Emerging Insights On Minimal Incision Osteotomies
There has been a renaissance in recent years of the once disparaged technique of minimal incision surgery. This author details why minimal incision osteotomies can be advantageous for certain conditions, offers surgical pointers and provides salient advice on overcoming complications.
Unfortunately, there remains a huge stigma with minimally invasive surgery due to some catastrophic results of a small number of unscrupulous surgeons performing minimally invasive surgery of the foot in the United States in the late 1970s and 1980s.
This is detrimental in my opinion. With the refinement of minimally invasive techniques that has occurred, use of the surgery with proper indications and, most importantly, excellent training, these techniques have greatly improved patient care. Minimal incision surgical techniques also allow for correction of deformities that would otherwise be associated with long postoperative morbidity and, frankly, would be untreatable otherwise.
Thankfully, due to the refinement and appropriate implementation in Europe by very credible and highly trained surgeons, who have approached this concept with a very judicious and cautious approach, there has been a recent resurgence of this type of surgery in the U.S. There has always been a small faction of podiatric surgeons who have maintained the practice of minimal incision techniques with generally excellent results.
However, widespread general acceptance professionally has been scant, perhaps because only the few poor outcomes generate acknowledgement. Usually, the only time mainstream foot surgeons would talk about it would be to denigrate the techniques based on complications that surfaced.1-5 There will be more implementation of this type of surgery in the future here. In my opinion, when appropriately trained surgeons perform this method of surgery with technical skill and proper indication, it is a good thing for the patient.
Currently, there are probably more variations of osteotomies in metatarsals alone than there are conditions of the foot. Indeed, the number alone for osteotomy variations for the correction of hallux valgus would account for most of these. Conceptually, the surgeon as well as the patient must think of an osteotomy as hopefully nothing more than a precise and controlled fracture, one which will position the bone in such a way so healing will result in a correction of the original deformity.
Until recently, many variations of osteotomy configuration have been solely predicated on the ability for one to apply fixation, primarily internal fixation and usually with screws. A perfect example of this is the Akin osteotomy. While surgeons most often envision external fixation as some type of mini-rail device, simple casting and splinting have withstood centuries of time as effective means to stabilize bone healing after fracture as well as osteotomy.
However, until recently, with minimally invasive approaches to osteotomies becoming more popular with increased utilization, there has been a wide consensus of opinion that internal fixation is required to attain the optimum result. Some have contended that it is below the standard of care to leave any osteotomy unfixated. This is simply not true in both my experience and given the exposure I have had to large numbers of cases presented in European foot congresses. In many cases, the dissection required to apply fixation results in more morbidity than if it had not been fixated initially. The data and clinical results certainly do not support that contention with our utilization of these techniques. I have also observed this in hundreds of cases I have reviewed in Spain.