This is yet another one of those
can vs
should things.
I don't WB anything until the skin is healed and the initial inflammation/healing window is passed (inflammatory + proliferative skin phases). You just see a lot more skin complications and edema and ecchymosis with immediate WB. The fixation loss is the least of the serious worries.
It's well worth doing NWB or protected for 2-3wks on everything you take to the operating room (yes, even for exostectomy, hammertoe, neuroma, soft tissue mass or skin lesion excision, ankle scope, etc). It will significantly help the pain and edema and perspiration and wound tensions to be minimized and therefore be a boon to the wound healing.
As clever as we want to think we are, the foot is full of sweat glands, gravity wins every time (edema), and stuff rolls downhill. It is good to really rest the tissues after any surgery to mitigate the early inflammation and edema and wound issues.
The DPMs who tell pts WB right away just end up with higher dehiscence, cellulitis, edema that delays return to regular shoes, wound infections, poorer cicatrix cosmesis, etc... not to mention rare loss of fixation or craked osteotomy or nonunion issues. It is not worth that just to try to "sell" surgery to the pt, and it's definitely not good pt care imo. Even if you don't mind minor dehiscence or pts needing more analgesics or foot/ankle staying edematous for a prolonged timespan, all you need is one serious wound dehiscence or infection needing IV abx or threat of septic joint or exposed plate, and you will probably get over the ego trip of immediate WB. Ditto for trying to have them keep the foot bandage clean and dry for 2 weeks... see them in 1wk (or even less if major surgery or slovenly DM pt or something).
Once you are an attending, you will realize that the patient is usually one step past what you say for WB status anyways (strict NWB = toe touch, toe touch = WB boot, WB boot = WB barefoot in the house, tennis shoes = any shoes, slow return to sports = full go, etc).
...mainly, the procedure (distal met osteotomy) just doesn't fix much.
Austin was probably the procedure I did more than anything in training. I saw hundreds, did 100+, we had them on the schedule daily. Now, I do maybe just a few per year (even though I do dozens of bunions annual). Distal met osteotomy has such a narrow indication in my mind: mild bunion + little/no arthrosis + little/no hypermobility + good bone stock. The distal met osteotomy offers almost zero benefit over Lapidus in terms of recovery/rehab time if you use proper Lapidus fixation (that was still developing when I was training, so DMO were more popular).
As you do bunions as an attending, see your pts long term, and see other DPMs' failed and recur bunions, you will probably find that Lapidus and first MPJ fusion are your workhorses, and the indications for first met osteotomies - distal or proximal - are really paper thin. Many
DMOs and any met osteotomies recur within even a few years (as the IM or HAV wasn't even corrected... definitely not the hypermobility). Other DMOs in older ppl will jam the joint and they get rigidus pain - also within a few years.
I revise MANY more distal met osteotomies and McBrides into MPJ fusions than I actually schedule Austins for ppl who've never had bunion surgery. The never-had-surgery bunions are probably 5-10x more likely to be Lapidus in my hands. The revision bunions or HAV+rigidus and failed implants/cheilectomy are nearly always first MPJ fusion. I think I have one guy scheduled soon who had a good Austin on the other foot by ortho, and he's actually a
rare good candidate for DMO: large eminence, mild HAV, good MPJ motion, low IM, almost no hypermobility. Other than that, it's probably all 1MC or MPJ1 fusions scheduled. No joke.
