At the 2024 American Orthopaedic Foot and Ankle Society (AOFAS) Annual Meeting, surgeons convened to dive into the topic of minimally invasive surgery (MIS) “beyond the bunion.” Moderated by Christopher P. Miller, MD, MHA, and Rebecca A. Cerrato, MD, the session kicked off with a brief history of MIS in the foot and ankle space with Eduard Rabat, MD. He characterized the chronology of these procedures as having 4 “seasons.”

The first, beginning as early as the 1940s, and extending until the end of the 1980s, he said, is the “beginning and downfall” of MIS. Significant complications led to the second season in the 1990s, shared Dr. Rabat. He called this the “desert crossing,” marking the abandonment of these techniques in North America. He noted that Stephen Isham, DPM, MD, DrHC was the MIS link between the United States and Europe, particularly when Mariano de Prado, MD, from Spain connected with him and began investigating these options. Dr. Rabat noted that the third season, or “the renaissance,” highlights significant theoretical and anatomical innovation in MIS techniques worldwide, from the late 1990s to the mid-2010s. He remarked that the current, fourth season places the field “back at square one,” but with expanding research and literature, more courses worldwide, and continued evolution of practices to improve outcomes. He contended that future outlooks should involve resident training in both traditional and MIS techniques, as “we are on a path of no return,” with minimally invasive options becoming standard of care in other surgical fields. However, he cautioned surgeons to not forget conventional techniques, as well.

MIS Perspectives in TTC and Hindfoot Fusion

Tyler Gonzalez, MD, MBA, FAAOS took the podium and agreed that most surgery is moving in the direction of MIS. He shared some key cases and surgical pearls from his experience in tibiotalocalcaneal (TTC) and hindfoot fusion. First, he urged surgeons to focus on good joint preparation, and to definitely check it, arthroscopically or open, when starting out with these techniques. He said one might choose to always check the prep, even when deeply experienced, and that he personally does so every time.

Position is key in the cases, he noted. He encouraged the audience to figure out what works for them, and to pursue good ergonomics with the burr. He shared he prefers a 2 x 20 mm Shannon burr. Good fixation, bone grafting, and incision placement is also vital, but he finds patients generally do well when these points are covered. Dr. Gonzalez said that more data is always needed, and that there must be continued impetus to research, innovate, train, and practice. He shared a colleague’s assertion that is it not a learning “curve,” but instead a learning “continuum” to be undertaken.

Zadek Osteotomy: Do We Need to Detach the Achilles Tendon?

Peter Lam, MD, MBBS, FRACS(Orth) from Australia then addressed the audience regarding the Zadek osteotomy for painful insertional Achilles tendinopathy. Detaching the tendon traditionally for these cases carries a host of challenges for surgeons and patients. However, he reviewed the historical literature from 1939 until today, along with his personal experience, and shared several important clinical notes. He said that there are currently 8 papers available on the Zadek osteotomy for these types of cases, 2 of which use MIS techniques. All take a dorsal wedge up to 10 mm, but there is a lack of discussion on how to decide the exact wedge size. They all place the vertex of the wedge anterior to the plantar calcaneal tubercle, but he noted that this will impact calcaneal pitch. There is some discourse on screw versus plate fixation, with less removal of screws necessary, he said, and on the role of the cavus foot in these cases.

Sharing his personal technique, and some his data, Dr. Lam concluded by stating that percutaneous Zadek osteotomy is a safe and effective alternative to an open take-down of the Achilles tendon. He finds a low complication rate with this approach, but noted that further research is necessary on wedge size, vertex placement, the role of the calcaneal pitch, neutral position, foot type (cavus, etc), and long-term follow-up.

Considerations MIS in Special Populations

Lorena Bejarano-Pineda, MD touched on the multitude of patient populations that could potentially benefit from considering an MIS approach to their foot and ankle surgery. She shared that a significant portion of US patients may belong to one of these groups, including the Hispanic, African-American, and Indigenous Peoples populations. However, one must look at these populations from a different angle, she mentioned, also considering older patients, those with disabilities, pregnancy, obesity, or diabetes.

How does this relate to MIS? Dr. Pineda stressed that individualized patient care is best, and that these considerations can play into surgical decision-making. She noted that MIS may serve as a safer technique to potentially improve complication rates and patient-reported outcomes. One example is less scarring, which can be of concern in a keloid-prone population. She cautioned, however, that one must always choose the best approach for each patient, whether MIS or open.

Approaches to an Under-Tapped Market

Bobby Ndu, MD, MBA presented next on marketing to underrepresented minority patient markets. He stressed that these patients are important, and as an example, pes planus is 2-3 times more prevalent in the Black and Hispanic populations.¹ However, he shared barriers that may exist to connecting with these patients that surgeons should be aware of. He said that stereotypes, false beliefs, and patient mistrust of the healthcare system can contribute, but that providers can work to change this. Next, he presented 5 points to consider in a marketing plan to incorporate these patients into foot and ankle surgery practices.

1.        Targeted Community Outreach
2.        Culturally Tailored Material
3.        Digital Marketing and Social Media
4.        Partnering with Minority Physician Groups
5.        Creating an Accommodating Environment

As a whole, he stressed that one’s efforts in this area must be genuine. However, he noted that there is an un- or under-tapped market of patients available which foot and ankle surgeons may be able to serve, and find very rewarding.

Are There Limits To MIS Forefoot Correction?

A. Holly Johnson, MD concluded the session by asking the audience to consider, “What else can we MIS in the forefoot, and should we still do some things open?” She pointed out that even if a surgeon decides MIS bunion correction is not for them, she feels it is vital to learn MIS approaches to Akin osteotomies, calcaneal osteotomies, and cheilectomy. There is significant debate on specific questions around distal versus proximal MIS bunion approaches, and hammertoes, but these are out of the scope of her discussion today. Dr. Johnson went on to share multiple challenging case examples, and the resultant lessons learned.

In particular, she focused on several cases where she performed distal metatarsal minimally invasive osteotomy (DMMO) on lesser metatarsals. Dr. Johnson explained that in her experience, single DMMOs are just not consistent, and can be very hard to predict. At minimum, she noted they must be done correctly, and the surgeon must have a sense of where the metatarsal head will end up. Overall, she stressed that the burr is a powerful tool, and encouraged the audience to be open to new concepts and techniques. Specifically, she said she hopes surgeons will consider mixing open and MIS techniques when appropriate, and to learn from each case.

References
1.        Golightly YM, Hannan MT, Dufour AB, Jordan JM. Racial differences in foot disorders and foot type. Arthritis Care Res (Hoboken). 2012 Nov;64(11):1756-9. doi: 10.1002/acr.21752. PMID: 22674897; PMCID: PMC3463748.