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I am curious as to how many foot surgeons are utilzing the mini-tight rope/bunionectomy procedure and what their results have been including patient satisfaction and post-operative results.Your response is appreciated.
dennis l berger dpm dlbdpm

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Good question Dennis. I too would be interested.
I've seen it performed, but to be quite honest, was not impressed with it.
Whether or not this is accurate, it seemed to me one of those procedures that was developed backwards, i.e., what procedure can we develop that will utilize something we can supply and sell?
I'd be curious as to how "comfortable" it is to have the first and second mets basically tied together and jamming the met/cun joints. Also the long term effects of the "buttons" on the shafts.
Steve

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DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA

Steve,
I have used it 9 times.And I have a complication rate of more than 50%.While it is technically easy to perform, I have fractured the 2nd MT,lost correction by loosening of the fiber wire,and had the brackets not maintain compression intra-operatively.The learning curve is depressing me.However, the positive results are most impressive.This is a classic no brainer for a short 1st MT with high IM angle and hypermobile !st ray
I was hoping to find others that would be using the device.While I believe the 1st MT transverse plane deformity is addressed,the saggital plane motion is not stabilized adequately with the procedure.Currently a second point of fixation was utilized.I'll see how that goes.
Dennis dlbdpm@yahoo.com

I've used it 3 times. Twice on the same patient for bilateral HAV w/ a 24 and 18 degree IM respectively. I used an Austin w/ a screw fixation as well as the mini-TR.

the closure of the IM is at least an extra 4-6 degrees. I find that very good. I am only about 3 months post-op on the first one, but patient is back into shoe and still has a mild bunion deformity. She knew this would be the case but is still pleased to not have to go into a cast post-op.

I had one pull-through on another osteoporotic patient with eventual fx of teh 2nd met. She's doing well and healing uneventfully.

I think it is ok. I agree no sagital plane restriction, but patient ambulate very quickly. I've not tried it on a smaller bunion so far.
Bruce

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Bruce E. Williams, D.P.M.
Breakthrough Podiatry

I've done close to 20, and our group practice has done close to 30 total. Those numbers include one tailor's bunion and one juvenile bunion.

When it works, it works great. There is less down-time than with a Lapidus or base wedge. There is also generally less edema and pain. Patients appreciate not having to be non-weightbearing. Since there's no osteotomy, there is no methead AVN or capital fragment displacement as one would risk with a head procedure. You also gain more correction and 1st ray linearity than with a head procedure. Biggest pre-op IMA was 19 degrees.

We've had four cases of 2nd metatarsal fracture or implant failure. In one case the 2nd met drill hole was too dorsal (I think). In two cases the patients were osteopenic. In the fourth case I haven't yet deduced what happened.

I think the biggest complication people are experiencing is 2nd met fracture. My hunch is that there is too much force concentrated at the small 2nd met button, and it causes a stress fracture leading to frank fracture in certain patients. I think we still need to clarify patient selection. I will no longer use it on patients with osteopenia. We need to figure out maximum patient weight limit.

Steve, we have had zero complaints of met-cun joint discomfort. I was concerned about that possibility too, but it has not been an issue.

Dennis, I have noticed a significant reduction in sagittal plane mobility, yet it allows a "normal" ROM, but I'm curios as to what was your second point of fixation that you mentioned?

Nat

Edit: Overall patient satisfaction has been outstanding except in the cases of failure. In those cases you can guess their satisfaction level.

Nat,
You are correct,when it works well,it is excellent.Failure causes a pain in the posterior.My feeling is the transverse plane is well controlled,but the saggital plane of the 1st mt is not--at least until adequate consolidation of the holes around the fiber wire has been attained.The second point of fixation was a 5/64 steinman pin driven transversely from mt1 through mt2&3.That puppy was rigid.I also figured the patient coulg continue to walk(with assistance) in the post-op shoe.I also incorporated a small posterior splint (3x12" by 3MMM).Currently there is no problem,the pin will stay 6-8 weeks,ROM will be unimpeded.

dlbdpm

I just saw a post-op this morning with a 2nd met fx. It is indeed a pain. I have started incorporating a plate beneath the lateral button such that it acts as a buttress against the 2nd met. I hope that the plate disperses the forces away from the button across more of the bone.

Nat;
at what point does utilizing a mini-TR and plate become as troublesome as just doint an Austing w/ a screw?

I still have not done one in a smaller IM, though I am contemplating it. BTW, my pull through did finally fx at the 2nd. She's healing well though.

cheers!
Bruce Williams

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Bruce E. Williams, D.P.M.
Breakthrough Podiatry

I can't recall how you ended up fixating the 2nd. Did you use a pin or plate?

I actually prefer using the TR for a smaller IMA (i.e., those folks for whom I would've done an Austin). They get a great reduction and I don't need as much tension in the suture to hold the reduction. My Austins all seem to need an awful lot of post-op PT to avoid ROM-limiting scar tissue. Even with PT, many patients end up with limited ROM. The TR's all seem to have great p/o ROM with less swelling and pain.

For me the debate is more TR v. Lapidus.

I caught a lecture at a conference last week during which the speaker was discussing "1st ray co-linearity." The topic discussed the alignment of not just the 1st met but also the soft tissues around the 1st ray. He felt that by addressing the bunion at the point of deformity (the 1st TMTJ) there was better alignment of all structures. It seemed logical even though he had no evidence. The TR and Lapidus gives better "co-linearity" than a head procedure. If only we could figure out how to reduce the 2nd met complications, this procedure would excel.

Further thoughts:

You know what I'd like to see? I'd like some type of semi-flexible rod that would cross the 1st TMTJ. The rod would hold the 1st met in an adequately reduced position, yet would have enough elasticity to allow physiologic ROM of that joint. Picture a leaf spring of some sort. It would have to be able to withstand practically infinite cycles prior to fatigue, rather than breaking like a K-wire or S-pin. One would not have to do an osteotomy or joint fusion. One would just reduce the deformity then insert the rod to hold things in place. Wouldn't that be nifty?

Nat

Nice timing, just this morning I had a mini-TR on the schedule but decided against it and did the good ol' Austin instead. She is 80 and has questionable bone stock. I didn't feel like fixing a 2nd met fracture in 4 weeks!

I did not think of it while this thread was fresh, but one of yesterday's cases reminded me to post here about another option. In the case of excessive 1st ray dorsiflexion one can also do a Cotton procedure to plantarflex the ray. We used an allograft plus OsStaple.

Nat

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Recent utilization of a second point of fixation has proven currently successful.It is my impression that the concept of the mini tight rope is excellent,however,the second mt does not have the necessary mass to control/limit the dynamic normal rom of the 1st mt.The mini tight rope does not always have the ability to control the hypermobility of the 1st ray(what it was designed to do) and that is why the 5/64 steinman pin inserted at the mt bases has proven successful in conjunction with the mini tr. The real question becomes efficacy.....since the s-pin remains approximately 8 weeks, why not just perform the osteotomy and proceed as before?
dlbdpm

I have been asking myself that same question. Since my recovery course has been extending from what seemed initially possible, the benefits of the TR are less pronounced. I have been holding my breath hoping that patients don't fracture the 2nd met, leaving me with a mess to clean up. The biggest benefit I've been seeing still is relatively less p/o edema and pain.

I am moving towards doing more Lapidus procedures using a locking plate plus Mini Rail external fixator.

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Hi Nat:
Just wondering why, on these "moderate" bunions, you do not use a distal metatarsal osteotomy with perhaps an Akin.
These do heal very quickly, are quite corrective and rarely have complications.
Steve

__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA

I have had less edema and stiffness with the TightRope than with the distal metatarsal osteotomies (DMO). For some reason my DMO's need a huge amount of ROM exercises to not scar down whereas the TR's stay very mobile. The anatomical structures appear to line up so nicely on x-ray too.

Speaking of DMO complications, I just saw a 4 week Austin p/o whose capital fragment shifted out of place into the intermetatarsal space. Son of a gun.

Nat

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Hi Nat:
Any new news with the tight rope?

I happened to bump into the rep yesterday who's pushing me hard to try it out. NO ONE in my town (four hospitals) has used it yet. Apparently the regular size tight rope has been used for tib-fib syndesmotic repair with good result.

In any event, he's visiting with me tomorrow to show it to me again.

Can I ask what your criteria is for selecting it?

Thanks

Steve

__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA

Sent to your PM inbox.

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I just took the ABPS recert exam on Friday. Wouldn't you know it there was a question on the tightrope on that exam!

At least I got one right!

Bruce

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Bruce E. Williams, D.P.M.
Breakthrough Podiatry

Are you serious?!?! When I talked to someone representing ABPS he discounted the Mini-TR, saying it was more-or-less invalid. Now they're testing on it!

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yep! Unless I got it wrong, which is a distinct possibility!, the main answer is that there are risks of a 2nd metatarsal fx w/ use of the device. Duh! Been there and done that!


Bruce

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Bruce E. Williams, D.P.M.
Breakthrough Podiatry

In my opinion the mini tight rope is inadequate to maintain IM reduction/hypermobilty as purported.a second point of fixation is required proximally in conjunction with immobilization.subsequently,the mini tr provides no benefit over osteotomy in the 1st mt. personally,I have abandoned the procedure as the risk is greater than the reward.the correction is not maintained as is easily accomplished with other more traditional procedures.

dlbdpm

Hi Dennis:
Thanks for the opinion based on your experience.
Do you happen to know how the mini was developed?
I have a sneaking suspicion that the regular sized tight rope was developed for syndesmotic tears and someone in R&D wanted to find another use for it; Failing to do this it seems reasonable they selected a common procedure (like bunions) and reworked the size and handed it over to marketing/sales force.

If someone were to explain and describe this procedure to me in anticipation of developing it, I would have a negative opinion as to it's chances of success.

Years ago there was a Podiatric Surgeon in New Jersey where I was doing a summer preceptorship who routinely put a 2X0 Tevdek suture between the first and second MTPJ capsules (basically tying the lateral 1st capsule to the medial 2nd) - I always felt it was rediculous to think this would stay in place upon weight bearing. I also feel its asking a lot of the second metatarsal to hold the first met in place via fiberwire.

Steve

__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA

I have not seen a technical description of it. But I saw impressive adverts for this ‘groundbreaking’ operation in the New York Post (?), when I was there last October. I got the impression this technique is functionally similar to the cerclage technique, right? I first knew about it 18 years ago during my surgical training, when I rubbed shoulders occasionally with a highly experienced orthopaedic surgeon whom I shadowed. He tried it out, once in a while - it never caught on, but the post-op x-rays I saw was showing the wire eating through the second metatarsal; now that was impressive to the attending Podiatry student. This picture burnt into my mind, as an education to avoid this procedure. Even when buttons got used there were 2nd metatarsal fractures. Has there been a technological advance since then, to improve on this ?

In my mind this procedure is conceptually flawed. This is simply because many of the cases of hallux valgus have a common theme. There are huge mechanical forces and the aggregate effect is that the joint segment simply buckles ‘under the weight’. For a lasting correction the operation has to have the potential to modify those weight bearing forces. This can be achieved in the time honoured way by altering the alignment of the 1st metatarsal, in both transverse and sagittal plane, and by considering the 1st metatarsal index also to balance out the forefoot pressure and encourage normal 1st MTP joint function. In this respect decompression can be a very useful adjunct, when carefully balanced and when taking into account those variables affecting your patient’s foot.

My 2c worth.

Interesting study in Vol. 29 No. 1 (jan 08) Foot & Ankle International on the tight rope. They compared the stability of the tight rope fixation for Tibfib syndesomotic ruptures vs Screw. The Tight rope did not fair well.
I have a feeling this system will be pulled eventually.
Steve

__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA

Steve, Dennis, Bruce, Nat and Dieter:

I have been reading the interesting discussion on the mini-tightrope bunionectomy and had some thoughts that I would like to share.

First of all, I am having a difficult time understanding how one could expect the rather large diameter 1st metatarsal to be able to be “pulled into place” by tying it to the much smaller diameter 2nd metatarsal without the 2nd metatarsal suffering some type of stress injury, such as stress fracture. The 2nd metatarsal is not adapted structurally to be pulled medially by a small diameter wire, especially with a hole drilled into the 2nd metatarsal [which will greatly increase the magnitude of stress within the bone adjacent to the drill hole] without some stress injury occurring. Possibly if the anchoring material was composed of a material that had less stiffness than a mini-tightrope, so that it would elongate more when a tensile force was placed across it, and possibly if the anchoring material was attached to the metatarsal across a broader surface area of the 2nd metatarsal, there would be much less chance of 2nd metatarsal stress injury using this type of bunionectomy.

Secondly, tying the 1st metatarsal to the 2nd metatarsal with some form of suture material for bunionectomy surgeries have been used for years by orthopedic surgeons. An orthopedic surgeon that I did surgery with over 22 years ago performed Lapidus bunionectomies by removing the 1st metatarsal-cuneiform joint and then tying the 1st and 2nd metatarsal necks together with non-absorbable suture. Thankfully, after I showed him how well a modified Reverdin bunionectomy or closing base wedge osteotomies worked at realigning and correcting bunions, without the post-operative morbidity of his preferred bunionectomy procedure, he quit doing bunion surgeries by his previous preferred method.

Third, I think Steve is right in saying that some companies are always looking for ways to make us use their surgical product, regardless of whether that product has been fully tested by experienced surgeons over an adequate period of time. This is made worse by the surgeons who, in their desire to make a name for themselves, experiment on patients by doing procedures that will allow them to say that “they invented the procedure”, without fully disclosing the many pitfalls with “their procedure”. Of course, in hindsight, everything seems to have much greater clarity. But in the case of the mini-tightrope bunionectomy, hopefully all of these stress fractures that are occurring on the 2nd metatarsals of patients won’t cause iatrogenic 3rd metatarsal head pathologies or iatrogenic 2nd digit hammertoe deformities or iatrogenic 2nd digit floating toe deformities in the future for these patients.

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Sincerely,

Kevin

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Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
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Voice: (916) 925-8111 Fax: (916) 925-8136
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I have done a number of the Minitightrope bunionectomies. The procedure requires a soft tissue release around the first metatarsal head in the same manner as any other bunionectomy. It also requires a second incision to place the tightrope through the second metatarsal. The hole is fairly large to accommodate the retaining button. The primary concern of lesser metatarsal fracturing has been during the healing process of this hole. The patient needs to be treated postoperatively with a protective boot and minimal weight bearing.

The concern for a second metatarsal fracture is a very legitimate one. I have seen two of them out of 9 procedures. Both occurred early in patients that were very active. The first was in a patient who simply did not use the recommended protective Aircast boot. Amazingly, she would not use the boot even after fracturing but went on to heal uneventfully.

There is clearly less postoperative disability with the procedure. In a flexible foot, the tightrope will reduce a large IM angle. The question of how they will do over time remains. Patients need to be very clearly advised regarding the newness of the procedure, the lack of long term follow-up and potential need for revision in the event of recurrence and failure. Knots can release and the tightrope can break too. With my longest follow-up of almost a year, even with the two fractures, the patients so far are happy. They also included two patients who had their other foot previously done the more standard way with a first metatarsal osteotomy. Both were much happier with the tightrope. Still, the numbers are way too small to constitute anything more than an observation to date. Time will tell.

Can anyone help code this procedure? Need CPT codes

Check your private messages.

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Did you ever get an answer to your question re tight rope surgery? Barbara L