Domain: Orthopedic Surgery / Podiatric Surgical Specialist
Persona: Senior Board-Certified Foot and Ankle Surgeon & Surgical Educator
Vocabulary/Tone: Clinical, technical, instructional, and efficiency-focused.
2. Summarize (Strict Objectivity)
Abstract:
This clinical presentation by Dr. Noman Sadiki outlines the technical execution of a minimally invasive surgery (MIS) bunionectomy using the Arthrex MIS Bunionectomy System. The session focuses on transitioning from inconsistent freehand methods to a guided instrumentation approach designed to reduce the surgical learning curve from 50 cases to approximately 15–20. Key instructional pillars include precise patient positioning using a limb holder, specific fluoroscopic "declination" views to visualize the first tarsometatarsal (TMT) joint, and the use of topographical markings to optimize wire trajectory and minimize intraoperative radiation. The procedure emphasizes controlled osteotomy of the first metatarsal, supination/derotation of the capital fragment, and a systematic triangulation method for achieving stable bicortical screw fixation.
Surgical Procedure & Key Takeaways:
0:00 – 0:58 System Advantages & Learning Curve: The Arthrex MIS system utilizes guided instrumentation for rotation, translation, and fixation. This methodology aims to provide consistency over freehand techniques, significantly reducing the competency threshold for surgeons.
1:01 – 1:59 Patient Positioning & Ergonomics: High-thigh draping is recommended to ensure unobstructed access. The use of a "Trumano" limb holder is emphasized to allow for multi-planar positioning and clear medial-side wire firing. The C-arm (large or mini) must be positioned comfortably beneath the extremity.
2:01 – 2:50 Fluoroscopic Optimization: Proper visualization of the first TMT joint is achieved by placing a bump under the fifth ray. This provides a slight declination of the first metatarsal, preventing the TMT joint from being obscured by the 90° beam.
2:52 – 4:45 Pre-Operative Topographical Marking: Surgeons should mark the wire trajectory between the first TMT and the Naviculocuneiform (NC) joint. These landmarks serve as a visual double-check for the targeting arm, helping to prevent "skiving" (sliding) of the wire on the bone and reducing fluoroscopy requirements.
4:46 – 6:04 Osteotomy Parameters: The incision is made 2.5 cm from the MTP joint. The osteotomy is performed along the long axis of the first metatarsal. A critical technical pearl is ensuring the cut is perpendicular to the metatarsal in the lateral view, rather than perpendicular to the floor, to avoid proximal angulation.
6:06 – 7:00 Manual Technique & Burr Trajectory: When standing at the bedside, the burr should be directed toward the surgeon to maintain the proper sagittal plane. The non-surgical hand must stabilize the capital fragment to feel vibrations, which alerts the surgeon to cortical breakthroughs and prevents soft tissue damage.
7:02 – 9:34 Translation and Derotation: The "gooseneck" translational component is seated in the intramedullary canal. Before fixation, the capital fragment is supinated to correct sesmoid rotation. The system's knob allows for incremental lateral translation, typically aiming for a 75–90% shift of the metatarsal head.
9:47 – 10:43 Sagittal Plane Stabilization: An accessory wire is used to pin the capital fragment to the stable second metatarsal. This maintains the sagittal position and aligns the sesmoids with the fifth metatarsal.
10:46 – 12:53 Targeting Arm Integration: The flexible targeting arm must be aligned with the pre-operative trajectory markings. High-thigh prepping is vital here to ensure the guide has sufficient clearance from surgical drapes or tourniquets.
12:56 – 15:10 Wire Triangulation: The proximal wire is advanced toward the lateral cortex approximately 10mm proximal to the osteotomy. Oscillating the wire during insertion prevents skiving and helps the tip cut through dense cortical bone precisely toward the target in the capital fragment.
15:12 – 18:41 Secondary Fixation & Parallel Guide: Once the primary wire is set, a 25° or 30° parallel guide is used for the second wire. Proper perichondrial purchase is established before firing the wire to ensure a parallel trajectory into the capital fragment.
19:13 – 21:19 Screw Insertion Protocol: Bicortical, non-compressive screws are utilized. The surgeon must drill slightly deeper into the capital fragment to prevent distraction at the osteotomy site. Bevel orientation is monitored via the driver handle markings, and final seating is performed manually with a ratchet wrench for maximum tactile feedback.
3. Post-Action
Target Review Group:
Orthopedic Foot & Ankle Surgeons: To evaluate the procedural efficiency and mechanical stability of the guided system.
Podiatric Surgical Fellows: To study the anatomical landmarks and fluoroscopic "tricks" to flatten the MIS learning curve.
Surgical Device Evaluators/OR Management: To assess the instrumentation's impact on operative time and radiation exposure (fluo-reduction).
Expert Review Summary:
"The Arthrex MIS Bunionectomy System represents a significant shift from 'feel-based' freehand osteotomies to a reproducible, guided framework. Dr. Sadiki’s protocol highlights that the success of the MIS approach is contingent upon two non-negotiable factors: the 'declination' fluoroscopic view to prevent TMT obscuration and the stabilization of the sagittal plane via the second metatarsal. By utilizing the 'gooseneck' for translation and the triangulation guide for fixation, surgeons can mitigate common pitfalls such as wire skiving and malrotation. This system effectively addresses the historic inconsistency of MIS bunion repairs, offering a structured pathway to achieve high-percentage lateral shifts and stable bicortical fixation with reduced intraoperative radiation."