Emerging Insights On Minimal Incision Osteotomies

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

   It is beyond the scope of this article to describe detailed surgical techniques. However, with the presentation of a few case examples, hopefully one can gain an appreciation of how powerful these techniques can be with extraordinary surgical outcomes.

How To Revise Failed Hallux Valgus Surgery

Revision surgery for failed hallux valgus correction can be one of the most demanding surgeries the foot surgeon performs. Considerations of revision surgery should include:
1. What does the patient desire?
2. What is really possible?
3. Does the planned revision place the patient at more risk for increased morbidity?

   As we have talked about the perils of treating radiographs and not patients, it is vital to understand what the patient does not like about the outcome. Sometimes, it has almost nothing to do with the original surgery (and almost never involves what the postoperative radiograph looks like). For example, say there is more of a separation between the hallux and second digit. The patient does not like that and wants the second digit corrected.

   A minimally invasive osteotomy may be the ideal correction for this type of revision as there is already significant scar tissue present and often no need to “redo the whole thing.”

   Complex clinodactyly deformity. In a complex fifth digit deformity, the use of a minimally invasive proximal phalangeal base osteotomy provides ultimate correction of this complex deformity with minimal postoperative morbidity and often little, if any, post-op pain.

   Diffuse metatarsalgia. Metatarsalgia is a common forefoot condition that can be difficult to treat and one must always evaluate whether an equinus condition exists concomitantly. If there is overwhelming gastrocnemius equinus, it is my opinion that one address this component primarily. This approach has much less postoperative morbidity than forefoot metatarsal osteotomies.10 Research has found the Weil osteotomy to be particularly beneficial to treat this condition and it is well suited to minimally invasive techniques.11

   Additionally, when it comes to high-risk patients with ulceration, studies have found minimally invasive osteotomies to be beneficial with a high level of efficacy and low complication rate.12,13 This may allow for intervention that open techniques would preclude.

How To Address Any Complications That Arise

As with any surgical technique, there will be complications. Fortunately, in my experience, they have been small and rare. I believe that most complications emanate from two things: inappropriate indication of the technique and failure somewhere in the postoperative course.

   With this type of surgery, my worst complication has been a delayed healing of three lesser metatarsal osteotomies in which the patient was feeling so well that she decided to start playing golf at six weeks post-op. Naturally, there was a long period of immobilization and bone stimulation with ultimate healing. Rarely will a lesser metatarsal osteotomy at the distal metaphyseal not heal if one gives it enough time. Another potential complication is an extrusion of bone paste postoperatively if one does not adequately remove it at the time of surgery.

In Summary

The use of minimally invasive osteotomies provides the surgeon with some very powerful techniques. These techniques can provide previously unattainable corrections of very complex and severe forefoot deformity. However, it is important to emphasize that these techniques require advanced training and gradual implementation.

   Dr. Barrett is an Adjunct Professor within the Arizona Podiatric Medicine Program at the Midwestern University College of Health Sciences. He is a Fellow of the American College of Foot and Ankle Surgeons.

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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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