Mini-tightrope surgery for bunions

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.

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.

Dr. Sadriech  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

(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 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.

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.

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