Emerging Insights On Minimal Incision Osteotomies
- Volume 25 - Issue 6 - June 2012
- 11278 reads
- 2 comments
You have to treat patients and not X-rays. It is also important to educate your patients about this preoperatively. Bear in mind they may seek a second opinion from someone who has no experience whatsoever with minimally invasive techniques. Such patients will really start criticizing your work when in fact you have done an excellent job. With the normal postoperative healing of bone, the ultimate result will be excellent. Those who have no experience with these techniques cannot judge the outcome of final osteotomy healing by what the X-ray looks like at four weeks post-op.
Rethinking Our Approach To Hammertoe Surgery
In hammertoe correction surgery, it is routine in the U.S. to perform some type of arthroplasty with removal of a portion of the articulation, whether it be the head of the proximal phalanx or a middle phalangectomy. In Europe, whenever possible, the concept is to try to avoid surgical dissection of the articulation during the correction, which decreases postoperative stiffness. Rather, one should implement correction with a minimally invasive osteotomy, either proximal or distal to the joint, in combination with other minimally invasive procedures like tenotomies and capsulotomies.
In the situation in which there is dorsal displacement of the proximal phalanx on the respective metatarsal head, which has been present for years, there is undoubtedly substantial bony re-adaptation between the base of the proximal phalanx and the head of the metatarsal. It is surgically naïve, in my opinion, to believe that some type of extensive soft tissue procedure (like a flexor tendon transfer) is going to allow for repositioning of the articular deformity present and that the soft tissue correction will be longstanding. If the joint is congruous in its deformed position and there is painless and functional range of motion, why not cut the proximal phalanx distal to the metatarsophalangeal joint (MPJ) and allow for a plantarflexory repositioning of the digit? These heal quickly, do not need fixation except for taping and result in an excellent outcome.
It is important to note that with this type of hammertoe correction, surgeons are also frequently performing minimal incision osteotomies concurrently and that there will not be a normal grasping motion of the digit post-surgery. An additional benefit of not having internal fixation is that while there is still bone plasticity (up to about three weeks), one can obtain additional correction by blocking the digit and manipulating it into more correction if that is necessary.
Why Minimally Invasive Techniques Can Be Advantageous
There are some forefoot reconstructions that are simply not possible with open techniques. Utilization of percutaneous osteotomies can allow for very satisfactory and functional outcomes with a minimum of trauma. Alternately, with a traditional open technique, so much tissue dissection would be required that the foot would be edematous and non-functional for a long period of time.