Why Minimally Invasive Surgery Is An Art Even If It May Not Look Like It

Stephen Barrett DPM FACFAS

Seven years ago, I couldn’t believe I had just paid $250 to stand there in a New York art gallery staring at a single red dot in the middle of a large, all-black canvas.

“It’s phenomenal, isn’t it?” a cultured voice whispered reverently near my ear. Since I was locked in a mental gymnastics event trying to decide why I had agreed to come to this affair in the first place, I did not hear her. “Excuse me,” the voice whispered more urgently, “it’s phenomenal, isn’t it?”

“It is a bloody red dot in the middle of a big black canvas. I could have done it in 30 minutes and that includes the time I would need to drive to the hardware store for a can of black spray paint,” I volleyed.

“Oh, no, no, no,” she scolded. “It’s a Kessler and maybe one of her best.”

“Really, it looks like she must have put a lot of effort into it,” I said sarcastically.

“Well, some people just don’t get it and never will,” she huffed while rapidly turning away, muttering something about gaining a perspective.

It was too simple, too easy. It lacked effort and artistry. At least, those were my dismissive thoughts at the time. It seemed like anyone could do it with no long years of training under a master required. I mean, why go to “art” school if you aren’t going to create an intricate masterpiece every time? It has to be hard to be worthy of our time, right?

Many years later, I again found myself in that same gallery. There it was still hanging in the same place. “Aha,” I thought to myself, “they couldn’t sell it. I was right all along.”

“Welcome,” the new curator said with a heavy Middle Eastern accent.

“It has not sold?” I questioned before introductions could be made.

“No, no, on the contrary. I bought it. Kessler was one of my students and this piece is incredible. Don’t you agree?”

“Looking at it now, seven years later, I see it differently. It is simple, it is effortless but it is art. I am finally gaining a new perspective myself.”

He shuffled closer to me and inspected my hands. “You are not an artist.” I pulled back a little. I told him that he was correct but I did appreciate art. “Then why did it take you seven years to come back to appreciate this piece?” I turned back to the large painting, seeing it as I had never before.

“I guess I had the right experiences with people I greatly trusted, and my bias faded slowly away.” He told me he was from Egypt, used to sleep in Picasso’s house and understood bias. Then he started telling me about the artist.

“She was one of my students, my greatest student in fact. But somewhere, she had lost her perspective and created a couple of pieces that essentially wrecked her career. Some people saw a couple of her latest works, ones that bastardized her whole genius and could never acknowledge her early greatness.”

Now I was interested in the personal history of the artist. I had to know more. “Why do you now appreciate her piece?” my new friend asked.

There was something I liked about this guy and if the dude actually did sleep in Picasso’s house, dammit, I was hooked.

“Well, I now realize that something which looks so simple is not and that many times, less is more.”

I left after a very long and enlightening conversation with the artist who owned the gallery. While walking up the crowded street, I became absolutely lost in thought staring at my non-artist hands. How could he tell I was not an artist by looking at my hands?

Finding The Artistry In Minimally Invasive Forefoot Reconstruction

Once back at the hotel, I opened my computer to start looking at a case my friend and colleague sent me. It was a case dealing with a minimally invasive surgical forefoot reconstruction. The outcome was obviously spectacular. The artist had created something beautiful and awe inspiring.

Looking at the pre-op and immediate post-op radiographs, there was nothing that revealed this wouldn’t be a great outcome to the trained eye (the untrained eye would have perceived it differently), and the artist’s technique was rock solid. The surgeon had performed the following minimally invasive procedures: a percutaneously fixated distal metaphyseal osteotomy of the first metatarsal, an Akin osteotomy, a second and third metatarsal osteotomy, and a fixated fifth metatarsal osteotomy. There was some digital work as well. The patron was overcome by the incredible result from her commission.

What this case did illustrate was that there are some valid guidelines for producing excellent minimally invasive “art.” Some readers may ask why I call this type of surgery art? It truly is “art” and some surgeons do not have any artist in them. However, that is not a valid reason to cast this type of approach into the rubbish, dismiss it and vociferously denigrate the techniques. Just like it took me seven years to get the Kessler, and I was guilty of criticizing it until I became enlightened, there was still much to learn.

The Artist’s Tips For Perfecting Minimal Surgery

So here are my tenets for those who initially choose to dismiss these extremely powerful techniques but have now have opened their cortices to surgical exploration.

1. Less truly is more. For example, one can do complex forefoot reconstructions with less pain for the patient, with less swelling and a faster return to regular activity.

2. Fixation is really needed on first and fifth metatarsal osteotomies, and not needed for the central three rays.

3. Akin osteotomies never need fixating if one performs them correctly with percutaneous techniques.

4. Same for lesser digit phalanges.

5. Generally, the true artists avoid the joint. They “paint” proximal and distal to it. For example, take the patient with a previously failed bunion surgery with lateral deviation of the hallux, but a fantastic and pain-free range of motion at the first metatarsophalangeal joint (MPJ). Do we really need to realign those sesamoids by a first MPJ procedure? No, you do not. Realign the hallux with a simple percutaneous Akin and the patient is happy, has a fast recovery, and the joint still works well.

6. Don’t judge the X-rays of some of this work unless you have a real understanding of what the surgeon did. Initially, it may look like there are more curves than Lombard Street (that is the most crooked street in the world in good old San Francisco for you geographically challenged ones). When I studied this art with the El Grecos in Spain, they would first show me the immediate post-op and while I was trying not to aspirate my tonsils, they would then pop up the one-year post-op film, and before and after clinical photos. “Wow,” I would say repeatedly looking at the result. Crooked at first, gapped at first, disturbingly “malaligned” by conventional standards but at one year post-op, it was downright beautiful. True art. For an example of the power of these techniques and initial “crookedness,” check out: http://www.podiatrytoday.com/case-study-treating-severe-fifth-digit-cont... .

7. If there is an overwhelming equinus contracture and you are contemplating a forefoot anything, correct the equinus. Trust me, it will help your reconstruction significantly. Would you put a new tire on your Bentley that is out of alignment?

8. It is okay to create hybrid art. Throw a percutaneous Akin in there with that first met Monet.

9. Educate patients on how important it is for them to follow post-op care. They cannot remove their dressings when they want, cannot walk with a propulsive gait and must wear a proper boot or post-op shoe.

10. Accept the fact that there are complications with any surgical technique but by “gaming” the system with careful planning and precise execution, they are minimal and one can avoid most of them.

11. If you are going to cut the second metatarsal, you probably in the majority of cases also cut the third and fourth. The El Grecos in Spain taught me this and based on their thousands of cases, who am I to argue?

12. Go slow when you start integrating these powerful techniques. You should be able to do it open well before attempting to do it with a small incision. These techniques are generally many orders of magnitude more difficult to perform with dexterity than the open techniques.

13. If patients are bad surgical candidates for an “open” technique, then they are probably bad surgical candidates for a minimally invasive technique. There are exceptions of course.

14. Osteotomies take the same amount of time to heal whether you perform them with open or closed technique, and with proper bandaging and splinting, you simply do not have to screw everything.

15. If you think a soft tissue correction is going to do it, be prepared for a bony correction. For example: When treating a transverse plane clinodactyly, a proximal phalangeal base osteotomy is really powerful. Break that bad boy, scoot it over 30 degrees, bandage her up and voila, you have a correction. They almost always heal. Just keep them splinted. You will like it but the patient will like it even more.

16. These non-fixated osteotomies give you some flexibility, Renoir. If it isn’t quite “perfect” at two weeks post-op, drop a little lidocaine in there and move it like you are working your bonsai tree.

Final Brushstrokes

The next day, I went back to the gallery to see my artist friend. He was glad to see me and we chatted for a while before I had to ask him how he knew I was not an artist by looking at my hands.

“There is no pigment under the nails,” he said. I then told him about my art and that maybe I had some pigment in my brain?

He most likely was correct when he quickly said, “That’s what you call it, pigment?”


Another good attempt to popularize percutaneous forefoot surgery. Absolutely agree with all "Artist’s Tips For Perfecting Minimal Surgery" of your paper but one. With properly directed osteotomy line and splinting, fifth metatarsal percutaneous osteotomy is very stable and never needs fixation.

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