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12/21/2016    Don Peacock, DPM

MIS Metatarsal Osteotomy Surgery vs. Akin Osteotomy on Elderly Patients (Michael M. Rosenblatt, DPM)

I agree with most of the post Dr. Rosenblatt
has eloquently described. It is essential that
surgeons address gastrocnemius equinus when the
deformity presents. It’s equally vital that we
incorporate bio-mechanical exams in our
surgical endeavors.

I do take some exception with his conclusion
that performing a MIS bunion correction without
fixation will always lead to second metatarsal
transfer pain. The research in this area
contradicts this statement. Non-fixated first
metatarsal osteotomies such as the landmark
research Dr. Dale Austin gave us is a good
example of that fact. He did not fixate his
osteotomy.

As with all bunion surgery complications
certainly do exist with respect to the
probability of transfer second metatarsalgia.
Legitimate concerns over first metatarsal
instability after MIS bunion correction has
been raised and has led to augmentation of
osteotomy angles and percutaneous fixation in
some MIS surgical circles.

One quality we sometimes forget to remember is
the etiology of what causes first metatarsal
instability. We know from clinical experience
that stabilizing the rear foot via correcting
equinus, stabilizing the STJ, stabilizing the
1st met-cuneiform and other techniques leads to
stabilization of the first ray. As an example,
correcting gastrocnemius equinus results in
less need for compensatory pronation giving
mechanical advantage to the peroneal longus
tendon in his effort to plantar-flex and
stabilize the first ray. The peroneal longus
pulls in a more transverse plane in a pronatory
foot and more plantar in a rectus foot.

We often and wrongly assume that first ray
instability is the cause of the bunion
deformity. However, it can also be viewed in
the exact opposite. The bunion deformity in
fact has an effect on the instability of the
first. Research has shown that by correcting
the bunion deformity the first ray stabilizes
when examining it from a biomechanical
standpoint. Presumably, this is achieved by
realigning the tendon structures of the 1st
metatarsal thereby increasing stability.

The truth is instability of the first ray in
the presence of a bunion deformity has its
etiology in both the rear foot and forefoot in
many cases. With all of this information it is
easy to see that a blanket statement about MIS
bunion techniques leading to undesirable 2nd
metatarsal issues is not accurate.

Dr. Rosenblatt is on target with most of his
post and we agree with 99% of it. We do not
agree with the conclusion that non-fixated MIS
bunion correction will always lead to transfer
2nd pain. The research in this area backs us up
on this disagreement.

Don Peacock, DPM, Whiteville, NC

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