When It Comes To Incisions, Less Is More

Stephen Barrett DPM FACFAS

"Outlined against a blue-gray October sky, the Four Horsemen rode again. In dramatic lore, they are known as Famine, Pestilence, Destruction and Death. These are only aliases.”

However, the four that I know are different from those in Grantland Rice’s 1924 New York Herald Tribune article. Those horsemen haunting me are Bias, Ms. Perception, Dogma and Evidenced Based (EB). These four evildoers of lore are opposite in spirit of the original four horsemen but just as passionate — and they are not aliases.

They do seem to appear on the horizon, shaking their all-knowing heads yet never losing focus of their dour glare in my direction when I venture into a new arena. I use the term “arena” as a general venue, which could range from an enchanted and animated chat with a fellow like-minded colleague next to a crowded bar in a populous unknown city to a formal meeting that functions as an annual conclave of a large academic society. Maybe they are in the same city.

With my four friends in uninvited tow, I traveled to the Crescent City early last month on a mission to spread the word on peripheral nerve surgery to members attending the annual meeting of the Academy of Ambulatory Foot and Ankle Surgery. I knew that as with almost all these endeavors that I would end up learning far more than I would ever be able to impart during my short time at the podium. Once again, that was the case. My job this time was to intellectually and academically destroy my four “friends” and see if I could begin an effective and permanent solution to keep these bad boys at bay once and for all. Maybe, just maybe, if I could whip this quartet into submission, real work with meaningful patient outcomes would increase and all would benefit.

Three of them (Bias, Ms. Perception and Dogma) would be easier to defeat than if they were accompanied by old EB, as anytime the elder three would get into trouble by themselves, they would invariably bring out old EB and say “Aha, now let’s see you debate him.”

You will know him when you see him. He will be all dressed up in a herringbone jacket, plain white shirt and solid color bow tie. He stares at you from above the top rim of his wire-framed glasses with eyebrows that could be mistaken for the largest caterpillars on earth, and would never utter the words: “Dude, how you doing?” during your formal introduction to him.

Bias and Ms. Perception are not so easy to discern in a crowd as they dance back and forth amorphously in oscillation between “yeah” and “nay” so quickly that they are most times unrecognizable. Dogma is just an old fart: a crusty curmudgeon who lurks around the rooms of academia like a misplaced Diener wearing phenol-laced aftershave, and has been around so long that he will never disappear. The best way to handle him is just push him into the corner with Fact and Outcomes, and hopefully the stench will not permeate too far into the arena.

My presentation on peripheral nerve physiology was well received but more important was seeing the lectures before and after my slotted time. Additionally important was the time spent at the breaks where attendees would show me before and after photos and radiographs of really complex reconstructions they had performed. Later that afternoon, I gathered with several experienced minimally invasive surgeons who were armed with all their greatest trophies, which happened to be digitized in highest resolution. Yes, my “friends” were right behind me, snickering and cajoling in sotto voce, but I could hear them.

“Look at that radiograph. There is bone callus on the three central metatarsals and look at how crooked those proximal phalanges are,” EB crowed. Just as EB was hitting a crescendo with his diatribe of indignation that there was no “screw fixation,” the colleague showed the pre-op radiograph, then the six-month radiograph, and then finally the before and after clinical photos.

The hot air whistling out of EB’s self-righteous, corpulent but well dressed body almost caused a discernable vacuum in the room. This case was a masterpiece, simple as that. This artisan had taken a foot, which with conventional surgery utilizing screws and plates, would have ended up in appearance as a red football from all the tissue disruption incurred in the process, and could not have even come close to the outcome she had achieved with her minimally invasive artistry.

I turned and snapped at EB: “Less is more, you pompous, dogmatic fool.” He could not respond as he was still mentally and intellectually whiplashed by what he had just seen. “Not only is less more but you can’t judge anything about outcome from one of a series of radiographs.”

Sometimes we forget that we are treating humans and not angles and their relationships on X-ray. “Oh, and by the way, EB, if you want to see long-term results, I have met some colleagues who have five-year follow-up radiographs and clinical photos. Do you care to look at those?”

Understanding The Emergence Of Minimally Invasive Surgery

In all surgical specialties, there is a ubiquitous movement right now that is close to reaching a critical mass. That movement is the development of more and improved minimally invasive surgical techniques, and the implementation of such techniques to improve patient outcomes. It is simply a surgical truth that less tissue disruption means less postoperative inflammation and pain, a faster return to regular activity, generally improved patient outcomes and, ultimately, improved patient satisfaction. If you educate patients and master the bandage, you are fixating their osteotomy. You are only doing it in a different manner.

While I do not expect the general reader of this piece to “jump off the cliff” and implement all of these techniques at once (which, frankly, would be impossible to do), I do expect all those open-minded, truly gifted surgeons that I know personally to really start looking at implementation of some of these hugely valuable techniques to improve their surgical outcomes. Your patients will thank you.

It has taken me a long time to get to the point where I routinely incorporate a minimally invasive technique with other, more conventional open surgery. I do fixate all first metatarsal osteotomies but rarely will I fixate a lesser metatarsal or phalangeal osteotomy. Has my complication rate gone up? No. In fact, I have better outcomes with less postoperative edema, pain and overall fewer complications. (Yes, I have had some complications but no different than those I have had with “traditional” surgery.) Greatest of all is what the patient usually says on the first postoperative visit: “Wow, that looks great and I didn’t have any pain.”

I would like to personally thank Ed Cohen, DPM, the President of the Academy of Ambulatory Foot and Ankle Surgery, and Borys Markewych, MD, the Scientific Chairman of the meeting, for inviting me to contribute in my small way to their meeting. I hope to be invited back next year so I can learn even more. I hope that you will attend as well. They have a great cadaver lab and everyone that I encountered had the desire to share tips and pearls, and help others learn new techniques and concepts. Some you may agree with and some you may not. But what a crime it is to not embrace something of great value because of what the four “friends” say. Of course, we will convene with our four “friends” to further subdue them with science and outcomes.

To put it bluntly, what I learned and to an already great extent already knew was that “less is more.” I have been trying to sell that “less is more” to my family at the holiday season time for a couple of decades now. It still has not hit home with them so perhaps I will be more successful selling you the concept from a surgical perspective because it really is true.

What You Can Do Right Now

1. Find someone who is doing this type of work and go spend a couple of days with them in their clinics. Watch them operate, but more importantly make rounds with patients postoperatively. See their results and listen to the patients. This is invaluable.

2. Register for the meeting next year. Just go.

3. When and if you decide that some of these ideas and techniques may help you achieve better results, implement them slowly with mentoring from someone with experience.

4. Go slow. Your experience will grow very quickly.

5. Realize initially that there is a real learning curve to all of these techniques and these techniques are not easy. In fact, open surgery is far less difficult. However, in my opinion, to be really successful, you must approach this as a “hybrid” type of surgery and be very skilled in fundamental surgical tenets prior to migrating into the minimally invasive world.

Best wishes for a happy holiday season.


Very well written! I enjoyed that a lot!

Dogma isn't always an old fart. Maybe taught by an old fart, but shockingly, even those with little experience practice it.

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