Foot and ankle surgeons have no shortage of choices when it comes to selecting instruments for surgical procedures. Our surgical team has found success in using the Koby line of instruments (OsteoMed) for the treatment of various conditions.
For the last four years, surgeons have found success using Koby instruments for three procedures commonly performed in the foot and ankle. Koby instruments are designed to perform the partial plantar fasciotomy for heel spur syndrome, intermetatarsal ligament decompression of neuroma and release of the gastrocnemius tendon in heel cord lengthening.1
The instruments consist of a separate set of tools in a sterilization tray that includes the KobyGard flex tip instrument, ligament and fascial separators, and a tissue locator (fascial elevator). A single-use, sterile blade is wrapped separately.
The instruments were originally designed and manufactured by Koby Surgical in 2001. The Koby Isogard was marketed as an alternative to the endoscopic plantar fasciotomy (EPF). OsteoMed took over the manufacturing and marketing of the system in 2004 and the system is now known as the KobyGard.
Prior to using the Koby instruments, we used the Instratek Endotrac system and performed EPFs.2 Their Edintrak instruments were also used for release of the intermetatarsal ligament. We had also devised a technique to use the EPF instruments to perform an arthroscopic gastroc recession. Unfortunately, when we would probe the surgical site after performing a procedure, we could usually feel an additional fascia, ligament or tendon.
To solve this problem, we would reinsert the triangle blade directly into the site and further release the soft tissue. However, this additional percutaneous release occasionally led to an over-releasing of the plantar fascia and damage to the sural or plantar intermetatarsal nerve.
Using the KobyGard system enables surgeons to address these problems. If you determine that a structure has not been adequately released after probing with the fascial elevator, one can easily reinsert the KobyGard flex tip instrument and further release the tissue.
The Koby system was originally designed around carpal tunnel instruments. One would place the KobyGard instrument around the tissue to be released and its tines protect the tissue. At its distal end is a stop that prevents tissue from entering the end of the instrument. Inside the tines is a groove for the blade to travel. The blades are designed to be long enough to cut the medial and lateral bands of the plantar fascia.
Working with Koby Surgical several years ago, we designed a longer Koby instrument that replaced the Instratek EPF instruments for use in gastroc recessions. The Koby instrument uses the same blade but the additional length makes it easier to encompass the gastroc tendon.
Minimally invasive plantar fasciotomy (MIPF). When performing a minimally invasive plantar fasciotomy, one would make a 1 cm vertical incision at the junction of the medial and plantar skin lines. Make the incision by palpating that area about 1 cm distal to the medial tubercle of the calcaneus. Deepen it by blunt dissection and insert the fascial elevator perpendicular to the long axis of the foot. Make a channel above and below the plantar fascia.
Then proceed to insert the fascial separator in the channel to prepare the soft tissue for the Koby instrument. Once the separator is in place, place the instrument in the incision, insert the KobyGard blade into the instrument and pass it back and forth several times until you have released the fascia. Remove the instrument and use the fascial elevator to palpate the fascia to ensure an adequate release. By reinserting the KobyGard instrument, one can release additional fascia until you have achieved the desired amount of release.
Minimally invasive Morton’s neuroma decompression (MIND). One may use a minimally invasive Morton’s neuroma decompression for intermetatarsal ligament release. To do so, one would incise the toe sulcus in the desired interspace with a 1 cm vertical incision. Deepen the incision by blunt dissection, insert the fascial elevator and make a channel above and below the intermetatarsal ligament. Place the ligament separator in the channel to prepare the site for the KobyGard instrument. After removing the separator, insert the instrument. One would insert the blade into the back of the instrument and transect the ligament until there is no more resistance.
Subsequently, the surgeon should remove the instrument and blade, and use the fascial elevator to probe the site to ensure a complete release. If a portion of the ligament remains, one should reinsert the KobyGard and use the blade to complete the release.
Gastroc recession. Palpate the medial side of the proximal portion of the tendo-Achilles until one can feel the soleus muscle. Just above the juncture, make a 1 cm vertical incision. Bluntly dissect the wound until you are able to introduce the fascial elevator and make a channel in front of and behind the gastroc tendon. Then place the KobyGard instrument in the channel. With the foot dorsiflexed, insert the blade into the instrument and release the tendon.
Often one will not attain a complete release on the first pass-through and must reintroduce the instrument and blade to complete the recession. The surgeon should only release enough to maintain the foot in a 90-degree angle to the leg.
Using the KobyGard system to facilitate percutaneous treatment with these three procedures has proven to be reliable, quick and relatively free of complications. An added benefit is that these surgeries do not have a long learning curve when it comes to mastering the techniques.
Dr. Lundeen is the Residency Director of the Winona Hospital Podiatric Residency Program in Indianapolis.
Dr. Burks is a Fellow of the American College of Foot and Ankle Surgeons and is board certified in foot and ankle surgery. Dr. Burks practices in Little Rock, Ark.
1. OsteoMed, Addison, Texas.
2. Instratek Incorporated, Spring, Texas.