Abstract
Introduction
Minimally invasive bunion surgery (MIBS) has become increasingly popular, demonstrating outcomes comparable to open hallux valgus correction. Although complications such as recurrence, hardware irritation, and infection are reported, nonunion remains rare, occurring in fewer than 1% of cases. Standard revision typically involves an open approach with hardware removal, bone grafting, and plating, which compromises the advantages of minimally invasive techniques.
Purpose
This case report presents the surgical technique for a MIBS symptomatic nonunion reconstruction utilizing the MIPO technique.
Case report
This report presents the case of a 25-year-old female with symptomatic nonunion following fourth-generation MIBS. At 6 months postoperatively, the patient reported persistent pain despite appropriate postoperative management. Imaging demonstrated maintained alignment and intact hardware, with computed tomography confirming the absence of osseous union. After failed conservative treatment, revision surgery was performed using a minimally invasive plate osteosynthesis (MIPO) technique.
Surgical technique
Revision involved partial hardware removal, percutaneous re-drilling of the osteotomy, and augmentation with autologous cancellous bone graft, bone marrow aspirate, and recombinant human bone morphogenetic protein-2. A low-profile mini-fragment plate was inserted percutaneously and secured with a combination of locking and non-locking screws. Postoperatively, the patient progressed through staged weightbearing and returned to full activity with minimal pain. Radiographs confirmed complete osseous union and stable fixation.
Conclusion
Nonunion following MIBS surgery is rare, and treatment options commonly involve open revision surgery. This surgical technique describes a minimally invasive revision option utilizing the MIPO technique.
Introduction
Minimally invasive bunion surgery (MIBS) has gained widespread popularity over the past decade, with outcomes comparable to those of open hallux valgus correction. ,, Although complications such as recurrence, hardware irritation, and infection are reported, nonunion remains rare, occurring in fewer than 1% of cases. ,,, When nonunion does occur, revision is typically performed through an open approach with hardware removal, bone grafting, and plating, which negates many of the advantages of the minimally invasive technique. This report describes the successful use of minimally invasive plate osteosynthesis (MIPO) to revise a painful nonunion following MIBS, thereby preserving the benefits of a percutaneous approach. ,
Case report
A healthy 25-year-old female presented with bilateral hallux valgus deformity, with a Foot Function Index (FFI) score of 57 and a visual analog scale (VAS) pain score of 7. Informed consent for participation in this study was obtained and signed by the patient. She underwent staged fourth-generation MIBS procedures for hallux valgus correction, with the right foot treated first and the left 6 months later. Standard postoperative management included protected weightbearing in a controlled ankle motion (CAM) boot and adjuvant bone stimulator use for each procedure. The right side healed without complication ( Fig. 1 ). At 6 months postoperatively, the patient had returned to function, and the left side underwent a similar fourth-generation MIBS procedure using the same two-screw construct. Six months later, she reported persistent pain in the left foot at the osteotomy site (FFI 71, VAS 5). Radiographs demonstrated maintained alignment with intact hardware but persistent radiolucency at the osteotomy site. Computed tomography confirmed the absence of osseous bridging ( Fig. 2 ). After failed conservative management, the patient elected to undergo revision surgery.
Radiograph of bilateral pre-operative anterior-posterior (AP) views demonstrating hallux valgus deformity (a,b). Final radiograph of right AP view post-operative following MIS first metatarsal osteotomy with akin osteotomy (c).
Radiograph (a,b) and CT (c) imaging of the left at 4 months post-operative following the index procedure, demonstrating a nonunion of the first metatarsal osteotomy.
Surgical technique
The patient was placed supine on the operating table. The operative extremity was prepared and draped in standard sterile fashion. The operating room setup was optimized with a mini C-arm fluoroscopy positioned on the patient’s right side, the back table on the left, and the surgeon at the foot of the operative table. No tourniquet was used, and all Shannon bur operations were accompanied by normal saline irrigation.
A marking pin was used to identify the previous incision sites using anatomic landmarks and fluoroscopic guidance. A medial incision was made at the surgical neck of the first metatarsal, proximal to the medial protrusion of the metatarsal head, at the level of the prior osteotomy. A second incision was made over the first tarsometatarsal joint, dorsal to the medial plantar vein and proximal to its junction with the medial marginal vein, to remove the plantar screw retaining the dorsal screw to preserve stability and alignment.
Through the distal incision, blunt dissection was carried to the bone, and the periosteum was elevated dorsally and plantarly with a mosquito clamp. A drill was introduced into the osteotomy site under fluoroscopic guidance. The area was then irrigated. This was followed by the introduction of a mixture of autologous cancellous bone graft obtained from the calcaneus, bone marrow aspirate, and recombinant human bone morphogenetic protein-2 (rhBMP-2). The medial soft tissue was elevated, and a low-profile mini-fragment plate was then advanced percutaneously through the medial distal incision, crossing the osteotomy. This was secured following standard technique with a combination of locking and nonlocking screws through percutaneous incisions, under fluoroscopic guidance ( Figs. 3–5 ). Once satisfied with the nonunion revision, all incisions were irrigated and closed with 3–0 nylon suture.
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