Video summary

Bunionectomy- Resident Training Series

Main summary

Key takeaways

Educational

Main Ideas / Concepts

The video is a resident training walkthrough for a long-arm Chevron bunionectomy, emphasizing:

  • Precise incision placement
  • Layer-by-layer dissection while protecting neurovascular structures
  • Careful soft-tissue handling (especially around the medial eminence/capsule) to preserve vascularity and minimize AVN risk
  • An osteotomy technique for a transpositional (long-arm Chevron) cut, oriented to avoid residual deformity requiring extra cuts
  • Fixation strategy using provisional K-wires to ensure stable parallel screw placement
  • Proper capsule closure and layered wound closure to maintain correction and tissue mobility

Detailed Methodology / Instruction List (Step-by-Step)

1) Incision Placement & Initial Exposure

  • Incision location (medial side of first metatarsal head region):

    • Find the top of the bone
    • Mark the medial side
    • Mark halfway between (described as the “safe zone”)

  • Confirm safe zone:

    • Palpate the dorsal-medial aspect of the first metatarsal
    • “Run your dots together” to create a consistent incision line

  • Rationale:

    • Dorsal-medial incision provides exposure
    • Helps avoid neurovascular bundles
    • Allows a lateral release if desired (but not done today)
    • Statement: most patients don’t need a lateral release

2) Skin-to-Bone Dissection (Entering the Operative Field)

  • Start incision through:

    • Skin
    • Dermis
    • Down to the subfascial layer

  • Tissue handling:

    • Use thumb and forefinger to spread tissues with tension
    • Use long controlled strokes
    • Avoid “chicken scratching”

  • After passing the vein layer:

    • Identify white fibrous capsule/contractile fascia

  • Opening tissue planes:

    • Use the blade on the tendon/capsular surface
    • Then turn 45° and use one sweep

  • Medial side technique:

    • Blade laid on bone, tilt about ~20°
    • Sweep along
    • Only section enough to allow the next instrument to enter (avoid overly deep dissection early)
    • Goal: stay controlled and “hug the bone”

3) Identify Structures & Create a Capsule/Soft Tissue Pocket

  • Identify:

    • Extensor tendon
    • Capsularis (capsule layer)

  • Enter between extensor tendon and capsularis:

    • Dissect down to the bone

  • After blade rise on the metatarsal head:

    • Stop
    • Use a pickup to protect the metatarsal head
    • Cut along the opening created by the pickup

First key move:

  • Dissect out the capsule along the medial base of the eminences/“failings” region (medial eminence area)
  • This creates a pocket to enable later blade access for treating collateral ligaments

4) Periosteum Elevation & Vascular Preservation Principles

  • Use a corner of the key elevator (not the flat surface):

    • Don’t push with the flat part
    • Elevate periosteum using the corner

  • Elevate “all the way around the corner”:

    • Technique is intended for a long arm Chevron

  • Vascular strategy:

    • Leave soft tissue intact on the lateral side where the nutrient artery comes in
    • The long-arm cut is designed so tissue is incorporated into the capsular fragment, creating a vascularized head
    • AVN risk is described as essentially nil

Distal periosteum/capsule handling:

  • Distally remove periosteum and joint capsule:

    • Work with the tip of the blade
    • Go toward the corner of the bump (eminence)

  • Avoid improper periosteum removal:

    • Don’t use a key elevator to remove periosteum off diaphyseal bone (risk of shredding due to sharp fibers adhered to bone)
    • Those portions must be done sharply

5) Collateral Ligament Release & Mobilization of the Head

  • After creating the pocket:

    • Drop blade down and cut up to release collaterals while hugging bone

  • Then:

    • Use pickup to access the capsule area
    • Assistant exits
    • Operator tilts down and finishes residual collaterals to free the head

  • Summary note:

    • Dissection described as completed in ~3.5 minutes

6) Remove the Medial Eminence (Before Osteotomy)

  • Remove eminence with a sagittal saw

  • For a transpositional osteotomy:

    • Cut eminence parallel to the medial (Kiafer/Jane?) form (as stated)
    • Core concept: not “parallelism” to the metatarsal shaft axis in the usual sense

  • Technique rationale:

    • If the bump is removed parallel to the shaft axis, head shifting may leave residual deformity that requires a curve cut
    • Instead, make the eminence cut parallel to the medial border of the medial form, so when the head transposes laterally, residual eminence comes off more easily

7) Plan Osteotomy Axis & Perform Chevron Osteotomy

  • Establish a cutting axis

    • Assistant retracts in the same direction as the cut
    • Use a plumb line guide to orient the dorsal wing

  • Critical alignment guidance:

    • Ensure the finger holding the line stays on top of the bone
    • If not on the correct cortical high point, risk cutting too long (distal/proximal misplacement)

  • Mark cutting guide between lines

Sagittal saw technique:

  • Hold like a fine instrument:
    • One finger controls handle; the other controls saw
  • Use negative pressure for control
  • Assistant protects EHL

Cortex approach:

  • Cut using one corner of blade
    • Proximally: “pop through” proximal cortex
    • Then use the same corner to work down
  • Description suggests this reduces heat generation (“less amount of heat”)

Bottom half:

  • Irrigation not needed (described as “always juicy enough”)

  • Maintain blade alignment in line with the guide pin

  • After completing one side/cut:

    • Transpose the capital fragment:
      • Counter-pressure between metatarsal bases
      • Thumb and forefinger manipulate toe/head into desired position

8) Provisional Fixation (K-wires) & Screw Parallelism

  • Place K-wires:

    • First K-wire is provisional
    • Starts distal-medial
    • Drive perpendicular to bone under the “full tower,” then gently rock until perpendicular to osteotomy

  • Screw parallelism strategy:

    • All screws should be parallel to the guide wire
    • Benefit: less chance of stress risers if parallel
    • Risk: divergent screws increase chance of stress risers

  • Max stability:

    • Use two points of fixation
      • Provisional drill hole distal → distal fixation screw
      • Proximal screw placed similarly

  • Screw sizing/choice (as described):

    • Uses two 2.0/20 screws (shown as “20/2.0” and “20-0” in subtitles)
    • Rationale: pitch/diameter provides more bone-to-metal interface on plantar aspect where cortex is thin

  • Steps around drilling/screw insertion:

    • Drill bit parallel to guide wire
    • Mini counter sink/depth gauge aligned parallel to drilling so screw landing prevents stress riser
    • Snug but do not fully tighten immediately
    • Tighten later after ensuring K-wires are removed appropriately (to avoid issues if K-wires weren’t perfectly parallel)

9) Final Adjustment & Checking

  • Remove any remaining K-wire(s) as instructed
  • Check screws and tighten “one last time”
  • Address any prominences if present: “now is the time”
  • Irrigate thoroughly

10) Closure Strategy (Capsule and Soft Tissues)

  • Closing emphasized as as important as the procedure

Capsule closure principles:

  • Maintain correction by “tightening the capsule”
  • No “crazy capsule” techniques—described as controlled and purposeful

Capsule tightening pattern:

  • Place a small sponge in the inner space
    • Assistant dorsiflexes the first MTH to avoid over-tightening capsule/extensor structures

  • Perform capsular closure asymmetrically:

    • Pull capsule distally first
    • Then pull the other side proximally
    • Goal: a tight medial capsule

  • Suture choice:

    • Typically close capsule with a 40 PDS (slow hydrolysis; described as degrading over ~3 months)

  • When tightening:

    • Reuse/restress by a “bias” direction (not straight across)
    • Use instruments/stitches (e.g., “Utah Stitch” per subtitles) to ensure tightness

11) Layered Closure of Subcutaneous Tissue and Skin

  • Ensure soft tissues are mobile (avoid restricting motion)

Subcutaneous closure:

  • Horizontal sutures
  • Optimal needle handling:
    • Don’t place too deep; keep a few millimeters away from skin edge
  • Avoid “bunching”

Skin closure:

  • Subcuticular approach
  • Back-and-forth running motion
  • Avoid “candy striping” to prevent bunching
  • Subtitles note thin skin; if needed for larger eminence:
    • Consider skin ellipse earlier
    • Example given: start about ½ centimeter proximal to apex and ellipse accordingly

Speakers / Sources Featured

  • “She” / “resident” / “assistant” are referenced as surgical team roles (no specific individual names provided).

Original video