Emerging Insights On Minimal Incision Osteotomies

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

   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.

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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