Emerging Concepts With Percutaneous Osteotomies
Although percutaneous surgeries were once fraught with complications, advances in techniques and hardware are leading to better outcomes. These authors offer pearls on performing percutaneous osteotomies and review step-by-step techniques for the forefoot, midfoot, hindfoot and ankle.
Foot and ankle surgeons have utilized percutaneous osteotomies since the 1970s. Unfortunately, during those early years, many doctors who performed the procedures had little or no formal surgical residency training in the percutaneous or open techniques. Due to this lack of training and no real continuing medical education-approved formal courses to perfect the techniques, there were a high number of complications and therefore many lawsuits.
The lead author personally had the opportunity to see and evaluate some of these patients as a student and surgical resident in Chicago in the 1980s. The lead author’s experience in his podiatry school clinic and residency program setting allowed him the opportunity to evaluate some of these travesties. In the 1980s, there was even a two-part investigational report on the evening news that was called “The Walking Wounded.” This investigational report documented some of these devastating cases and outcomes that gave percutaneous procedures a bad reputation. Although many of us found that we could utilize the concepts of minimal incision surgery (known back then as MIS surgery) for some procedures, most surgeons abandoned the techniques due to the bad rap they received.
It was also around this same time that Ilizarov was developing techniques, percutaneous procedures, external fixators and recommendations for managing limb deformities and congenital abnormalities. It was not until the late 1980s when these procedures and fixation devices came to America. Subsequently, orthopedic and foot and ankle surgeons started to apply these techniques and concepts for a variety of surgical procedures on the extremities.
In the 1990s, Paley and his associates developed a systematic evaluation process for applying specific angles in the evaluation of lower limb deformities.1 This process added to the existing angles that we foot and ankle surgeons have been utilizing for years. Now the angles, procedures and techniques have become an integral part of surgical training programs as well as board certification in foot surgery and reconstructive rearfoot/ankle surgery.
Since the 1990s, there has been a significant improvement in internal and external fixation by many of the orthopedic companies, especially for foot ankle surgery. These improvements have provided us the opportunity to apply these principles to more of the procedures that we perform. It was only 10 or 15 years ago when there was only a small group of surgeons applying these techniques. However, now most residents who perform reconstructive procedures are applying the sound principles and fixation devices to provide better reproducible results and outcomes for our patient population.
Key Principles In Deformity Assessment
Principles in deformity assessment are now well established and published in numerous texts and peer-reviewed journals.2-5 These concepts and associated angles are commonly referenced and utilized in foot and leg surgery here and abroad. These standard angles help us determine where deformities are located and how we should go about correcting them. We now have a much better understanding of osseous and articular deformities, and the structures at risk that we have to take into consideration when performing surgical interventions. Surgeons now apply these sound principles to prevent other deformities or injuries of adjacent structures when performing surgery on the foot, ankle and leg.
We have to thank individuals such as George Vito, DPM, Guido LaPorta, DPM, Bradley Lamm, DPM, and other individuals for bringing these concepts to our profession and helping teach the early courses to our colleagues.
How Intraoperative Fluoroscopy Has Made An Impact
The use of intraoperative X-ray has become a mainstay in musculoskeletal surgery. Previously, most foot and ankle surgery occurred through direct visualization. Typically, one took postoperative X-rays or intraoperative flat plate radiographs after completing the procedures.
Now nearly every surgical center has fluoroscopy available for the surgeon to be able to evaluate the surgical techniques throughout any case. Most hospitals now have multiple units available for their surgeons so they can provide better intraoperative assessment of open and percutaneous procedures. This has helped improve outcomes and surgical corrections, not only for musculoskeletal surgeons but many other specialties, thus allowing more percutaneous, minimally invasive and endovascular procedures. Without this “live” radiographic assessment, it would be nearly impossible to perform most of these techniques.
Pertinent Pearls On Percutaneous Applications In Forefoot Surgery
Percutaneous osteotomies in foot surgery are happening more frequently. Probably the most commonly performed procedure is for brachymetatarsia. This technique allows for lengthening of a congenitally short metatarsal through a percutaneous osteotomy (corticotomy) with distraction osteogenesis utilizing a small external fixation device. This provides the surgeon the ability to lengthen the metatarsal gradually over a period of time. In the past, the procedure was open with an osteotomy and bone grafting, often preventing the surgeon from getting the exact length desired due to the structures at risk such as the neurovascular bundle, tendons and capsule. This gradual distraction technique allows gradual lengthening of not only the bone but also the associated soft tissue structures.
Metatarsal lengthening through callus distraction is relatively simple. Surgeons can use fluoroscopy to identify the metaphyseal bone and the shaft of the metatarsal, and subsequently place the pins for the mini external fixator. After determining the exact location and slope of the device, remove the fixator. Make a small incision, perform the corticotomy and reapply the fixator for gradual distraction to the appropriate length. Lengthen the metatarsal at a rate of approximately 1 mm per day and do not remove the fixator until the regenerated bone has healed.
Surgeons are also utilizing percutaneous procedures to address a shortened bony segment from previous osteotomies or arthrodesis procedures. We performed an arthrodesis procedure that resulted in shortening of the first ray. In a case like this, the patient had an implant removed and a joint arthrodesis resulting in significant shortening. Using the same principles one would employ for brachymetatarsia, surgeons can perform distraction of the metatarsal to the desired length and position. We use a similar technique for this procedure and lengthen the ray in a similar fashion.
Surgeons can also use the percutaneous technique to correct deformities that are a result of a growth abnormality or previous fracture. One can apply the correction of rotation of angulation (CORA method). This technique utilizes the bone axis in determining the level of deformity. Accordingly, one can apply a percutaneous technique in the correction process. Identify the proximal and distal mid-diaphyseal lines to determine the exact CORA of the healed fracture. Perform the corticotomy at the level of the previous fracture or remote to that site if the bone is sclerotic or an undesired location for the osteotomy. In this case, perform a dome osteotomy away from the healed fracture. This allows correction while one is realigning the metatarsal axis of the deformed metatarsal.
A Primer On Techniques For Midfoot And Hindfoot Surgery
Similar techniques exist for midfoot and hindfoot deformities. Percutaneous calcaneal osteotomies are becoming more popular with surgeons utilizing the drill and osteotome or Gigli saw techniques. Both approaches are very successful while minimizing soft tissue, periosteum and bone dissection. The most common location is for a posterior displacement calcaneal osteotomy.
The left photo depicts a foot with a calcaneal valgus. One can use fluoroscopy to determine the location of the posterior calcaneal osteotomy. Make a small incision and then place multiple drill holes into the calcaneus along the marked line that demonstrates the desired location of the osteotomy. Use an osteotome to connect the drill holes. Displace the calcaneal tuber medially and fixate it.
The technique of percutaneous corticotomy with gradual distraction was in use for a period of time for lateral column lengthening but most surgeons have returned to the open osteotomy with bone grafting since it remains highly successful with minimal complications.
What About Ankle And Distal Leg Surgery?
Surgeons can use percutaneous procedures to correct articular and near articular deformities around the ankle. These procedures include correction of malaligned fusions or fractures and congenital deformities. Although appropriate alignment is a factor during arthrodesis procedures, there can be malalignment that can result in pain or difficulty with ambulation. A malalignment of an arthrodesis can cause adjacent joint arthritis and one should correct this if and when it arises. If the deformity is at the level of the arthrodesis, surgeons can perform a focal dome osteotomy. One can perform this procedure via small percutaneous incisions in the metaphyseal bone, thus avoiding the previous surgical site of the ankle and having virgin bone for healing in the distal tibia.
Place a half pin centrally at the level of the previous arthrodesis site perpendicular to the axis of the leg. Temporarily attach a two- to three-hole pin holder to this half pin as an axis guide. Small stab incisions at the distal aspect of the tibia correspond to the radial arm of the pin holder. One should place multiple drill holes through the tibia, typically six to eight in number. Then fracture the bone between the drill holes with an osteotome and mallet. Rotate the tibia to the desired position and maintain it with percutaneous fixation. Monitor the entire procedure with fluoroscopic assistance.
Surgeons can make acute corrections in deformities or malunions of approximately 20 to 30 degrees as long as they consider the structures at risk (i.e. neurovascular structures). If the deformity is larger or there are concerns of damage of the adjacent structures, consider a gradual correction with external fixation.
One can treat near articular deformities in a similar fashion. This percutaneous procedure allows the surgeon to correct the deformity while sparing the articular surfaces of the joint. Here one identifies the level of the deformity and places a half pin in the distal tibia near its articular surface. Apply the same steps to this percutaneous osteotomy of the distal tibia. If the fibula is intact, perform an osteotomy through a separate incision to allow realignment of the fibula. One can also perform this through a minimal incision approach.
Since this particular deformity was in a varus position (see right photo), we decompressed the tarsal tunnel to prevent tension or injury on the nerve during acute correction. Once the osteotomies are complete and the bony segments are in the desired position, introduce fixation through a percutaneous technique.
Deformity corrections can require a combination of open and percutaneous techniques. Small deformities in the leg, when they are at a significant distance proximal to the ankle, can have a dramatic effect on the articular surfaces. A simple sagittal plane deformity can have a dramatic effect on the ankle joint. The frontal plane X-rays demonstrate no deformity, only shortening. However, the proximal tibia fracture site healed in a malaligned position and the sagittal plane deformity caused destructive forces at the ankle. Over time, the ankle degenerated, resulting in pain and difficulty ambulating.
If a surgeon were to only perform arthrodesis on the ankle, the patient would have a significant gait disturbance and difficulty ambulating. If one considers a total ankle replacement, there would be significant shear on the components resulting in loosening, subsidence or polyethylene wear. Cases such as these require addressing the ankle arthritis through arthrodesis or ankle replacement and realignment of the leg to allow for restoration of the mechanical axis so the patient can have a near normal gait pattern.
In this case, the patient chose the arthrodesis over the implant. Therefore, we performed the ankle arthrodesis at the same time as the gradual correction of the tibial deformity. We applied a standard transfibular technique for the arthrodesis and maintained this with an external fixator. Proximally, we performed a percutaneous corticotomy and gradual distraction through the use of a monolateral fixator. Once the arthrodesis site healed, we removed the distal fixator and maintained the proximal device until the regenerate bone consolidated.
This article provides examples of the current trends for percutaneous osteotomies but we only touched upon the other considerations when performing these procedures. The emerging concepts must include sound surgical principles; a thorough understanding of alignment considerations; recognizing structures at risk when performing deformity correction; knowledge of the best locations to perform procedures; when it is acceptable to perform an acute or gradual correction; and the fixation constructs. This requires the surgeon to have appropriate surgical training in a residency and/or multiple courses to learn when, where and how to perform these procedures.
The future utilization of percutaneous techniques will continue to emerge as we see the quality of training and fixation constructs continue to improve. It was not so long ago that we would not have even considered doing some of these procedures. We continue to see the evolution of musculoskeletal surgery and this could not have taken place without the current and future surgical pioneers and the development of improved fixation devices.
Dr. Mendicino is a Foot and Ankle Surgeon for OhioHealth Orthopedic Surgeons in Columbus. He is a Fellow of the American College of Foot and Ankle Surgeons.
Dr. Catanzariti is the Director of Residency Training at the Western Pennsylvania Hospital in Pittsburgh. He is a Fellow of the American College of Foot and Ankle Surgeons.
1. Paley D, Tetsworth K. Percutaneous osteotomies: Osteotome and Gigli saw techniques. Orthop Clin North Am. 1991; 22(4):613-624.
2. Mendicino RW, Catanzariti AR, Reeves CL, King GL. A systematic approach to evaluation of the rearfoot, ankle and leg in reconstructive surgery. J Am Podiatr Med Assoc. 2005; 95(1):2-12.
3. Mendicino RW, Catanzariti AR, Reeves CL. Percutaneous supramalleolar osteotomy for distal tibial (near articular) ankle deformities. J Am Podiatr Med Assoc. 2005; 95(1):72-84.
4. Mendicino RW. Distal tibial osteotomies. In Chang TJ (ed): Master Techniques in Podiatric Surgery, chapter 35. Lippincott Williams and Wilkins, Baltimore, 2004.
5. Mendicino RW, Catanzariti AR, Reeves CL. Posterior calcaneal displacement osteotomy: a new percutaneous technique. J Foot Ankle Surg. 2005; 43(5):332-5.