Reconsidering Foreign Advances In Minimally Invasive Surgery

Stephen Barrett DPM FACFAS

I recently returned from nearly three weeks of travel, study and surgical observation in Europe. The trip began with an opportunity to participate in the European Foot and Ankle Society Biennial Congress in Geneva, Switzerland. This was followed by additional meetings in Austria to visit with orthopedic surgeons and three days of surgery in Barcelona, Spain.

When we travel, Americans like to bring back stuff. Most of the time when I get my foreign stuff back to the United States, my souvenirs quickly get forgotten and just begin to accumulate dust. There will be no dust collection on most of the stuff I am bringing back this time because this “stuff” is in my mind.

I have to preface this report by telling you that I planned this trip to Europe solely to collect this surgical stuff. When I first started going to Spain in 2005 to teach endoscopy, I started to see things that were out of our (or at least my) surgical conceptual ability. This most recent visit was my seventh trip to Spain so you can see these surgical “things” I saw have haunted me now for a while. As surgeons with “growth mindsets,” we want to learn techniques from other surgeons.

However, when we see certain things we are not familiar with or that initially appear contrary to everything we do professionally, we want to dismiss them arbitrarily for many reasons. We may say, “That is not the way we do things in the U.S.” We may say, “That can’t work — it only looks good in the OR.” We may raise the question: “How can this be so well done here and I have not heard about it?”

However, I keep going back. During the last couple of visits, I have not only seen the techniques but I have also seen patients in the clinic so I could assess the surgical outcomes myself. Some of them were as far out as five years post-op.

The “certain things” I started to observe on my first trip to Spain in 2005 were minimally invasive percutaneous forefoot techniques such as Akin osteotomies, distal metaphyseal osteotomies (similar to the Weil osteotomy, only more proximal), hammer digit syndrome correction and hallux valgus reconstruction. These minimally invasive surgeries were called MIS techniques in the U.S. in the late 1970s and 1980s. These procedures got a really bad reputation and there were some catastrophic results.

We all know about this type of surgery and what some poorly trained surgeons did at that time. These surgeons had a lack of surgical ability and an incredibly weak understanding of pathomechanics, compounded by zero medical ethics. These “cowboys” simply made an indelible stain on the parchment of the history of forefoot surgery. I was in training when all this occurred.

Needless to say, I had a really bad bias against this “type” of surgery. Now you can understand my five year mental war trying to get my neurons wrapped around the fact that what I was seeing in Europe was resulting in such incredibly excellent forefoot reconstructions.

Nearly every surgeon will agree that there is more than one way to do something correctly that will render an excellent outcome. Most surgeons will also agree there are some techniques that are sometimes labeled as “bad” simply because there was a poor technician or improper indication — sometimes both. I now know this is the case with, shall we say, “percutaneous” surgery. Maybe a simple change in nomenclature will help those like myself to open the mental door a little more to take a peek.

So how did the MIS surgical techniques that started off poorly in the U.S. almost 40 years ago end up being re-imported to the American territory of forefoot surgery? As I noted above, some techniques have gotten the bad rap because of bad surgeons. However, there are many surgeons who achieved excellent results with minimally invasive surgery and have done so in the U.S. for many years. You only hear about bad things because reporting good things is not sexy and seldom is there a patient who comes to you because he just wanted to show you how great a result he had from his previous surgeon. No, you only get the disgruntled patient who was maybe the 1 percent of this surgeon’s body of that particular work. You cannot judge the surgeon from that but we all do.

Saluting The Surgeons Who Have Pioneered Minimally Invasive Surgery

Stephen Isham, DPM, MD, was one of the pioneers of minimally invasive surgery in the U.S. and introduced his techniques to Mariano De Prado, MD, an orthopedic surgeon from Murcia, Spain. Dr. De Prado has done incredible work in teaching and writing about these techniques and has collaborated with Pau Golano, PhD, a Professor of Anatomy at Barcelona University, to produce an incredible textbook with dissection photos that illustrate many different percutaneous techniques. (In my opinion, Dr. Golano may be the best anatomist/photographer in the world for the foot and ankle.)

Several years ago, I had the great fortune to spend time with Dr. De Prado both in the OR and his clinic, and have seen his results and long-term follow-up radiographs. I should mention that Dr. De Prado puts on a congress, which I participated in last year that had 500 European orthopedic surgeons in attendance. So you can see this is not a little thing.

Combined with this was the opportunity for me to learn from my dear friend and colleague Eduard Rabat, MD, a traumatologist orthopedic surgeon who specializes in foot and ankle. His pedigree is incredible as well as he spent many years under the tutelage of Antonio Viladot, MD, perhaps the father of all foot surgery in Spain. Dr. Rabat, like Drs. De Prado and Isham are true surgical artists. What I have learned from him over the last five years are things that certainly have not collected any dust.

Olivier Laffenettre, MD, heads up an organization, the Group de Recherche en Chirurgie Mini Invasive du pied (GRECMIP), in Bordeaux, France. This organization puts on a couple of courses each year that I would highly recommend you attend if you have interest in this type of surgery. I am also trying to convince Dr. Rabat to have GRECMIP do a course in the U.S. so you can get some great European souvenirs without having to skip across the pond.

Before integrating MIS techniques into your forefoot surgical armamentarium, I would caution you in several areas. First, these are not simple operations. In fact, the complexity is much more than with open surgery and these gentlemen have spent considerable amounts of their surgical lives immersed in refinement and mastery of their techniques. Second, if you cannot conceptualize in three dimensions, this surgery is not for you. Finally, make sure that you have extensive cadaveric training and spend time with a surgical mentor and integrate these techniques slowly into your practice.

I will end this by simply saying thank you to these great surgeons who have worked so hard to improve forefoot surgical reconstruction and have given me much more than a dust collector.


Hi Steve

Edwin Probber, DPM, once told me that MIS percutaneus foot surgery would be recognized once he was dead. He died this year. The Academy of Ambulatory Foot Surgery taught all of these European doctors the art and practice of MIS. I personally taught MIS to many Europeans back in the late 1980s at the AAFS Cadaver Course in New Orleans

I applaud Stephen Isham, MD, for continuing the work of S. Kessler, who was his mentor, as well as Ronald Strauss, Jerry Jacobs, Koback Brothers, Al Brown and the thousand podiatrists who did MIS and still do

Every day, I meet new doctors who talk about MIS and their positive experiences over tens of years.

The AAFS was the originator and founder of MIS, and this organization needs to be mentioned. I am glad you enjoyed your trip and I still remember when these doctors you meet would look to the AAFS for their education. Many of these doctors are members of the International Divison of the AAFS.

I would like to thank all of the MIS podiatrists that I may not have mentioned. I applaud everyone.

Sincerely yours,

David Zuckerman, DPM, F-AAFS

Minimal incision surgery is not new. Some of it is acceptable (some tenotomies, toe exostectomies). Most of foot surgery is performed better with long incisions, maximizing exposure of complex anatomy and avoiding blind damage to tissue.

Some famous foreign orthopod is doing this now! So what? Let us not look at the names but evaluate procedures critically.

Dear Dave,

Thanks for sticking up for MIS. Any time you would like to see an original surgery or hear one of my father's lecture, just call. He was making videos long before some of these doctors were even able to voice an opinion. Every surgery comes with a risk. The doctors know this as do the patients. He would say good results comes from a good patient. You make a good patient. My father was confident, reassuring and genuinely concerned for all his patients before, during and after care. I know this from standing next to him hundreds of times whether it was a consultation, surgery or just a phone call from a worried patient.

As for Dr Gertsik ... Have you noticed how they are doing gall bladder, appendix and so many other surgeries lately? Look a little familiar? Well someone had to be the first. You want to evaluate procedures? Long incisions and maximum exposures are better? Better for who? With MIS, the healing time is shorter, the scarring is less and the rehabilitation time is a walk in the park. Why don't you evaluate that? Can you do MIS? Don't knock it until you try it.

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