Emerging Insights On Minimal Incision Osteotomies

Author(s): 
Stephen L. Barrett, DPM, FACFAS, MBA

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.

Comments

Stephen,

Very nice summary of techniques that started in the USA, were perfected in the USA and were taught to the European orthopedic community. The AAFS was the originator of all of these techniques. I am glad that you also have began to see how MIS procedures were always for the benefit of the podiatric patient as well as the profession. I personally have post MIS procedures that are 30 years old and I am not one of the great pioneers that started this technology. Let's give due respect to Edwin Probber, DPM. Abe Plon, Ronald Strauss, Larry and Marty Koback, DPM, Larry Kales, Steve Donis, DPM, Stan Rosen, DPM , Ed Martin, DPM, Jerome Jacobs, DPM, and the list continues.

We need to start showing respect and giving due to these podiatrists and not the Europeans who are just riding the curtails of these great podiatry leaders. Thanks.

Don't forget to thank Stephen Isham, DPM, who currently practices in Idaho, for all of his numerous contributions. Stephen was a podiatric pioneer of MIS techniques and gained a significant international following after teaching these techniques to orthopedic surgeons around the world. He obtained his MD degree at a foreign medical school, which gained him a wider audience but he was always sure to promote that he was first and foremost a podiatric surgeon. He along with other US podiatrists DID teach these techniques to European orthopedic surgeons and they DO respect podiatrists.

The European orthopods are documenting their outcomes of thousands of nonfixated osteotomies. These osteotomies heal well without nonunions because the periosteal blood supply is kept intact by the minimal dissection and because the osteotomies have autogenous bone paste, which acts as a bone graft matrix around and within each osteotomy. Some doctors use percutaneous k-wires to fixate the osteotomies but the majority use taping as a form of external casting/splinting just like they were taught by the podiatric pioneers.

The ACADEMY OF AMBULATORY FOOT SURGERY (AAFS) along with the presently named AMERICAN BOARD OF MULTIPLE SPECIALTIES IN PODIATRY were the US platforms for launching the current growing worldwide phenomenon of minimal incision foot osteotomies.

Really loved your article. Thanks man.

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