Emerging Insights On Minimal Incision Osteotomies

Stephen L. Barrett, DPM, FACFAS, MBA

   As with any surgical technique or philosophy, there must be implementation with a criteria for proper procedure selection. Without such judiciousness, all techniques can be doomed to failure.6 There are also hybrid situations in which one can perform the osteotomy with a minimally invasive technique and still use fixation (usually all first metatarsals). One can also use a minimally invasive osteotomy simultaneously with other traditional techniques for treating other concurrent pathology, such as in the treatment of lesser metatarsals with concurrent hallux valgus correction. When it comes to discussion of minimally invasive osteotomy techniques, the bone that one is addressing greatly influences whether some type of fixation, other than external taping or splinting, needs to occur. A general rule of thumb is that all first metatarsal osteotomies require fixation.

Pertinent Insights On Bone Healing Principles

Successful bone healing depends on many factors ranging from the metabolic condition of the patient to which bone is involved. Fracture healing is similar to osteotomy healing and the type of fixation can affect outcome. Note that gaps in osteotomies or fractures up to 6 mm can heal physiologically.7

   Any osteotomy that surgeons can perform with the least amount of periosteal disruption is preferable as the periosteum can contribute up to one-third of the blood supply to the bone. This is one considerable aspect that can improve with a minimally invasive osteotomy versus a procedure with large maximal dissection.

   There are essentially three types of fixation: internal (screws, plates, cerclage wiring, etc.); external (casting and splinting in addition to percutaneous K-wires and mini-rail devices); and biologic.

   In minimally invasive osteotomies of the lesser metatarsal, for example, the concept of biologic fixation occurs in addition to the orientation of the osteotomy itself. Due to the minimal amount of dissection and the orientation and position of the osteotomy where there is relatively good alignment in all planes, the undisrupted soft tissues provide support. Additionally, the soft tissues improve blood supply in comparison to where there was maximal dissection required for plating, etc.

Are You Treating The Patient Or The Radiograph?

Conceptually, surgeons love to see postoperative radiographs that show perfect anatomical alignment and demonstrate elaborate screw or plate placement. A 1 mm gap in an otherwise perfect osteotomy can cause surgeon apoplexy but the reality is there is no likelihood of an outcome that is impaired or even less than perfect.

   Frequently the perfect X-ray does exist but this does not always correlate to the surgical outcome. There still may be a lack of full deformity correction, the joint may be stiff and painful, or the foot may still be extremely edematous due to the extent of the surgery. In contradistinction, the X-ray may look horrible, may be considered a complication, and the patient has no sequela and is extremely pleased with the outcome. When beginning to implement minimally invasive osteotomies and techniques into your surgical armamentarium, you will likely need to have a mental readjustment period when it comes to assessing surgical outcomes, particularly when evaluating radiographs.



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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