Emerging Insights On Minimal Incision Osteotomies
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.