The syndesmosis bunionectomy

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  In January of 2017, Dr. Doug and his daughter Molly (currently a podiatric medical student) traveled to Hong Kong to visit Daniel Wu, a Canadian trained orthopedic surgeon.  Dr. Wu has been performing a unique bunionectomy surgery for over 20 years, and while his results are remarkable, the procedure has never really taken off in the United States.  What Dr. Doug witnessed was truly remarkable: postoperative bunionectomy patients, who had both feet operated on, were walking into Dr. Wu's office two weeks after surgery for their first postop visit!   Dr. Doug observed firsthand the surgery and follow up of severe bunions with this technique.

   Dr. Wu's procedure is a 'syndesmosis bunionectomy' that does not require cutting or breaking the bone, unlike almost all other bunionectomy procedures.  The metatarsal deformity is manually realigned and held in place with ultra high strength suture while the formation of a ‘new’ ligament between the metatarsals is facilitated with special 'fishscaling' techniques of the adjacent metatarsals and application of platelet rich fibrin. While walking is permitted from day one, it is necessary to avoid too much walking. There is a maximum # of steps per day that are allowed and a reduced rate of walking which are crucial for healing.  It is 4-6 months before running or brisk walking for fitness can be done.  

   This bunionectomy technique not only corrects the deformity with less surgical trauma, but returns the foot back to its 'anatomically normal' form in ways no other procedure involving bone cuts or fusions can.

   Dr. Ichikawa began early trials of this surgery on select patients beginning in 2017.  It is his hope that this will quickly replace the traditional 'bone cutting' surgeries that are popular today. 

Currently there is only one other surgeon worldwide performing this procedure, Dr. Dieter Fellner, in New York City. 

Click the black box below to visit Daniel Wu, MD's website  from Hong Kong featuring the syndesmosis procedure.

Contact Dr. Ichikawa: If you are a potential patient or a foot/ankle surgeon and are interested in learning more about this procedure, please email him at his university email: Patients who have had the surgery should be contacting him through his secure portal on this website or the ecare messaging system through the University of Washington. That way all conversations will be charted.

The Syndesmosis Bunionectomy with realignment without the need for bone cuts or screws.

Here is a typical xray before and after surgery.

Here is a typical xray before and after surgery.

Traditional bunion surgery with an angulated and shifted bone cut and screws.

This is an example of ‘traditional’ bunionectomy surgery that employs the use of an ‘osteotomy’ or bone cut to angulate the first metatarsal and screws that maintain that position until bone healing occurs. Note that a second toe surgery was included in this procedure. Note that the 1st metatarsal is shortened by this procedure!

This is an example of ‘traditional’ bunionectomy surgery that employs the use of an ‘osteotomy’ or bone cut to angulate the first metatarsal and screws that maintain that position until bone healing occurs. Note that a second toe surgery was included in this procedure. Note that the 1st metatarsal is shortened by this procedure!

Why is the syndesmosis bunionectomy superior to other procedures?

It’s natural:

The syndesmosis bunionectomy is the the only procedure for bunion reduction that will give true 'anatomical' or naturally correct orientation and length to all the metatarsals. With other procedures, the 1st metatarsal and sometimes 2nd metatarsal are cut, realigned and fixated in the new position with hardware. This will often shorten the bone and place increased pressure on adjacent metatarsals

It’s kinder and gentler:

Without the cutting or bone or fusing of joints, the pain and inflammation from this procedure are significantly reduced. Patients with experience in both have said it is about 1/4 the pain and inflammation of a bone cut surgery. The recovery will allow for immediate weight bearing, but overall waiting for brisk walking and running is still long!

Long term study:

This procedure has been extensively studied by Dr. Daniel Wu, including 5 year followups, all with very good results. His studies are reference at the bottom of this page.

Bilateral (both feet) surgery is possible:

Since weight can be put on the surgical foot immediately afterwards, it is possible (although a bit of work!) to have both feet done at the same time. There is huge savings in medical and time off work costs associated with this. There is a nice photo essay on a patient’s journey through bilateral bunion surgery at the bottom of this page.

No osteotomy (bone cutting) complications: 

While not common, complications in the bone healing process can happen anytime the bone is cut or a joint is fused. This sometimes means more time in a boot or on crutches and occasionally another surgery with bone grafting. This cannot happen with the syndesmosis bunionectomy.

Less expensive:

The syndesmosis bunionectomy is charged out at a lower fee since a bone cut is not necessary. There are no plates or jigs from surgical companies that the hospitals, surgery centers, and sometimes patients will have to absorb. Many of the plate systems alone will cost upwards of $1000.

Why are so few surgeons doing this procedure now?

Right now, there are only 3 surgeons doing this exact procedure. Many others may be doing something similar. The questions is why?

  • The learning curve for this procedure is steep: There have been more than one surgeon, well trained in conventional surgery that has tried and abandoned this technique. Early failures have probably ushered them away from this bunionectomy.

  • It is a highly technical and time consuming surgery, taking up to twice as long as a typical bone cutting procedure. This is due to the exact placement of sutures and delicate work to release the big toe joint in an appropriate fashion.

  • It was never incorporated into the residency training or foot surgeons who have for years relied on bone cuts for bunion correction.

  • There is no medical corporation behind it. Because of the lack of a proprietary plate or piece of hardware, the marketing incentive in not present.

  • Surgeons can only charge 1/2 to 1/3 the surgical fees for this because it doesn’t require a bone cut.

Click the black box below to visit Dieter Fellner, DPM's website from New York City.

Below is an informative video made by Daniel Wu, orthopedic surgeon from Hong Kong.

Below is a foot model diagram of the syndesomosis bunionectomy.

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Below is a foot model diagram of the syndesmosis bunionectomy in relationship to traditional bone cutting or joint fusing surgeries.

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Is the syndesmosis bunion procedure for you? 

   While the syndesmosis bunionectomy procedure allows both feet to be done at one time and allows for immediate walking, certain restrictions will be placed on the patient's walking for 6 months.  If these restrictions are ignored, then complications like stress fractures of the metatarsals or recurrence of the bunion will occur.  This procedure requires strict adherence to postop protocols.  

•   You will be required to have a Fitbit or activity tracker to help you limit your walking after surgery. 

•   A forefoot cast will be utilized at two weeks after surgery for a total of ten weeks.  This will be removable after about 2 weeks when the initial foot swelling goes down. Some patients can even fit this cast into a roomy athletic shoe. 


•   A postop shoe  will be required for 3 months. 


•   Monthly visits and x-rays will be required for the first 6 months.

•  Step requirements are as follows: 

•                     Minimal walking the first month

•                     3,000-5,000 steps per day at a slow pace for the 2nd month

•                     3,000-5,000 steps per day at an average pace for the 3rd month. 

•                     After three months your can increase your steps per day by 1000 each week.  

After four months you can walk unlimited steps in good athletic shoes.  

After six months there are no restrictions with shoegear or activity.

A Surgeon’s eye view of the Syndesmosis Bunionectomy!

Below is a video of the actual procedure seen from the perspective of the surgeon. It’s a 13 minute video with no blood since a pneumatic ankle tourniquet is used.

If you’re thinking about this surgery, the link below explains the surgery and gives you some very specific recommendations for how much walking after surgery you’ll be doing:

From out of state or out of country? The link below is a comprehensive note on managing surgery in the Seattle area and recovery elsewhere. Phone consults, self pay costs, and day before preop visits are all covered:

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