Today we’re going to do a modified Wilson osteotomy for this young lady’s bunion. It’s a pretty bad bunion. You can see when I load the foot how bad this one is. And we look for flexibility to get a decent result and the joint is flexible. I can manually adduct the toe and push the metatarsal head in which is promising for such a bad foot. So, this is what we’re trying to aim for. The anesthesia is complete. I did an ankle block and I’m just showing my landmarks. Here we can see the plantar cortex, the dorsal cortex, the.
Dorsal lateral cortex, and I’ve marked off the extensor tendon and the joint. Here’s a side view, a medial view, and here is the V that I’m going to make in the first metatarsal neck. And here’s the apex of the V which is approximately where I’m going to make my incision which is the width of a 15 blade but I’m gonna just check and make sure we’re frozen. Feel anything over here No Excellent. Right to bone. There it is. And there’s our medial incision. And I will introduce a shannon 44 to make the pilot hole or the failsafe hole.
So we’re gonna start the pilot hole or the failsafe hole. The patient feels buzzing but no pain, if she feels any pain I will put more freezing in, or local anesthetic. And there you see we are half way between the dorsal and plantar cortices according to my lines. Here’s an anterior view and you can see the shannon is approximately parallel to the supporting surface. It’s okay if it’s plantar flexed slightly but we don’t want to dorsiflex it. There you see, I’m a little bit proximal because I want to get extra correction, and this is.
A dorsal view and right in the neck and we’re aiming towards the second metatarsal at a right angle to the long axis. Okay, I’m gonna make my second incision medial and plantar at the neck of the metatarsal close to where the medial skin meets the plantar skin. Okay, we’ve made our second incision and I’m using a Locke elevator to free up the capsule. It’s really fairly easy to do from that incision. So the capsule is now freed up. I’m going to begin to remodel the bump with a shannon 44 medium. I start with the shannon to just.
Remove a little bit. And you want to be right on bone, you should hear that lovely sound that the patients love so much. I’ve created a little bit of space so now I can introduce a 3mm wedge burr which is, ah, which will remove the hypertrophic bone a little bit easier. It’s not necessary to remove the entire bump because when you perform the osteotomy the head is gonna shift laterally and it’s no longer gonna be sticking out as much. So I’m gonna remove part of it now and then I will do the osteotomy and then I will remodel.
Whatever is left to be remodeled. As you can see, we’ve remodeled a significant amount of the bone, but I’ve left part of it. Now, we’re gonna get as much debris out as possible. It comes out as paste, there’s not a whole lot here but there’s enough that we wanna clear it out. There’s the paste. Now we’re going back into the failsafe hole with a second shannon and I’m gonna perform the dorsal cut. And you have to remember you’re pivoting from the opening here, so whichever way we want the tip to go, your hand has to go the.
Opposite way. So if I want the tip to go dorsal and distally, my hand must move plantarly and proximally. And I’m cutting the lateral cortex in a dorsal distal direction. Now we’re doing the dorsal cortex. We’re back in and we’re gonna complete the dorsal cut. I’m now on my third shannon, I’m gonna go back into the failsafe hole or the pilot hole and I’m gonna cut the plantar part of the V. Now I’m cutting the lateral cortex in an inferior distal direction and my hand is going in a superior proximal direction. We’re gonna complete.
The plantar cut. I’ve cut through the lateral cortex and now I’m cutting the plantar cortex from lateral to medial. I’ve completed the V and I’m just gonna confirm that by introducing a Locke elevator and I can feel that it’s separated. Now I’m going to transpose the head laterally to reduce the IM angle. Now I’m gonna check. This is a dorsal view and you can see the head has shifted laterally toward the second metatarsal and it’s looking good. This is a lateral view, the head is slightly plantar flexed, so when I fixate.
It I will dorsiflex it slightly, like that. I’m going to now introduce my.045 Kwire. I’m gonna remove the excessive wire, I’m just gonna twist it a little bit. Okay, I’ve checked with my XiScan, my fluoroscope, and the positioning looked good, so I’m gonna put the second Kwire in. Perfect. Now I’m going to remove the excess. And the fixation is complete. Okay, so we’ve done the Wilson osteotomy, I’ve remodeled the bump, I will make it a little bit smoother, and I’ve done the Kwire fixation and you can see the deformity has been reduced but.
We’re still going to do an adductor release and an Aiken procedure. We’re going to do an adductor release and a partial lateral release and I’m just checking with a 78 to make sure we’re at the joint. Feels good. I’m gonna get rid of the 78 and introduce a 64. And we’re right where we want to be. I’m at the plantar aspect of the joint, the plantar lateral aspect and I’m adducting the toe as I do it. And you can feel the celery. And I’m not cutting the entire capsule, just the plantar lateral capsule where the adductor.
Tendon is. And that feels pretty good. You can see the toe is a little bit straighter just from that release, and now I’m gonna do an Aiken osteotomy at the base of the proximal phalanx. I’ll do my proximal phalanx osteotomy, the socalled Aiken procedure, and I’m gonna make a failsafe hole just lateral to the extensor hallucis longus tendon, it’s gonna be right around here. I’m gonna make my opening with a 64, you can make it slightly longer if you need to. And I’m making my incision right down to bone, just slightly wider than.
The width of a 64. I’m going to now do the failsafe hole just lateral to the extensor tendon and medial to the lateral cortex. I’ve checked the positioning with my XiScan and I’m going back in. It’s good, and I’m gonna complete the osteotomy with a second short shannon. I’m now cutting the plantar cortex from lateral to medial so my hand is moving in a lateral direction. I’ve cut the lateral cortex and now I’m cutting, I mean, the plantar cortex, now I’m cutting the medial cortex. I’m gonna try to leave the lateral cortex.
Intact. And that’s approximately what it’s going to look like, the Aiken is done, the bump is reduced, the osteotomy has been performed. I’m just going to go back into my plantar incision and make everything nice and smooth. Now I’m gonna go back through the plantar opening and just make sure the osteotomy site is nice and flush and there’s no plantar ledge proximal plantar ledge to irritate the patient. That feels pretty good, actually. I like to get rid of as much of the debris as possible so I’m going to flush with sterile.
Saline. This is the osteotomy site. And I’ll go back through the plantar incision where I removed the bump. Try not to splash your cameraman. And I’m going to go back in with a small hand rasp. Make sure there’s nothing in there that needs to come out. There’s nothing left, then I’m done. We’ve cleaned up the foot, you finish with your sutures of choice here I put a horizontal mattress and another horizontal mattress plantarly and dorsally, two simple sutures, one here for the Aiken, and one here for the adductor. So we’re done,.
This is redundant skin, it will tighten up. It is not necessary to remove it the way it is the way you might consider doing it in conventional surgery so the scars are much smaller. And that’s approximately what we’re gonna end up with. Okay we’re gonna start with a nonstick dressing. And then some gauze a 4×4 over that. Betadine, please. Drip it on the wire. Over here, the medial incision. Over here, the inferior medial incision. Okay. And a little bit at the adductor and at the Aiken. Good. Now I’m gonna put some 3x3s on.
Either side of the wire ends so that the to reduce the irritation on them. I’ve put more 3x3s anterior and posterior to the Kwires to reduce the pressure on them. I’m gonna wrap the foot with some conforming gauze or whatever you like to use. And I’ll just put a 3×3 around the fifth met head. A little bit extra. And I will adduct the toe in a slightly overcorrected position. If there is concern about the head dorsiflexing, you can use a dancer’s pad under the metatarsal head to relieve some of the plantar pressure.
That will dorsiflex the head of the metatarsal. I’m gonna put a few pieces of hypoallergenic tape on the foot to hold everything in place. It does not have to be tight because we have Kwire fixation. If you don’t have the Kwires, then you must make it tight. We’ll overcorrect the great toe a little bit. Put some 3 tape around it to hold everything in place and make it look nice and neat. And these BandAids are just covering up the areas where I did the ankle block. And there’s your finished product. Tomorrow will be five weeks since.
We did the surgery. It’s looking good, and I’m gonna put one more dressing on. Our patient will take it off at home next week. And she wants to say a few words. I’m so excited, my foot looks great, and I can’t wait to get the next one done. It is now April 7th, we did this bunion surgery on December 17th, so it’s less than four months since we did the surgery. And we can see what it looked like before and what it looks like now. And we can see that the toe is moving well, good range of motion, and you can see that there.