Emerging Concepts With Percutaneous Osteotomies

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Author(s): 
Robert W. Mendicino, DPM, FACFAS, and Alan R. Catanzariti, DPM, FACFAS

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.

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