Bunion Surgery Lecture at the World Congress of Podiatry in Rome скачать в хорошем качестве

Bunion Surgery Lecture at the World Congress of Podiatry in Rome

Sheldon Nadal DPM lectures on minimally invasive bunion surgery at the World Congress of Podiatry in Rome, Italy in November of 2013. Visit us on the web: http://www.footcare.net We’re going to talk about the Plon-Arnold modified Wilson osteotomy, which is a minimally invasive procedure for bunions. It is a V-shaped osteotomy. Here is your V and the apex points proximally. It is in the transverse plane and the head of the first metatarsal is then displaced laterally to reduce the intermetatarsal angle. Its indications are for a mild to moderate hallux abducto valgus deformity. The first metatarsal phalangeal joint should be flexible or you won’t get a good result and mild to moderately increased metatarsus primus varus angle. If you use it for a severe bunion you won’t get as good a result and if it is track bound you will not get as good a result. The procedure was originally described by an orthopedic surgeon named Wilson in England in 1963. It was basically an oblique osteotomy from distal medial to proximal lateral. It was suggested by Dr. Weil of Chicago to doctors Kessler, Plon and Arnold in the 70s, that it might make an interesting minimally invasive procedure. Plon and Arnold modified the procedure from an oblique osteotomy to a V-shaped osteotomy to give it more stability. They made a fail-safe hole at the neck of the metatarsal to start the osteotomy. It is designed to be performed under local anesthesia in the office. You can do it with a ankle block or with local infiltration and a modified Mayo block. These are the keys, the most important part is the instrumentation. This is a short Shannon burr. You can combine the procedure with an Aiken osteotomy so you use the short Shannon for the Aiken. This is a medium Shannon burr or Shannon 44 with which you make the osteotomy of the neck of the first metatarsal and this is a 3 millimetre wedge burr which can be used to remodel the hyperostosis, the dorsal medial eminence. This is a Locke elevator which I use to free up the capsule from the head of the first metatarsal. You can also smooth the bump with a short cottle nasal rasp. This is a very interesting piece of equipment. It is called an eye magnet. This is not a procedure for beginners and it should be performed with fluoroscopy. This is mine from 1986, my handheld fluoroscope which, thank goodness still works. The equipment for performing the osteotomy should be a high torque low speed machine. I like to draw landmarks before I start. This is the plantar medial cortex, this is the dorsal medial cortex, this is the lateral cortex, this is the Extensor Hallucis Longus tendon and here is your osteotomy, the V pointing proximally. This is the dorsal part of the osteotomy and this is your first metatarsal phalangeal joint. I start by making an incision with a number 15 blade halfway between the dorsal medial and the plantar medial cortices. This is for the fail-safe or pilot hole. Then I begin making the pilot hole with a Shannon 44 burr from medial to lateral, halfway between the dorsal and plantar cortices and this shows it on the saw bones. I am trying to make it at a 90-degree angle to the long axis of the second metatarsal because that is the long axis of the foot for all intents and purposes. You can change the osteotomy angle from proximal medial to distal lateral to reduce shortening but you’ll find that it is more difficult to displace the metatarsal head laterally if you do that. Here we are starting. We have done the fail-safe hole from medial to lateral from the medial cortex through the lateral cortex with one burr and then switch burrs. Here is the burr, here is what it looks like. It is basically parallel to the supporting surface of the ground. You can plantarflex it slightly if you want to. Here I have made a second incision a little dorsal to the first incision for the purpose of remodelling the bump. I used to make it dorsally. Now our Spanish colleagues have taught us that you are less likely to cause any damage if you do it plantarly. So now I make the second incision plantarly. It is easier to remodel the first metatarsal head through a second incision than through the original incision and here you can see the two incisions. Really, you don’t have to make it much wider than the width of a number 15 blade. You can make it wider if you need to. Here I am putting in the Locke elevator and pushing it through under the capsule to free up the medial eminence and this is a Shannon 44. I am beginning to reduce the bump and the medial eminence with a Shannon 44 and then I continue using a three-millimetre wedge burr because it is easier to remove bone. I remove part of the bump before I perform the osteotomy and then after I’ve completed the osteotomy I’ll remove whatever is left. The reason I do that is because you do not need to remove the whole bump.