Over 150 different procedures have been described in the scientific literature for correcting bunions. Minimally invasive surgery (MIS) has become an increasing topic of interest in foot and ankle surgery recently, since 2023. The concept of “minimal invasive” sounds good, perhaps sounding like conservative care. But let us explore what it really means and the risks associated with these procedures.
Minimally invasive bunion surgery (MIS) involves correcting bunions through small incisions, often using a high-speed rotary burr to cut bone, with reasons for its popularity including less pain and faster recovery. However, Dr. John Hoy at the Seattle Foot and Ankle Center does not recommend or perform these procedures due to significant concerns about potential complications like nerve injury, bone non-viability, and deformity recurrence. These techniques are not a current standard of care and have not been historically taught in medical schools and residencies. Dr. Hoy, who has performed bunion surgeries since 2000, limits treatments to established procedures with proven efficacy.
Currently, the most common MIS procedures for bunions involve correction via a distal metatarsal osteotomy, a cut at the end of the bone just behind the big toe. The main difference between traditional and MIS bunion surgery is the size of the incision, as illustrated below.
Performing MIS from the outside is done through small cuts. The bone cuts can be made with a saw or with a specialized power rotary burr designed to perform at 6,000 rpm to prevent heat or soft tissue damage. One can dial in bone cuts and movement of the bone to achieve appropriate correction and fixation of the deformity. Fixation can range from the use of pin fixation to the use of specifically designed headless hollow screws that span the bone and cut.
Reasons for popularity include: less pain, less postoperative swelling, better cosmetic appearance and faster recovery. However, with the small incision, the obvious drawback is the inability of the surgeon the visualize the anatomy of the surgery!!
Possible complications of first ray MIS techniques, and the reason why they are not universally adopted by surgeons, including Dr. Hoy, include:
• mechanical and thermal injuries producing nerve injury;
• soft tissue and bone non-viability associated with high-speed burr use;
• infections due to prolonged exposed K-wire placement;
• bone displacement due to instability of the cut and poor fixation resulting in non-healing;
• bone shortening and overaggressive bone resection;
• non-viability of the bone due to disruption of the blood supply;
• deformity recurrence due to lack of complete correction;
• extra bone formation; and
• joint stiffness and cysts due to driving skin cells deeply with the instrumentation.
Dr. Hoy has had to treat patients whose bone did not heal and had pain and difficulty walking after having this type of surgery from other providers. This is not a procedure offered in this practice.
Dr. John Hoy at the Seattle Foot and Ankle Center in Seattle, Washington, has been performing bunion surgeries since 2000, for 23 years before MIS procedures popularized. We don’t know how long this trend will last, or if they will take hold over the coming years. These procedures have been previously dismissed, are not a current standard of care, and have not been historically taught in medical schools and residencies. Dr. Hoy limits treatments only to tried and true procedures with which he has experience.
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