Percutaneous Bunion Surgery Proves Minimally Invasive Bunion Repair Is Possible
Posted by Jenn F. on Wednesday, November 22nd, 2017
Dr. Josef J. Geldwert is one of the few New York City surgeons trained in percutaneous bunion surgery. Minimally invasive foot surgeries are popular for lateral ankle stabilization, ankle fusion, osteochondral lesions, calcaneal fractures, and calcaneal osteotomies, but poor results in the 70’s and 80’s caused American podiatric surgeons to shy away from non-invasive methods of bunion correction—that is, until now.
The first percutaneous bunionectomy was performed by another local surgeon at Mount Sinai Hospital last spring. “Though it’s relatively new here, it’s popular with European orthopedists,” explains Dr. Geldwert. “Some doctors are waiting to see more favorable clinical research results, but trade publications like Podiatry Today are abuzz with news of the microsurgery.”
The best bunion surgery depends on the method the surgeon is most comfortable performing and individual contraindications. For eligible patients, “The obvious advantages for the patient are immediate weight-bearing and the fact that it’s minimally invasive,” Dr. Geldwert says. Still, it’s important to understand all the facets of percutaneous bunion surgery in order to find out if it’s the ideal bunion correction method for you.
Research About Minimally Invasive Bunion Surgery
Percutaneous bunion correction was first described in 1990, with a 10-year follow-up completed in 2000. Bosch and colleagues performed the technique through a 5 mm incision, completed an extracapsular osteotomy, and stabilized the fragment using a wire placement that was removed a month after surgery. Full protective weight-bearing was allowed in a surgical shoe immediately after the operation. The study authors reported an 81 percent satisfaction rate based on radiographic measurements and a 95 percent patient satisfaction rate based on pain scores after 10 years.
Since then, percutaneous bunion correction has continued to evolve and show positive results:
- In 2005, Magnan and cohorts performed a percutaneous bunionectomy with a two-year follow-up, at which point there was a 91 percent patient satisfaction rate among over 100 patients.
- In 2008, Giannini and colleagues described the osteotomy with minor modifications as “simple, effective, rapid, and inexpensive.” They found a 92 percent satisfaction rate in 54 patients.
- In 2017, Crespo and colleagues looked at 108 patients with a follow-up of two years and found that 76.5% of the subjects were “satisfied” or “very satisfied.” Less than a quarter of all patients suffered some residual first metatarsal pain. The main advantage to percutaneous bunion surgery was “low post-operative pain.”
How is Percutaneous Bunion Surgery Done?
To perform a percutaneous bunionectomy, a qualified foot surgeon will use the following steps:
- The patient is placed on a surgical table facing upward, with under-thigh padding that bends the knee at a 30-45 degree angle.
- Regional anesthesia is administered to numb the area.
- A 2 mm Kirschner wire is inserted with fluoroscopic guidance to hold the foot in a stable position.
- The surgeon makes a 5 mm incision at the first metatarsal, down to the bone.
- Iris scissors elevate the soft tissue to prevent tendon entrapment.
- A 1.8 mm K-wire is inserted to create multiple drill holes.
- An osteotome or mini-micro sagittal saw is used to complete the osteotomy.
- A hemostat is used to move the bone fragment out and prevent bleeding.
- Fluoroscopy confirms correct wire positioning and bone positioning.
- The wound is closed with a 4.0 Monocryl suture.
What Happens After Percutaneous Bunion Surgery?
Once the bunionectomy is completed, the foot is dressed up in 4×4 gauze, ABD pads, cast padding, and an Ace bandage. Right away, the patient will wear a flat postoperative shoe. Patients are free to move about as they please—to the bathroom, dinner, and between rooms—on foot, as long as they are comfortable.
Dressings remain in place until the first postoperative visit about one week later. At this first visit, the doctor will change the dressing and take radiographs to confirm that all hardware is still firmly in place. At this point, the patient may begin showering regularly again, so long as they apply iodine to the pin location and use gauze wraps to prevent edema and pin site infection.
At the second post-operative visit, a month later, the pin is removed with sterile pliers—typically with no need for local anesthesia—and the patient transitions to wearing a sturdy tennis shoe. Gentle range of motion exercises of the metatarsophalangeal joint are introduced.
Follow-up radiography is required at eight and 12 weeks. Most patients are able to pursue full activities and sports training sometime between eight and 12 weeks, provided that healing is on schedule.
Percutaneous Bunion Surgery Risks
Pin site infection is the most common concern with minimally invasive bunion surgery, even though the entry-point is very small. Patient compliance with site cleaning and pin protection usually prevents infection easily. At the first sign of infection, Dr. Geldwert will prescribe an oral antibiotic like cephalosporin, clindamycin, or penicillin. The issue usually resolves within a few days of care. So far, none of his cases have progressed to osteomyelitis bone infection.
The stability of the hardware is another concern with this type of bunion surgery. Several cases of premature hardware loosening before the one-month mark have occurred, but there was no loss of surgical correction or adverse effects associated with these cases. A very small number of patients may experience irritation of the dorsal medial hallucal nerve from the pin, which causes some numbness for a few weeks after the pin is removed. To date, there have been no cases of lasting paresthesia.
Percutaneous Bunion Surgery Benefits
There is much to love about the minimally invasive bunion repair Dr. Geldwert offers:
- There is minimal dissection of soft tissue, which preserves flexibility and mobility and allows for earlier functionality.
- The operating time is significantly decreased, with most cases resolved in well under a half hour.
- Weight-bearing, ambulation, and mobility are allowed.
- The cosmetic incision is much smaller than with other types of bunion surgery, so there is minimal scarring and pain.
- K-wire fixation is relatively inexpensive compared to traditional fixation.
Who Should Have Percutaneous Bunion Surgery?
Patient selection is an important consideration for surgeons who want to keep complication rates low and patient satisfaction rates high. Patients may not be suitable for the procedure if they have:
- Past compliance issues
- History of poor vascularity
- Uncontrolled diabetes
- Past failed bunion surgeries
- Stiff arthritic joints
- Degenerative arthrosis
- Petiarticular bone spurs
Smoking is also a concern but not necessarily a contraindication. Most doctors will ask that you quit smoking for a couple months while active healing is taking place. Hypermobility of the medial column or metatarsocuneiform joint are of no concern. Hallux valgus deformity angles ranging from 20-40 degrees have seen success with this technique. Otherwise, percutaneous bunion surgery is safe for most individuals. Just be sure to discuss all the factors with your foot surgeon to ensure you are a good fit for this procedure.
Where to Get Percutaneous Bunion Surgery in NYC
At the Center for Podiatric Care and Sports Medicine, we offer percutaneous bunion surgery using the latest techniques and research. Dr. Josef J. Geldwert is a board-certified in foot and ankle surgeon with more than 40 years of operating room experience. As such, he is a recognized authority on the latest bunion correction techniques. For more information or to set up a consultation, contact us today.
If you have any foot problems or pain, contact The Center for Podiatric Care and Sports Medicine. Dr. Josef J. Geldwert, Dr. Katherine Lai, Dr. Ryan Minara and Dr. Mariola Rivera have helped thousands of people get back on their feet. Unfortunately, we cannot give diagnoses or treatment advice online. Please make an appointment to see us if you live in the NY metropolitan area or seek out a podiatrist in your area.