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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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