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Peacock Modified Reverdin-Isham-Bosch (PRIB)
Distal first metatarsal osteotomies are widely accepted for treating mild to moderate HAV deformities.(1) These osteotomies lend themselves well to MIS techniques. (2) Drawbacks may arise due to shortening observed when performing through and through osteotomies(3). The rationale behind modifying the Reverdin-Isham, Bosch is aimed at bringing about a MIS osteotomy which can directly address PASA, IM angle, and achieve plantar flexion and/or lengthening of the first ray when needed. The author calls this the PRIB procedure and is the acronym for Peacock, Reverdin, Isham, Bosch procedure.(4,5)
A percutaneous punch incision is performed with a 64 blade and is made over the plantar medial border of the first ray where the metatarsal head fans out in the distal diaphyseal area. The incision is continued down in a single cut until reaching the periosteum. From this position the 64 blade is used to underscore the capsule at the first metatarsal phalangeal joint employing a sweeping motion. Under fluoroscopy a 3.1 wedge burr is inserted and the medial prominence is resected from the first metatarsal head. Pressure is applied to the first metatarsal phalangeal joint area and the medial eminence is eliminated as bone paste.
The first step of the osteotomy involves a wedge osteotomy in the distal diaphyseal area of the first metatarsal leaving the lateral portion of the cortex intact. This is accomplished using a straight Isham burr. The osteotomy is angled at a 35°-45 from dorsal distal to plantar proximal and is angled distally to help maintain length of the first metatarsal in patients with a relatively short 1st ray. It can be made parallel to the 2nd metatarsal or proximal if desired. The final cut of the osteotomy involves completing the lateral cortex cut with a J stroke movement leaving a lateral plantar shelf. This maneuver will allow for further 1st ray lengthening and added stability for patients requiring plantar flexion of the 1st ray.
The osteotomy is then shifted by inserting a Locke elevator through the incision site into the medullary canal of the 1st ray and using this as a fulcrum to transpose the osteotomy. Prior to laterally shifting the osteotomy a percutaneous lateral release is done. Thumb pressure can transpose the osteotomy in some patients. With the lengthening style cut the Locke elevator maneuver is easier. Subsequent to displacing the osteotomy fixation is accomplished via percutaneous K wire. This fixation technique permits torqueing to further close the PASA correction. The osteotomy can be plantar flexed by distracting the distal fragment and pressing the medullary portion of the fragment on to the plantar lateral shelf created by the osteotomy.
Advantages of PRIB:
The advantage of this osteotomy is that it allows for correction of large IM angles over 16 and can directly address PASA while limiting shortening realized with through and through osteotomies. Also, by creating the plantar lateral shelf, added stability is gained with patients demanding plantar flexion of the first ray.
Disadvantages of PRIB:
The most obvious disadvantage of this osteotomy is its more proximal placement than standard distal osteotomies, such as the Austin etc. This characteristic will result in a less stable osteotomy requiring fixation.
The PRIB technique borrows from already established osteotomies including the Reverdin- Isham and Bosch techniques. The procedure can be performed under local anesthetic in the office setting and the technique can be performed in 15 minutes. The PRIB is usually done in conjunction with an Akin osteotomy. Other than the fluoroscopy no special equipment is needed and the cost of the K-wire is not prohibitive to office based procedures. Figure 1 and 2 are Preops. Figure 3 and 4 are 3 week post ops. Figure 5 and 6 are 2 month post ops.
Note very little shortening and plantarflexion achieved via this osteotomy technique. In the presented case the hallux osteotomy was intentionally performed to allow for dorsiflexion of the proximal phalanx to address mild functional hallux limitus issues. The author feels a surgeon should be judicious when dorsiflexing the proximal phalanx since this can result in a hammered great toe and/or toe purchase issues especially when not plantar-flexing the 1st met at the diaphyseal area . Under most bunion correction circumstances the surgeon should endeavor not to dorsiflex the proximal phalanx.
Don Peacock, DPM (professor AAFAS), ACFAS
Fig 1: Preop Weight Bearing AP
Fig 2: Preop Weight Bearing Lateral
Fig 3: Post op 2 weeks Weight Bearing
Fig 4: post op 2 weeks Weight Bearing
Figure 5 and 6---- 2 month Post op
1. Austin DW, Leventen EO. A new osteotomy for hallux valgus: a horizontally V displacement osteotomy etc. Clini Ortho 1981;157:25-30
2. Schilero J:Minimal incision podiatric surgery. Principals and applications. J Am podiatry Med Assoc 75(11): 586-574, 1985
3. Zlotoff H: Shortening of the first metatarsal following osteotomy and its clinical significance. J AM Podiatr Assoc 67(6): 412-426, 1977
4. Isham S. The Reverdin-Isham procedure for HAV: Clin Pod Med Surg 1991;8: 81-94.
5. Bosch P, HAV correction method Bosch: 7-10 year follow up. Foot Ankle Clin 2000; 5:458-98.
Minimally invasive foot surgery lends itself well to the treatment of diabetic ulcers and of infected bone tissue. MIS techniques allow for osteotomies away from infected bone and can be combined with tendon re-balancing to achieve stellar results in eliminating diabetic foot ulcers.
The Academy will have Dr. Monroe LaBorde MD, teaching techniques of tendon re-balancing that reduce pressure areas in the foot allowing ulcers to heal. These methods have proven effective as outlined in multiple published research articles.
For those attending the Academy seminar this June 2016, they can expect to be exposed to both lectures and hands-on cadaver teaching allowing for implementation of these techniques into their practice.
Here is a case where the author used both tendon re-balancing techniques learned from Dr LaBorde with the use of minimally invasive surgery to reduce a bony prominence in a Charcot patient. This intervention allowed for complete resolve of the chronic ulcer.
The patient underwent gastrocnemius recession and MIS debridement of Charcot exostosis by minimally invasive surgical techniques.
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