Advances catalyze minimally invasive foot, ankle surgery
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Although minimally invasive surgery for the foot and ankle has been around for decades, improvements in tools, implants and surgical training combined with a growing body of literature have inspired renewed popularity of these surgeries.
The resurgence is supported by recent results showing MIS bunionectomy is an effective procedure for bunion correction and joint fusions. A study by Andrés Carranza-Bencano, MD, PhD, and colleagues showed isolated MIS subtalar arthrodesis can improve wound healing and reduce neurovascular injury while maintaining a 92% fusion rate. Results like this have surgeons exploring new potential applications of MIS foot and ankle procedures in larger patient populations. Anish R. Kadakia, MD, FAAOS, professor of orthopedic surgery and chief of the division of foot and ankle at Northwestern University – Feinberg School of Medicine, said he believes foot and ankle MIS could change the way surgeons practice.
Source: Alexa Y. Hsu
“In my opinion, minimally invasive surgery is what arthroscopy was to sport surgery 30 years ago,” Kadakia told Healio | Orthopedics Today.
He added, “We are right at that cusp for minimally invasive surgery. It is the way to do things in the future, if possible.”
Advancements in burr technology
A primary reason why MIS foot and ankle surgery has become more effective in recent years is due to the advancements in burr technology, according to Kadakia.
“People have realized burrs have to be designed for certain problems. It is not a one-size-fits-all technology,” Kadakia said. “Now, each burr is designed for different things, whether it is cutting the bone in half or moving a little bit of bone. The shape of the burrs has made it procedure specific.”
In addition, Noman A. Siddiqui, DPM, MHA, FACFAS, director of podiatric surgery at the International Center for Limb Lengthening and chief of podiatry at Sinai and Northwest Hospitals, said the use of low-speed, high-torque burrs have allowed surgeons to preserve patients’ soft tissues.
“In the past, there were burrs that you could use for MIS; however, the challenge was they were high-speed, high-torque, not as accurate and potentially harmful to the soft tissue and bone if used without strict control,” Siddiqui told Healio | Orthopedics Today.
“However, more recently, there has been more focus on utilizing high-torque, low-speed burrs that can specifically allow you to focus on areas that would be more challenging if you were utilizing a burr that was high speed, high torque. Low-speed, high-torque allows you to make an osteotomy and not disrupt the soft tissue,” he added.
Improvement in implants, technique
Improvements in instrumentation, implants and advanced surgical techniques continue to rapidly drive the resurgence of foot and ankle MIS procedures, according to Andrew R. Hsu, MD, chief of the division of foot and ankle surgery at the University of California, Irvine Medical Center and a Healio | Orthopedics Today Editorial Board Member.
“Surgeons and engineers have designed a wide array of new shifters, guides, jigs, screws, nails, anchors and other devices in order to help make foot and ankle MIS possible,” Hsu told Healio | Orthopedics Today.
Hsu said he believes as MIS training and techniques become more streamlined and effective these procedures will become the new standard for a diverse array of traditionally open foot and ankle surgeries with the goal of improved clinical outcomes and decreased complications.
David I. Pedowitz, MD, professor of orthopedic surgery and chief of foot and ankle at Rothman Orthopaedic Institute, said the widespread dissemination of MIS techniques has also sparked the growth of the procedure.
“What we could say about minimally invasive surgery over the last couple of decades is that it is becoming mainstream,” Pedowitz, a Healio | Orthopedics Today Editorial Board Member, said. “It is not just the technological aspect; it is that the techniques have become adopted by hundreds of surgeons. That is remarkable because it changes the way we think about our approaches to surgeries that we have been doing for a long period of time.”
Benefits of MIS
With the strides made in foot and ankle MIS technology and techniques, there has been a major improvement in patient benefits, according to Kaitlin C. Neary, MD, FAAOS, of St. Luke’s Health System.
“[Patients] understand the benefits of minimally invasive surgery and seek that out,” Neary told Healio | Orthopedics Today. “At the end of the day, when you are keeping incisions small [and] preserving blood flow and biology to the surgical site, you are going to have quicker healing, improved bone and tissue healing, faster recovery and better patient satisfaction and better patient care, which is what we are all after.”
According to Hsu, the most clinically relevant benefit of MIS for his patients is the ability to decrease wound and soft tissue complications.
“Safety always comes first. In the modern era, we should not have to accept that wound complications and painful scars are an inevitable part of foot and ankle surgery,” Hsu said.
He added, “Once you reduce complications, you can start pushing the envelope in terms of how much decreased dissection, faster recovery and better results we can achieve.”
Once a surgeon masters or gains a high level of proficiency with MIS procedures, they can also experience benefits themselves, such as significantly reducing the time of the procedure, according to Siddiqui.
“From an OR standpoint, the patient is not under anesthesia for as long, so you are able to accomplish the procedures at a quicker rate. From the surgeon’s standpoint, now not having to deal with the soft tissue issues, meaning not having to worry about a wound having a problem, that is obviously a desirable outcome,” Siddiqui said.
Expanded opportunities
Although MIS has the capacity to correct smaller deformities, like bunions, Neary said the possibilities of foot and ankle MIS procedures can be used in more complex situations.
“The bunion is exciting, but what you can do for the rest of the forefoot, what you can do for joint prep, osteotomies, Charcot correction, the sky is the limit in terms of what we can do minimally invasively now that we have access to these systems,” Neary said. “There have been all sorts of new applications for minimally invasive approaches that have blown up over the past 10 years and even in the last 3 to 4 years.”
However, Kadakia said the benefits of MIS with smaller procedures, like hammertoe deformity correction, should not be overlooked.
“It was a huge game-changing leap for Charcot, but it is a small portion of the population,” Kadakia said. “If you can do minimally invasive Charcot, it is a big deal, but it is not just for the big procedures. That is not the best way to think about MIS because you are boxing it into an area where it is great for complicated things only and MIS is beneficial for most of the procedures we do.”
Potential risks
Despite the benefits and opportunities MIS affords surgeons and patients alike, Pedowitz acknowledged there are still risks and complications associated with the procedures.
“The complications you can get with open surgery are all complications you can get with MIS surgery,” Pedowitz said. “Specifically with the burr, you have to be conscious of the fact that you cannot see what you are doing necessarily with your eyes. You have to use feel, you have to use your anatomic landmarks and fluoroscopy. The minimally invasive burr, even though it is high-torque, low-speed, it can still create heat and cause bone necrosis.”
Source: Andrew R. Hsu, MD
Hsu said the ability to reduce the risks and shorten the learning curve associated with MIS procedures will determine both the indications of the procedures as well as who regularly performs these procedures.
“If we can make MIS cases easier and more reproducible, it allows surgeons across more diverse practice environments to be able to safely do these types of procedures,” Hsu said. “MIS can then benefit a larger number of patients across the country.”
Steep learning curve
Another challenge that may prevent MIS from becoming utilized on a wider scale is the steep learning curve that surgeons face.
“Because [MIS surgery] is blind in the fact that you are not seeing what you are doing and relying on X-ray, you have to know your surface anatomy,” Kadakia said. “In your mind, you have to know the 3D anatomy of wherever you are working, you should know where every structure is in your head. If you do not know that, you cannot do this surgery.”
One barrier to overcoming the learning curve associated with MIS is the accessibility and willingness to do the necessary education and training required to master the technique, according to Neary.
“This is not like using a new plate or a new screw for the first time where all you have to do is look at it and you can implement it,” Neary said. “This is something that you need to do fairly extensive training beforehand, and that includes sawbones labs, doing a full-day lab where you have access to cadavers and then starting slowly with patients, doing less complicated procedures and techniques and slowly building up.”
Pedowitz said surgeons can also reduce the learning curve of MIS on their own by using techniques and instruments in an open fashion.
“You can use the minimally invasive burr but do the surgery open so that you can correct for a variety of things that you might not be able to achieve yet in a minimally invasive fashion,” Pedowitz said. “There are a variety of ways in which you can blunt the learning curve on your own.”
Surgeon bias
According to Siddiqui, another barrier to the wider implementation of MIS in the foot and ankle community is a longstanding negative surgeon bias toward the procedures.
“For the longest time, there was such a negative surgeon bias toward minimally invasive surgery,” Siddiqui said. “When you have surgeons who are conscientious of doing the right thing for their patients, and they have had a certain type of outcome that is predictable with open procedures, and now it is coming up against a resurgence of MIS, I can see the reluctance to want to change because of prior experience.”
He added, “Now, the onus is on surgeons like me and others who are doing a lot of MIS to show that it is safe, effective and better for the patient through research. That is where the change is going to be.”
Kadakia said surgeons may be apprehensive to attempt MIS due to the possibility of having bad postoperative outcomes. However, he added MIS is worth the possible risks because it may be better for the patient long-term.
“It is hard because you will have complications when you do [MIS] the first time,” Kadakia said. “I do not care who you think you are, you are going to have cases where you are going to tell yourself if I did this open, it would have been better for the patient. That is why you have to practice in the lab, and you have to be honest with your patient.”
Future of MIS
More data on joint preparation and the clinical outcomes showing MIS is superior to open procedures may also help surgeons become more comfortable with performing MIS procedures, according to Kadakia.
“A lot of the research now has to be focused on, like for fusions: Can you prepare the joint properly and how do you prepare the joint properly?” Kadakia said. “Then for the harder [surgeries] like Charcot or calcaneal osteotomy, the question has to be: Is the wound complication rate that much better and are the clinical outcomes that much better than open that it justifies the difficulty and the extra skill set to do this?”
In the future, instrumentation and techniques of MIS will continue to improve and expand the procedure and its scope, according to Pedowitz.
“There are going to be different tools that we have for fracture fixation and fracture reduction, different milling techniques to take out bone so that we can put in implants differently, three-dimensional imaging that we can get in real time in our operating rooms which will allow us to not have to see different aspects of the bone and the soft tissue at the time that we are doing the surgery,” Pedowitz said. “They are researching MRIs that can be done intraoperatively. There already are stereotactic radiographic techniques to follow screws as they take unusual paths. That is the future of MIS.”
However, Hsu said the most important thing for the future of MIS foot and ankle procedures is refusing to only accept and rest on what is already known.
“What is exciting and starts moving the field forward is the question of what could be,” Hsu said. “We need to stay disciplined in learning new skills, developing new implants and techniques, and translating that into better outcomes proven in the literature. There are inevitable barriers along the way, but innovation is driven by the constant desire to be better and the possibilities for MIS foot and ankle procedures are tremendous.”
- References:
- Carranza-Bencano A, et al. Foot Ankle Int. 2013;doi:10.1177/1071100713483114.
- Lause GE, et al. J Am Acad Orthop Surg. 2023;doi:10.5435/JAAOS-D-22-00608.
- Patel MS, et al. Foot Ankle Clin. 2019;doi:10.1016/j.fcl.2019.05.002.
- Wendler DE, et al. Foot Ankle Orthop. 2022;doi:10.1177/2473011421S01001.
- For more information:
- Andrew R. Hsu, MD, of the University of California - Irvine Medical Center, can be reached at andyhsu1@gmail.edu.
- Anish R. Kadakia, MD, FAAOS, of Northwestern University, can be reached at kadak259@gmail.com.
- Kaitlin C. Neary, MD, FAAOS, of St. Luke’s Boise Medical Center, can be reached at kaitlincneary@gmail.com.
- David I. Pedowitz, MD, of Rothman Orthopaedic Institute, can be reached at david.pedowitz@rothmanortho.com.
- Noman A. Siddiqui, DPM, MHA, FACFAS, of Sinai and Northwest Hospitals, can be reached at siddiqui.dpm@gmail.com.
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