Bunionectomy via medial incision

Members do not see these Ads. Sign Up.

I think that most podiatric surgeons use a dorsal or dorsomedial approach when doing a bunionectomy, whereas most orthopedic surgeons favor a medial approach. Please correct me if I'm wrong, but that's what I've seen first-hand.

The main reason I was taught to not do a medial incision was that it leaves a scar directly against the shoe, and would cause irritation.

The main reason I was taught to do a dorsomedial incision was that it gives 1st interspace access for the lateral release.

Has anyone done a fair number of both approaches? Can you give your own experiences with each, specifically related to the following questions:

1. Can one do a decent lateral release via medial incision, reaching with the blade plantarly to release the fibular sesamoid, then transecting the adductor hallucis tendon transarthrodially? Would it result in less interspace p/o edema since there was no interspace dissection?
   
2. Does having a medial incision result in less scar tissue adhesion on the dorsal 1st metatarsal head since you would not have to dissect there? Does it therefore result in better post-op ROM?
   
3. Any differences in post-op prolonged numbness? The medial incision is further away from the dorsomedial nerve branch to the hallux.

 

Nat,

I was fortunate in residency to train under both podiatric and orthopaedic surgeons. Your observation, in my experience, is correct that most pods prefer a dorsomedial approach - very scared of the potential painful medial scar. The orthos don't seem to care about the scar and will often do a second incision over the first intermetatarsal space for lateral release. Depending on your beliefs, a lateral release may not even be necessary (Boberg, and others I'm sure, believe that the osseous work alone should correct the underlying deformity). I hedge my bets and go for the release anyhow, but I digress.

Now take into account the "aesthetic movement" that outrage some and intrigue others. A bunionectomy with no visible scarring? Sounds great to your 20-40-something female (or metrosexual male) patient.

My approach is simple. Get the best possible result while leaving little evidence that I was there. I learned from Dr. Hatch (among many things of which I thank him) that there are two things people really remember about their surgeon - the post-operative dressing (being neat and nice) and the scar he/she leaves behind. So to answer your question, I've done a fair share of both approaches, but gravitate toward the medial approach. I will typically extend the incision proximally and slightly dorsally for improved exposure. In doing so, I can often complete a lateral release as if I entered dorsomedially. Doing an intraarticular lateral release can be difficult if the joint is tight and visuality is limited - I always worry about chondral damage and nicking the flexor tendon(s).

With regards to post-operative scarring and mobility. I have noticed better post-operative mobility from the medial approach presumably from the limited dorsal scarring. There seems to be a little more swelling post-operatively, but the end result is more cosmetically pleasing. I have had no cases of dreaded scar irritation (knocking on wood as I type). I use a 4-0 Monocryl subcuticular closure with steri-strips, but am always up for learning something new from our plastic surgeon friends. Essentially all osteotomies (distal, shaft and base) can be done from a medial approach. I do my Lapidus through two smaller incisions - one medial to the first MTPJ and one dorsal to the first MTCJ.

I too am very curious as to what others out there are doing. Perhaps someone can convince me that I'm incredibly wrong. Love to learn.

Matthew

 

Thanks for your input Matthew. I did my undergrad in Greeley and spent a week shadowing Dr. Dan Hatch during that time. That was in 1994!

I have been able to do a lateral release transarthrodially a few times, but if the IM angle is large and the sesamoids are subluxed far into the interspace then I can't quite get it satisfactorily.

I consider not doing the lateral release only in mild bunion deformities (say 12 degrees or less). Otherwise I find it necessary to avoid p/o hallux valgus.

Why don't you do your Lapidus with a medial incision at the TMTJ?

Nat

 

--small world! I think the world of Dr. Hatch. Received my ACFAS fellowship pin from him when he became president - too cool.

--the only way I've found to successfully do this release on high IM angles through a medial approach is with a McGlamry elevator and an 11 blade or long-handled 67 blade. Not easy.

--why I don't do a completely medial Lapidus? I'm alone in practice with minimal support, orthopods breathing down my neck fearing competition, and I simply lack the balls. Whole 'nother story. Currently seeking well trained foot and ankle surgeon for busy full scope southeastern virginia practice, yada yada.

matthew

 

Have you had a chance to play with Arthrex's new Lapidus locking plate? It's pretty sweet. I haven't used one in a patient yet, but we had a cadaver lab yesterday. It can provide compression, and being a locking plate, should be very stable.

I have no affiliation with Arthrex, by the way. I'm just impressed by their small joint products.

 

I more than played with the Lapidus locking plate...I placed one about 3 weeks ago. It was a revision Lapidus from one of our colleagues who couldn't fingure out why the joint didn't fuse the first time - perhaps it was the screw head in the joint or the cartilage left behind plantarly?!?! Anyhow. She was a 30ish CMT patient. I removed the hardware, distracted with a minirail, prepped the joint, packed some bone graft, compressed with the minirail, and then applied the Arthrex plate medially - she's walking on it at 3 weeks and looks solid on x-ray. Check out the Arthrex cross-bridge for Achilles. I too have no financial interest in Arthrex - just admiration.

matthew

 

Nice work! We had an achilles repair a couple of months ago using their stuff. Pretty impressive considering how they've only been in the small joint business for a couple-few years.

 

Say Matthew, when you say "walking on it at 3 weeks" do you mean heel-walking or full-on weightbearing? Is the patient in a p/o shoe or camwalker?

I'd like to get my patients weighbearing as quickly as possible but the idea of 3 weeks makes me sweat.

 

She is fully weightbearing in a post-operative shoe. Bear in mind, she has double fixation (medial lapidus plate and external fixator) and she's the type of patient that will be hesitant to walk on it anyhow, so she's probably more on the heel. One never knows what patients do when they're not in the office and in my experience, most patients error on the side of non-compliance.

BTW - Did a fully medial Lapidus yesterday with standard crossing screw fixation - didn't have access to the Arthrex plate. Had excellent exposure throughout including lateral release. I'll let you know how she heals - looked great on the table.

matthew

 

Oh, the ex-fix is still in place. I didn't catch that before. Without leaving the ex-fix in place, do you think you'd go NWB for 6 weeks?

 

With just the medial Arthrex locking plate? No, patient would be non-weightbearing for 6-8 weeks. Would consider a second dorsal plate and/or interfrag compression (in leiu of the ex fix) to early weightbear, but otherwise I wouldn't trust the single plate for early weightbearing. I'm guessing that with time, I'll likely use the plate/exfix combination as my standard as the ex fix certainly helps with distraction and joint preparation and allows for early weightbearing. Just need to find a different mini-rail that's more adjustable - perhaps Smith and Nephrew or SBI.

 

The Smith and Nephew device does not look as if it has distraction capability (via a threaded rod). Do you know if it does? I haven't played with it; I've just seen their product picture.

In what way do you wish the Minirail were more adjustable? Is it the pin axial rotation?

 

Medial approach:
I think classic orthopedic approach was two incisions, one medially and one over the interspace. Scar at the medial incision can be a problem, but the main reason I do not use it is because of the neurovascular bundle medially.

It's so much easier to use a dorso-medial approach and then underscore medially without damaging the neurovascular bundle rather than having an incision right over it, especially a curvilinear one, and trying not to damage it.

Also, general orthopods tend to make one incision - skin to bone.

Steve

 

Thanks Steve.

Nat

 

Matthew,

The Rep came by the office today and I was able to play around with the Mini Rail a bit.

1. Do you use the straight rail?
2. There was an articulating version that seem applicable to a Lapidus.
3. Do you prefer to mount your rail medially or dorsally?
4. Are the pins really strong enough to resist full weight bearing?

Nat

 

I got to use the Orthofix Mini-Rail for the first time yesterday, and I liked the device well enough. I also used three OsStaples for "back-up" just in case I need to remove the ex-fix early for whatever reason.

I placed the rail medially but had to make a second dorsal incision for two of the staples. Closing the skin around the rail was difficult, and I was told some surgeons like to close first then place the rail percutaneously under fluoro. Do any of you do it that way?

The Trilogy rep (provider of the OsStaples) was in the room with the Orthofix rep. Trilogy has their own ex-fixator and he kept trying to sell me on their rail. I was waiting for a Rep-fight to break out by the back-table!

 

I have trained with Podiatric surgeons and Orthopedic surgeons. The dorsal incision (dorsomedial) is best, by far. It allows much better visualization, much cleaner capsulotomy, and much more efficient closure. I have not seen sufficient medial-incision cases post-operatively, because I haven't done them since residency. I have seen failed bunionectomy surgeries (both dorsal and medial incisions)- and the shoe pressure with hypertrophic scar formation is not uncommon-

 

Hi Nat:
What procedure did you use it for?
STeve

 

Sorry for the omission. I used the Mini-Rail and OsSaples in a Lapidus.