Insights on Postoperative Care for Bunions After MIS
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Transcript
Tyler Gonzalez, MD, MBA, FAAOS: Let's talk about our postoperative recovery. So, Dr. Shipper, what's your typical—what do you do from a postoperative recovery or weight-bearing status? What do you do from, would you put them in a cast, a splint, a boot, a shoe, what's your protocol postoperatively?
Oliver Schipper, MD: Sure. So first of all, I just do a first ray field block for the procedure itself. So just day one, I keep them heel weight-bearing just so obviously you don't want to put them weight when they're numb. You know, for anyone who's still doing an ankle block or even a God forbid a pop-sap or pop-adductor block, I think that's kind of overkill. You know, especially a pop adductor, you can certainly see, you know, permanent paresthesias, rarely, you know, permanent paralysis or neuropathy. Really, just a first-rate field block is great, and especially for older patients versus an ankle block, you know, they can put weight on their heel right away, so lower risk of them falling. That's, again, what I do. I just do it up at the level of kind of proximal, or like around the first TNT joint, I'd say.
But anyway, so heel weight-bearing during day one and then, like I said, I've done everything. Right now, I'm doing a short boot for four weeks and I want to go back to a sneaker. I do like them to put them in something because it's very hard when you meet a patient in clinic, especially if you only met them one time before surgery to know, are they going to act like they had surgery or are they not going to act like they had surgery, right? And I like doing something, whether it's a boot, whether it's a heel postop shoe, just to slow them down, protect them from themselves, just because sometimes it's hard to know who's going to act like they had surgery and who's not, but it's a move for short, short, short move for four weeks.
Dr. Gonzalez: Good point you bring up and Brian alluded to it. This MIS surgery and all, and you guys can tell me if you agree or not, I find that patients tend to, I have to protect them from themselves because they have so little pain that they tend to be more aggressive. They're like, “Oh, my foot doesn't hurt. I can walk on it. I can climb this ladder.” This didn't exist in a lot of open procedures because swollen, hurt, they didn't want to put weight on it. Now they're not on pain meds. They feel good. So why not? They feel that they can do more, more quickly. So I've actually found that this evolution, people tend to be—listen less because they hurt less and think they're good to go.
You know, how many times is a patient, Oliver, come in with their sneaker at four weeks when they're like, oh yeah, I took off the boot. I felt great. It hurt worse, right? Or Brian, the guy at one week climbing the ladder, right? I see this happen a lot because, which didn't happen in these big open procedures because they were miserable. They didn't want to do anything.
Brian Loder, DPM, CWS, FACFAS: I agree, completely Oliver. I mean, Tyler, I agree completely with that statement. I don't use a boot. I tend to use a flat shoe. Heel weight at the beginning for the same reason Oliver said, but after two or three days, I go ahead and have them flat wear the boot, the shoe. I convert them to a tennis shoe at week five. One of the things I do do is I have them put ice on five times a day for the first five days to reduce swelling, to get a control of that at the beginning and inflammatory process. So I've really pushed the ICE on these patients, which helps with the pain control. But what I also tell them to do is on week five, they're gonna go into a tennis shoe, a tie shoe specifically, 'cause I want them to cinch it down to help squeeze out the edema. And then as the day goes on, I let them loosen it and then start over again the next day to keep it snug.
I think one of our biggest problems that we have, and this is something that we have not talked about, is the amount of swelling we get at week five to eight, because now they're more active, they're on it more, and they're back into regular shoe gear, and it's putting a little bit strain on the screw site. So we have to battle that swelling at that beginning, because they want to get back into a shoe. So I try to get them to work the swelling down themselves in the early set between week five and eight.
Dr. Schipper: So, Brian, now, now I know why I have all these people coming from Michigan saying, Hey, I heard you can do surgery where I'm in a sneaker of four weeks instead of five weeks like that guy in Michigan.
Dr. Loder: Oh, is that what happens?
Dr. Gonzalez: Yeah. That's right. That's exactly right.
Dr. Schipper: It's that slow rehab protocol. No, but I—Brian actually brought up a great point about the swelling and, and that is honestly so important. I think it's important to counsel patients to expect six months of swelling. And honestly, that's for all of foot and ankle surgery. Probably most surgeons do that already, but it's important because, again, this is bunion surgery. A lot of people are doing this, so ultimately they can wear more shoe wear or increase their shoe kind of wear abilities, right? And at three months, they typically will not be able to fit in the nice tight dress shoes. And that's why you always lay, lay crave, tell them six months. And if And unless you want to do Brian's tight shoe technique, there is also like a $20 four-foot compression sleeve. You can probably get through—there's multiple vendors for it, but it's just called four-foot compression sleeve. We do offer that too. We just got some patients put it on first thing in the morning because as Brian said, they will swell as the day goes on.
What are the next steps in the evolution of MIS for bunions?
Dr. Gonzalez: I want to know what you guys think the next steps are. Where's the evolution coming with MIS bunion surgery? What are the next steps? Where is it going since you guys have been on it from the beginning to now? You know, I'll start with Dr. Loder. Like what do you think the next steps are in MIS bunion surgery? Where is it going? How do we get everybody doing it? How has it become the mainstream of bunion treatment?
Dr. Loder: I think it's lowering the—it's increasing the adoption rate and lowering the comfort curve. And I think the industry is trying to figure that out with different options, whether it's intramedullary plates, or jigs that work more accurate so people don't have to surgeons don't have to freehand. I think the industry is coming up with better and better options to make adoption quicker and easier and more attractive to our surgeons. And that's the key because it is the comfort curve and learning curve of this procedure that scares individuals. And we're starting to get away from that by making it almost system proof that they can do it every time the first time. And that I think is the biggest key. I think by 2030, there won't be many open procedures being done for bunions anymore. I think our adoption is going to fly in the next two to three years and people are going to start jumping on board to do this procedure.
Dr. Gonzalez: Dr. Schipper?
Dr. Schipper: Yeah, I mean, I think Brian hit it head on. I completely agree with him. You know, we've obviously done a ton of work.
Dr. Loder: Can we repeat that? You agree with me?
Dr. Gonzalez: It's recorded. It's recorded.
Dr. Loder: Thank you.
Dr. Schipper: Can we cut that out, please? Can we cut that one section out, please?
No, but seriously, I mean, I think initially it was placing the wires for the screws, you know, I think we, through teaching improve that technique, but then having a jig really allayed a lot of fears for surgeons about kind of jumping in and felt like with the jig, they could place the wires more easily, more reproducibly. You know, the other one is still the burr is still a, it's a new tool in tool in your toolbox. It's not something that a lot of surgeons who are out in practice had training on. Now, that is changing dramatically because really, MIS, if you look at fellowships now both in podiatry and orthopedics for foot and ankle, really, there's greater adoption now in the marketplace. A lot of residents are now getting exposure. Fellows are then getting exposure. You know when they get in the practice, it's the first time they're touching the bursa. I think that part will change over time, but I think industry will probably work on having ways to do these minimum basic techniques, maybe with the saw still, that kind of give you a similar correction, hopefully lower pain, you know follow the same principles, but maybe don't force surgeons to use a burst. I think that and we talked about that a little bit earlier, but I think that'll be the one other option that also increases adoption other than what Brian said.
Dr. Gonzalez: Well, you know, I couldn't agree with both of you more. I just want to say thank you both for being on tonight. I would tell the audience, you know, both Brian Loder and Oliver Schipper are really active on LinkedIn. They post a lot of their great cases, technique tips, things like that, so you can follow them. And I thank you both for being on tonight and with that we'll call it.
