PROstep Minimally Invasive Surgery HALLUX VALGUS CORRECTION USING PROSTEP MICA MINIMALLY INVASIVE FOOT SURGERY: TWO CASE STUDIES

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1 PROstep Minimally Invasive Surgery HALLUX VALGUS CORRECTION USING PROSTEP MICA MINIMALLY INVASIVE FOOT SURGERY: TWO CASE STUDIES AS PRESENTED BY: JOEL VERNOIS M.D.

2 016798A Case Study 1 PROstep Minimally Invasive Foot Surgery Hallux Valgus Correction Using PROstep MICA Minimally Invasive Foot Surgery: Two Case Studies CASE STUDY 1: SEVERE BILATERAL HALLUX VALGUS CORRECTION Patient History This 63-year-old female patient presented with painful bilateral bunions. She was not able to wear any closed-toe shoe without pain and so wore flip-flops as much as possible for relief. Examination On clinical examination, the patient was found to have severe, bilateral hallux valgus (Figure 1) with mild metatarsalgia on the left foot and bilateral high mobility of the TMT joints. She had normal mobility of the first MTP joints and negative grind test. The sesamoids were pain-free on palpation, as were the first TMT joints. She had no callus under the lesser metatarsals, but reported sensitivity of the left foot at the second metatarsal region. She confirmed metatarsalgia after prolonged walking or standing (three hours or more). Contributed by: Joel Vernois, M.D. W. Sussex, England Mr. Vernois is a paid consultant for Wright Medical. Wright Medical provided financial support for this case study. 1 FIGURE 1. Preoperative photograph of the patient s bilateral bunions These results are specific to this individual only. Individual results and activity levels after surgery vary and depend on many factors including age, weight, and prior activity levels. There are risks and recovery times associated with surgery, and there are certain individuals who should not undergo surgery. This case study is a publication of Wright Medical Group N.V. or its affiliates 2

3 Case Study 1 PROstep Minimally Invasive Foot Surgery Discussion of Pathology The left second MTP was sensitive with mild instability. X-ray showed a severe hallux valgus deformity with intermetatarsal angles of 13 (left) and 18 (right), and hallux valgus angles of 36 (left) and 44 (right) (Figure 2). Treatment Plan Considerations for correcting this deformity included a diaphyseal osteotomy such as a Scarf osteotomy or a proximal procedure such a basal or Lapidus osteotomy. The limitation of a proximal osteotomy is the restriction of heel weightbearing for six weeks, and our goal for this patient was immediate postoperative weightbearing. After discussion of options, the patient elected bilateral, minimally invasive, distal Chevron/Akin osteotomy using the PROstep MICA System. The metatarsalgia appeared to be resultant of the first ray deformity, and I anticipated that the pain would resolve upon correction of the hallux valgus deformity. Surgery Bilateral, percutaneous, extra-articular, reverse-l Chevron (PERC) osteotomy was performed under fluoroscopy. Because the apex of the chevron is dorsal-to-plantar, the first metatarsal head was lowered to decrease the load on the second metatarsal head. Two PROstep MICA screws were placed medial-to-lateral and proximal-todistal to improve stability and avoid subsequent loss of fixation. It is important to place the first screw sufficiently proximal to allow room for the second screw to be placed in the same plane. Following the Chevron osteotomy, a percutaneous Akin osteotomy was performed bilaterally for final correction of alignment of the hallux. One bicortical PROstep HV screw was placed in each proximal phalanx to maintain correction (Figures 3 and 4). 2 Figure 2. Preoperative, weightbearing AP x-ray of bilateral hallux valgus. 3

4 Case Study 1 PROstep Minimally Invasive Foot Surgery 3A 3B FIGURE 3A. Postoperative, weightbearing left (3A) and right (3B) AP x-rays following PROstep MICA (minimally invasive Chevron Akin) surgery 4

5 Case Study 1 PROstep Minimally Invasive Foot Surgery 4A 4B FIGURE 4. Postoperative, weightbearing lateral left (4A) and right (4B) x-rays following PROstep MICA (minimally invasive Chevron Akin) surgery. Postoperative Care* The surgical dressing remained in place for the first two weeks postoperative, during which time the patient was allowed to bear weight on her heel. At two weeks postoperative, the patient was seen by a nurse to remove the dressing and ensure the wound was healing properly. At that time, the patient was allowed full weightbearing in a postoperative flat shoe for the next three weeks. At five weeks postoperative, the patient was allowed to transition into her own shoes and resume regular, low-impact activities. At ten weeks, the patient was cleared to resume all activities as desired. Follow-up in the clinic was performed at six weeks, three months, and one year postoperative (Figures 5 and 6). * Postoperative care is the responsibility of the medical professional. 5

6 Case Study 1 PROstep Minimally Invasive Foot Surgery 5 Figure 5. One year postoperative, the patient has good range of motion. 6 Figure 6. One year postoperative, the correction is maintained, and the patient reports she is able to comfortably wear closed-toe shoes. 6

7 016799A Hallux Valgus Correction Using PROstep MICA Minimally Invasive Foot Surgery: Two Case Studies CASE STUDY 2: MODERATE BILATERAL HALLUX VALGUS CORRECTION Patient History The patient presented as a 46-year-old woman with moderate bilateral bunions (Figure 1). She reported no pain from her bunions when barefoot or when wearing open shoes, but she reported that closed shoes were painful for her. She reported no other pain associated with her feet. Contributed by: Joel Vernois, M.D. W. Sussex, England 1 FIGURE 1. Preoperative photo of bilateral, moderate bunions that were painful in closed shoes. Examination and X-ray On clinical examination the patient had moderate, bilateral hallux valgus with normal, pain-free mobility of the first TMT joint and negative grind test. She showed no metatarsalgia and was pain-free on palpation of the sesamoid. No callus was observed under the lesser metatarsal heads. X-ray showed a moderate hallux valgus deformity with intermetatarsal angles of 13 (left) and 18 (right) and hallux valgus angles of 36 (left) 44 (right) (Figure 2). Mr. Vernois is a paid consultant for Wright Medical. Wright Medical provided financial support for this case study. These results are specific to this individual only. Individual results and activity levels after surgery vary and depend on many factors including age, weight, and prior activity levels. There are risks and recovery times associated with surgery, and there are certain individuals who should not undergo surgery. This case study is a publication of Wright Medical Group N.V. or its affiliates 7

8 Case Study 2 PROstep Minimally Invasive Foot Surgery Surgery The left foot was addressed in this surgery. Percutaneous extra-articular reverse-l Chevron (PERC) osteotomy was performed under fluoroscopy. The first metatarsal was corrected with moderate translation and fixed with one PROstep MICA screw to maintain correction. Final correction was accomplished with an Akin procedure fixed with one bicortical PROstep MICA screw (Figures 3 and 4). 2 FIGURE 2. Preoperative AP x-ray showing the intermetatarsal and hallux valgus angles. 3 FIGURE 3. Postoperative weightbearing AP x-ray of the left foot. 8

9 Case Study 2 PROstep Minimally Invasive Foot Surgery 4 FIGURE 4. Postoperative, weightbearing lateral x-ray of the left foot. 9

10 Case Study 2 PROstep Minimally Invasive Foot Surgery Postoperative Care* and Follow-up Because the procedure was a distal osteotomy, the patient was allowed heel weightbearing immediately postoperative. The patient was seen at two weeks postoperative for dressing removal and wound check. At that point she was allowed full weightbearing in a flat surgical shoe and allowed to introduce regular, low-impact activities including walking and swimming. At five weeks, the patient was given clearance to resume her normal footwear. At 10 weeks, the patient was allowed to resume high-impact activities. At three months postoperative, the patient showed good healing and maintenance of correction (Figure 5). She had good range of motion in dorsiflexion (Figure 6) and plantarflexion (Figure 7). 5 FIGURE 5. The right foot was corrected with the same surgery and was also showing good healing and maintenance of correction. * Postoperative care is the responsibility of the medical professional. 10

11 Case Study 2 PROstep Minimally Invasive Foot Surgery 6 FIGURE 6. Dorsiflexion at three months postoperative 7 FIGURE 7. Plantarflexion at three months postoperative 11

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