Emerging Insights On Minimal Incision Osteotomies

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

   This is especially true for rheumatoid reconstructions. When employing the minimal incision technique, there are the added benefits of less tissue disruption in an immunocompromised patient and a faster return to normal function. However, with central metatarsal osteotomies, my highly trained colleagues in Spain caution that it will take a minimum of three months for them to heal and be non-painful. They almost always recommend doing the second, third and fourth metatarsals concurrently.

   Another very useful indication for a minimally invasive osteotomy is the example of the patient with a failed hallux valgus surgery. There are cases in which patients have had a prior open hallux valgus reconstruction and they are still not happy because the hallux is still (albeit slightly) laterally deviated and touching their second digit. They do not want to go through another lengthy post-op recovery and their first MPJ works well with no pain and a normal range of motion. Another procedure aimed at the level of the first MPJ is certain to result in more stiffness and morbidity.

   A simple percutaneous osteotomy (Akin) of the proximal phalanx works extremely well in this situation. It allows for minimal restriction of activity after surgery and the patient only has to tape/splint the digit for four to six weeks with virtually no postoperative morbidity. There is another advantage to this type of non-fixated osteotomy.

   If the patient desires even more correction after surgery, while there is still plasticity in the bone (up to about three weeks), one can locally anesthetize the digit and manipulate it into better position. This is not possible when one uses rigid internal fixation (see “A Closer Look At The Necessity Of Internal Fixation For Different Osteotomies” below).

Keys To Transitioning Into And Learning Minimally Invasive Techniques

Performing minimally invasive surgery is more difficult and demanding than performing open surgery. There is a steep learning curve for some of these techniques. It would be my recommendation to begin with simple digital work for hammer digit correction and then phase into increased utilization for techniques such as proximal Akin osteotomies. Then one can finally progress to distal metaphyseal work on lesser metatarsals.

   I highly recommend the excellent textbook Minimally Invasive Surgery, which is translated into English for a review of these techniques.8 The anatomical illustrations alone are well worth the cost of the text. As with any surgical procedure, let alone a whole foreign conceptual type of surgery, there are many nuances that one should contemplate before entering into this type of surgery.

   While there is a strong need for the surgeon to be keenly aware of anatomy and topographical location, there is also a strong reliance on the use of intraoperative fluoroscopy to ascertain proper position of the cutting instrument prior to making the osteotomy. Surprisingly, there is very little trauma to surrounding soft tissues with good technique and the use of recommended instrumentation.9

   Special instrumentation is required. For example, you cannot use high-speed rotary instruments as the heat generated will result in a high propensity for thermal bone necrosis. Use low RPM side cutting burrs. For lesser metatarsal osteotomies, we use small, traditional power saws while the assistant applies cooling, sterile water. We have not encountered thermal bone necrosis. This deviates from use of the side cutting burr for lesser metatarsal osteotomies but provides for less of a learning curve and more precision.

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David Zuckerman DPMsays: June 7, 2012 at 9:31 pm

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.

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Robert Lee DPMsays: June 15, 2012 at 7:26 pm

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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