I have been asked to comment on ‘mini-tightrope bunion surgery’
This is currently promoted as ‘the latest technique’. For that you should read ‘new and therefore unproven’. The outcome of any foot surgery is to be measured over many years – perhaps a minimum of twenty – since these feet need to serve their owner for those years ahead.
Apr 30, 2006 Juliette Jowit, transport editor. My day as an eco-driver in Holland. Having Herman Kobes in the car with me is like having three of the four worst back seat drivers in the world. Dr JP Driver-Jowitt F.R.C.S. Orthopaedic Surgeon. 3 Norfolk Road, Newlands, 7700, Cape Town, South Africa. Surgery: +27 (21) 674-1820. Fax: +27 (21) 683-5677. Driver-Jowitt Jp Dr - HOSPITAL SUPPLIES AND EQUIPMENT, Cape Town, 7405, Norfolk Road 3, TEL: 0216741., South Africa, On this page: Driver-Jowitt Jp Dr, ZA100620829. Jon Driver-Jowitt Full textFull text is available as a scanned copy of the original print version. Get a printable copy (PDF file) of the complete article (571K), or click on a page image below to.
The concept is not new. I contemplated this approach many years ago and have done cadaveric studies to try and establish its merits. However there were a number of significant complications to be anticipated. For that reason I have never done this surgery and would not endanger my patients in this way. Many variants of this have been attempted in the past, including using screws to force together the metatarsals of the great and second toes, and the smaller and thinner second metatarsal. That did not work, as the screw rapidly pulled out of the bone, leaving a weak second metatarsal, which then often broke. So it is not as new as these authors would have you believe. What is relatively new is the ‘tight-rope’ originally designed for other purposes, and characterized by the ‘toggle’ which allows this band to be tightened (and over-tightened) relatively easily and the material ‘fibrewire’.
The loads on the foot are very high. These are multiplied during walking be various leverages, and the loads on the mini-tightroap wire are likely to be sufficient to cause the wire, or toggle to cause pressure atrophy of the bone, where this is attached. This could cause the implant to cut free of bone, damaging the bone in the process.
A number of surgeons/podiatrists have felt sufficiently confident to place their procedure on U-tube. Therefore they must expect a commentary (although I notice that the comment facility on some has been disabled) and I will use their claims to answer my reader.
Let us take their demonstrations one at a time to point out criticism.
Firstly there does not seem to be a single procedure, but a number of not so closely related variants.
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Dr. Sadriech http://www.youtube.com/watch?v=dX6WKjsPpVc.places inserts the wire a fair way down the great metatarsal and it penetrates the base of the second metatarsal in such a way as to interfere with the joint between the second and third metatarsal bases – potentially damaging that joint – a potent source of future pain.
He says that the ‘bunion’ is an ‘outgrowth’- which it is not – and promptly cuts off a perfectly normal part of the great metatarsal head, damaging that joint with the potential for a future osteoarthritis He describes this a ‘removal of the actual (mumble)’.
Dr. George Homes http://www.youtube.com/watch?v=dX6WKjsPpVc
(An orthopaedic surgeon this time) also cuts away the normal metatarsal head, calling it a ‘medial exostosis’ presumably on the basis that if something is given a nasty sounding name surgical removal is approved. However he puts the wire through quite a different part of the great metatarsal from the previous surgeon, and also through the phalanx (the toe itself). Therefore there are now two drill holes through great metatarsal, with a not insignificant weakening of a bone which has to accept great loads. A subsequent ‘fatigue fracture’ would not come as a surprise. He says ‘cuneiform bone’ when the structure is actually the metatarsal.
The large incision on the inside (medial) is placed exactly over the medial digital nerve. If this is damaged it will produce chronic numbness and/or pain, particularly if the shoe make abrasive contact with this area, as is usual.
Dr. Allen Selner http://www.youtube.com/watch?v=9ibAY0f5MyE&feature=related treats someone who does not have a bunion, and does not have a crooked toe (as he claims). This patient has an entirely different problem (not a bunion), a ‘hallux rigidus‘ with a dorsal cheilosis. This is an outgrowth, but related to an entirely different entity, and the lump is not placed on the inside of the great toe, but on top of the metatarsal.
Dr Selner draws on the x-ray, claiming that he is demonstrating ‘arthritic bone’. It is not (and neither is it the dorsal cheilosis). Once again this is normal anatomy which does not deserve to be deformed in the way we saw on the u-tube.
One more point, forcing the great metatarsal towards the second ray (toe) must damage and adversely realign the great metatarsal-cuneiform joint. This is well demonstrated in the skeletal models in the u-tube presentations but ignored in the commentary.
Drivers Jowitt Senior
I notice that many of these people have general anaesthesia, when a regional (local anaesthetic) block would have many advantages.
I may not have answered my reader’s query entirely, but I hope that I have demonstrated that caution is due when a medical procedure is claimed to be a ‘major advance’ the ‘newest’ and similar hyperbole.
Any similar or specific queries will be welcomed, and I invite responses from the three surgeons mentioned, or any other people professionally involved in foot problems. Perhaps these same patients might also like to comment as time passes.
Filed under: Orthopaedic Surgery |
This document might mislead patients. Exerpts from this booklet are repeated in bold italics.
Drivers With Handles
“You have been selected for a Weil Osteotomy”. This is patronising and unfair because the availability of alternate surgery is not mentioned. Why is it not said that the Weil osteotomy involves cutting through a perfectly normal, functional bone anticipating that it will eventually unite?
“If the main problem, or an important part of it, is that one of the metatarsals is too long relative to the others or points too far downwards the Weil Osteotomy would usually be advised. “ There is little reasoning here. The irrationality of the “metatarsal parabola” concept has been addressed elsewhere on this web-site. The other commonly bandied explanation is that the metatarsal head has “dropped”. (As phrased here, “points too far downwards”) This is also nonsensical, since during standing the metatarsal heads are all in contact with the floor surface. They cannot “drop”.
“For some the joint at the toes base (“metatarso-phalangeal joint”) is so tight and stiff that it cannot easily be straightened. A Weil Osteotomy of the metatarsal will relax the joint sufficiently to allow it to straighten and heal without excessive pressure”. Is it claimed that the cause of “claw tows” and similar are caused by “tight joints”? The is no evidence of any type for that. This is simply wild, misleading, speculation. There is no evidence whatever that the Weil Osteotomy “relaxes the joint”. Indeed one of its claimed benefits is a tightening of the plantar plate.
“Will I have to go to sleep (general anaesthetic)?”
Alternatives suggested in this brochure are an “injection in the back, leg or around the ankle can be done to make the foot numb while you are awake”. Presumably these alternatives are a spinal or epidural anaesthetic, sciatic block or local infiltration around the ankle. Why are they not described as such? Patients are usually well informed about these terms.
All these listed forms of regional anaesthesia have the disadvantage of being long acting. All these are unpleasent when administered. with a variety of possible complications. “Ankle block” is notably painful.What is important in foot surgery, and particularly in the elderly, is that the anaesthetic should be reversed promptly, so as not to leave a dangerously insensate foot. None of these procedures allow that, whereas there are others (not listed) which allow prompt return of sensation.
Regional Anaesthetic block is the management of choice. It has none of the complications or unpleasantness of general anaesthesia, and -not unimportant – is easily reversed allowing safe, tactile, walking. The later has great importance for the safety of the elderly.
What will happen afterwards? “For the first two weeks you should avoid walking if possible and only put your weight to the heel”. Difficult and dangerous in the elderly.
Risks. “About 8 in 10 people have an excellent result from the Weil Osteotomy. Up to 2 in 10 do not for a number of reasons”. Much fairer to the patient is to say that “About two in ten have a poor result”. [The Weil Osteotomy possibly has a more than 20% chance of failure, depending upon various reviews.] Is that acceptable that that the procedure fails for one in every five persons? This leaflet then goes on to give excuses for failure. All these appear fatuous.
“The foot tends to swell up quite a lot after surgery. Swelling is part of your body’s natural response to any injury and surgery is no exception. In addition your foot is at the bottom of your body so fluid tends to collect in the tissues and cause swelling. People vary in how quickly the swelling disappears after the operation and 6 months is not all that unusual. Provided you are not having undue pain and inflammation there is probably nothing to worry about and you can afford to give it time”. To imply that swelling of the lower limb should not be of concern is not correct. Swelling of the lower limbs, of whatever cause, is undesirable. The reasons will not be listed here. There are good reasons to believe that anyone who has swelling of the lower limb three days after surgery should be treated with an elasticised stocking.
Another complication baldly listed is deep vein thrombosis and pulmonary embolism. Is it not imperative that patients should be warned in advance of signs and symptoms of this condition? Knowing of its existance, and seeking prompt medical attention should any symptoms pointing to the possibility, is mandatory.
Drivers Without Admin
Filed under: bunion, bunions, callouses, callus, claw toe, corns, Curly toes, Deep vein thrombosis, Foot Surgery, Forefoot Deformities, hammer toes, National Health Service UK, Orthopaedic Surgery, Overlapping toes, Tailors bunion, Weil osteotomy | Tagged: NHS foot surgery, North Bristol National Health Service | 2 Comments »