellent,however,the second mt does not have the necessary mass to control/limit the dynamic normal rom of the 1st mt.The mini tight rope does not always have the ability to control the hypermobility of the 1st ray(what it was designed to do) and that is why the 5/64 steinman pin inserted at the mt bases has proven successful in conjunction with the mini tr. The real question becomes efficacy.....since the s-pin remains approximately 8 weeks, why not just perform the osteotomy and proceed as before?
  14. Nat

    Nat Active Member

    I have been asking myself that same question. Since my recovery course has been extending from what seemed initially possible, the benefits of the TR are less pronounced. I have been holding my breath hoping that patients don't fracture the 2nd met, leaving me with a mess to clean up. The biggest benefit I've been seeing still is relatively less p/o edema and pain.

    I am moving towards doing more Lapidus procedures using a locking plate plus Mini Rail external fixator.
  15. drsarbes

    drsarbes Well-Known Member

    Hi Nat:
    Just wondering why, on these "moderate" bunions, you do not use a distal metatarsal osteotomy with perhaps an Akin.
    These do heal very quickly, are quite corrective and rarely have complications.
  16. Nat

    Nat Active Member

    I have had less edema and stiffness with the TightRope than with the distal metatarsal osteotomies (DMO). For some reason my DMO's need a huge amount of ROM exercises to not scar down whereas the TR's stay very mobile. The anatomical structures appear to line up so nicely on x-ray too.

    Speaking of DMO complications, I just saw a 4 week Austin p/o whose capital fragment shifted out of place into the intermetatarsal space. Son of a gun.

  17. drsarbes

    drsarbes Well-Known Member

    Hi Nat:
    Any new news with the tight rope?

    I happened to bump into the rep yesterday who's pushing me hard to try it out. NO ONE in my town (four hospitals) has used it yet. Apparently the regular size tight rope has been used for tib-fib syndesmotic repair with good result.

    In any event, he's visiting with me tomorrow to show it to me again.

    Can I ask what your criteria is for selecting it?


  18. Nat

    Nat Active Member

    Sent to your PM inbox.
    Last edited: Feb 20, 2008
  19. Bruce Williams

    Bruce Williams Well-Known Member

    I just took the ABPS recert exam on Friday. Wouldn't you know it there was a question on the tightrope on that exam!

    At least I got one right! :dizzy:

  20. Nat

    Nat Active Member

    Are you serious?!?! When I talked to someone representing ABPS he discounted the Mini-TR, saying it was more-or-less invalid. Now they're testing on it!
  21. Bruce Williams

    Bruce Williams Well-Known Member

    yep! Unless I got it wrong, which is a distinct possibility!, the main answer is that there are risks of a 2nd metatarsal fx w/ use of the device. Duh! Been there and done that!

  22. In my opinion the mini tight rope is inadequate to maintain IM reduction/hypermobilty as purported.a second point of fixation is required proximally in conjunction with immobilization.subsequently,the mini tr provides no benefit over osteotomy in the 1st mt. personally,I have abandoned the procedure as the risk is greater than the reward.the correction is not maintained as is easily accomplished with other more traditional procedures.

  23. drsarbes

    drsarbes Well-Known Member

    Hi Dennis:
    Thanks for the opinion based on your experience.
    Do you happen to know how the mini was developed?
    I have a sneaking suspicion that the regular sized tight rope was developed for syndesmotic tears and someone in R&D wanted to find another use for it; Failing to do this it seems reasonable they selected a common procedure (like bunions) and reworked the size and handed it over to marketing/sales force.

    If someone were to explain and describe this procedure to me in anticipation of developing it, I would have a negative opinion as to it's chances of success.

    Years ago there was a Podiatric Surgeon in New Jersey where I was doing a summer preceptorship who routinely put a 2X0 Tevdek suture between the first and second MTPJ capsules (basically tying the lateral 1st capsule to the medial 2nd) - I always felt it was rediculous to think this would stay in place upon weight bearing. I also feel its asking a lot of the second metatarsal to hold the first met in place via fiberwire.

  24. Dieter Fellner

    Dieter Fellner Well-Known Member

    I have not seen a technical description of it. But I saw impressive adverts for this ‘groundbreaking’ operation in the New York Post (?), when I was there last October. I got the impression this technique is functionally similar to the cerclage technique, right? I first knew about it 18 years ago during my surgical training, when I rubbed shoulders occasionally with a highly experienced orthopaedic surgeon whom I shadowed. He tried it out, once in a while - it never caught on, but the post-op x-rays I saw was showing the wire eating through the second metatarsal; now that was impressive to the attending Podiatry student. This picture burnt into my mind, as an education to avoid this procedure. Even when buttons got used there were 2nd metatarsal fractures. Has there been a technological advance since then, to improve on this ?

    In my mind this procedure is conceptually flawed. This is simply because many of the cases of hallux valgus have a common theme. There are huge mechanical forces and the aggregate effect is that the joint segment simply buckles ‘under the weight’. For a lasting correction the operation has to have the potential to modify those weight bearing forces. This can be achieved in the time honoured way by altering the alignment of the 1st metatarsal, in both transverse and sagittal plane, and by considering the 1st metatarsal index also to balance out the forefoot pressure and encourage normal 1st MTP joint function. In this respect decompression can be a very useful adjunct, when carefully balanced and when taking into account those variables affecting your patient’s foot.

    My 2c worth.
    Last edited: Feb 27, 2008
  25. drsarbes

    drsarbes Well-Known Member

    Interesting study in Vol. 29 No. 1 (jan 08) Foot & Ankle International on the tight rope. They compared the stability of the tight rope fixation for Tibfib syndesomotic ruptures vs Screw. The Tight rope did not fair well.
    I have a feeling this system will be pulled eventually.
  26. Steve, Dennis, Bruce, Nat and Dieter:

    I have been reading the interesting discussion on the mini-tightrope bunionectomy and had some thoughts that I would like to share.

    First of all, I am having a difficult time understanding how one could expect the rather large diameter 1st metatarsal to be able to be “pulled into place” by tying it to the much smaller diameter 2nd metatarsal without the 2nd metatarsal suffering some type of stress injury, such as stress fracture. The 2nd metatarsal is not adapted structurally to be pulled medially by a small diameter wire, especially with a hole drilled into the 2nd metatarsal [which will greatly increase the magnitude of stress within the bone adjacent to the drill hole] without some stress injury occurring. Possibly if the anchoring material was composed of a material that had less stiffness than a mini-tightrope, so that it would elongate more when a tensile force was placed across it, and possibly if the anchoring material was attached to the metatarsal across a broader surface area of the 2nd metatarsal, there would be much less chance of 2nd metatarsal stress injury using this type of bunionectomy.

    Secondly, tying the 1st metatarsal to the 2nd metatarsal with some form of suture material for bunionectomy surgeries have been used for years by orthopedic surgeons. An orthopedic surgeon that I did surgery with over 22 years ago performed Lapidus bunionectomies by removing the 1st metatarsal-cuneiform joint and then tying the 1st and 2nd metatarsal necks together with non-absorbable suture. Thankfully, after I showed him how well a modified Reverdin bunionectomy or closing base wedge osteotomies worked at realigning and correcting bunions, without the post-operative morbidity of his preferred bunionectomy procedure, he quit doing bunion surgeries by his previous preferred method.

    Third, I think Steve is right in saying that some companies are always looking for ways to make us use their surgical product, regardless of whether that product has been fully tested by experienced surgeons over an adequate period of time. This is made worse by the surgeons who, in their desire to make a name for themselves, experiment on patients by doing procedures that will allow them to say that “they invented the procedure”, without fully disclosing the many pitfalls with “their procedure”. Of course, in hindsight, everything seems to have much greater clarity. But in the case of the mini-tightrope bunionectomy, hopefully all of these stress fractures that are occurring on the 2nd metatarsals of patients won’t cause iatrogenic 3rd metatarsal head pathologies or iatrogenic 2nd digit hammertoe deformities or iatrogenic 2nd digit floating toe deformities in the future for these patients.
    Last edited: Feb 29, 2008
  27. Alank

    Alank Member

    I have done a number of the Minitightrope bunionectomies. The procedure requires a soft tissue release around the first metatarsal head in the same manner as any other bunionectomy. It also requires a second incision to place the tightrope through the second metatarsal. The hole is fairly large to accommodate the retaining button. The primary concern of lesser metatarsal fracturing has been during the healing process of this hole. The patient needs to be treated postoperatively with a protective boot and minimal weight bearing.

    The concern for a second metatarsal fracture is a very legitimate one. I have seen two of them out of 9 procedures. Both occurred early in patients that were very active. The first was in a patient who simply did not use the recommended protective Aircast boot. Amazingly, she would not use the boot even after fracturing but went on to heal uneventfully.

    There is clearly less postoperative disability with the procedure. In a flexible foot, the tightrope will reduce a large IM angle. The question of how they will do over time remains. Patients need to be very clearly advised regarding the newness of the procedure, the lack of long term follow-up and potential need for revision in the event of recurrence and failure. Knots can release and the tightrope can break too. With my longest follow-up of almost a year, even with the two fractures, the patients so far are happy. They also included two patients who had their other foot previously done the more standard way with a first metatarsal osteotomy. Both were much happier with the tightrope. Still, the numbers are way too small to constitute anything more than an observation to date. Time will tell.
  28. auna

    auna Welcome New Poster

    Can anyone help code this procedure? Need CPT codes
  29. Nat

    Nat Active Member

    Check your private messages.
  30. Barbara L

    Barbara L Welcome New Poster

    Did you ever get an answer to your question re tight rope surgery? Barbara L
  31. Nat

    Nat Active Member

    Barbara, I count 28 replies in this thread. Was there something further you wish to ask?

    Edit: Make that 29 prior to yours.
  32. NewsBot

    NewsBot The Admin that posts the news.

    Last edited by a moderator: Sep 22, 2016
  33. Toetruk

    Toetruk Welcome New Poster

    I have done over 25 of these and have had very good to excellent results. Most importantly the patients are happy. I had one 2nd metatarsal fracture when I first started doing them, but none since I am using the 1.1 K wire technique Also, I had one where Fiberwire became loose and did the procedure again with no problems to date.

    It is an excellent alternative to base wedge osteotomies when the patients will not tolerate being non-weight bearing, especially in older patients.

    Robert Leisten DPM DABPS
    Houston, Texas
  34. NewsBot

    NewsBot The Admin that posts the news.

    Use of the Mini TightRope® for Correction of Hallux Varus Deformity.
    Gerbert J, Traynor C, Blue K, Kim K.
    J Foot Ankle Surg. 2011 Jan 22. [Epub ahead of print]
  35. scfitzner

    scfitzner Member

    For your typical TR how far distally are you doing it? I was also thinking of meeting with the rep and figuring out a way to replace the lateral button with a 3 hole plate? maybe overboard, who knows?
  36. Nat

    Nat Active Member

    I have done several with a 3-hole plate. The lateral (round) button fits into the plate hole nicely so you wouldn't have to replace it. You just thread the TR through the plate during installation. I just saw one such patient 2 years post-op (for a different complaint) and her correction is holding but the 2nd metatarsal has bowed a couple of degrees secondary to tension from the implant. As a result, her 2nd toe has deviated slightly towards the hallux.
  37. Bear23

    Bear23 Member

    There were procedures listed in the 60's and 70's with using some sort of 'rope' fixation between the second and first metatarsals. they appeared to fall out of favor, I feel the TR is just the same thing. If you can't correct a IM angle correctly, then why try to cheat it?

    I think the complication rate is too high for my comfort zone.
  38. Nat

    Nat Active Member

    Until a procedure is "perfect" (i.e., completely painless, immediate recovery, without complications, long-lasting, etc.) then there is room for improvement. I will therefore keep one eye open towards new technology and techniques. If I recall correctly the similar procedure that people did in the 1960s and 1970s involved simply a lasso of suture surrounding both the first and second metatarsal bones, which resulted in the suture "sawing" through the metatarsal bones.

    At this point I have more or less abandoned the bunionectomy with mini tight rope. I believe there is a narrow selection criteria for the ideal patient, which would include good bone stock, normal body weight, sedentary lifestyle. At least where I live people do not fall within that narrow window very often. Or, they may be within that selection criteria at the time of surgery but eventually stray out of that selection criteria at which point they may have complications. In a couple of cases the implant did not release and the second metatarsal did not fracture, but the button became enveloped deep within the metatarsal bone. The bone over time "swallowed" the button slowly and the patient therefore lost some correction. On a physiological level, it was pretty impressive to see Wolfs Law working in this fashion. Unfortunately, on a clinical level it was not so cool.
  39. Bear23

    Bear23 Member

    It would be no different than a screw migrating due to weightbearing forces or other factors.

    I just don't see a little poly rope taking the place of a properly planned procedure. I've used the TR on ankle fractures with tib fib diastasis with good results.
  40. Primum nil nocere.

    I wrote the following comments over three years ago about this procedure. I wonder how many poor patients now have iatrogenic dorsiflexion deformities of the 2nd metatarsal, floating 2nd digits, 2nd digit hammertoes and transfer metatarsalgia to the 3rd metatarsal as a result of the many 2nd metatarsal fractures that have occurred as a result of podiatric surgeons experimenting on their patients with this ill-advised procedure?


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