Challenging the Dogma of Podiatric Surgery on MIS Bunion Surgery and Brachymetatarsia

Without a doubt, I received exceptional training in my residency program. From basic to complex foot and ankle surgeries, trauma, and limb preservation, I felt confident starting my post-graduate fellowship. My residency provided well-trained faculty who brought different sets of surgical skills and techniques to the program, ultimately providing surgical diversity to the residents.
 
The majority of my training was based on traditional surgical approaches, which is critical in providing a solid foundation for a young surgeon. I quickly realized as I entered the next phase of my training that the surgical “dogma” that we learned throughout school and residency would be challenged—and should be challenged.
 
My fellowship training is unique in that it focuses on minimally invasive surgery (MIS) techniques in commonly performed podiatric surgical procedures and with MIS becoming a mainstay in our profession, I feel the timing of my fellowship is serendipitous. In just a few short months of my fellowship, I’ve gained a whole new skill set that I didn’t think was possible. MIS has gained popularity in foot and ankle surgery, particularly as it pertains to hallux abducto valgus (HAV) correction. Numerous publications have reported reproducible patient satisfaction utilizing this technique.^1–5 Given the minimalist approach and efficient correction of mild, moderate, and severe HAV deformities, patients often have quicker time to recovery and return to function, with fewer wound complications while preserving joint range of motion.^1–5
 
On a weekly basis, I see postoperative patients who have undergone MIS bunion surgery, I anticipate their results and can’t wait to hear about their overall satisfaction. I’ve seen patients 2 weeks from surgery all the way 6 years postop and they are all generally satisfied. It truly amazes me to see how well patients do.
 
Surgeons can apply MIS to other surgical procedures—flatfoot and cavus foot reconstruction, supramalleolar osteotomies, Charcot reconstruction, ankle/subtalar joint arthrodesis, and many more. Any good MIS surgeon can vouch that you cannot do minimally invasive surgery properly without an exceptional knowledge of anatomy and a proper understanding of open technique. I am fortunate enough that I learned open procedures in my residency while now in fellowship acquiring new MIS techniques in these same procedures.
 
Another “dogma” that I’ve seen been questioned is acute correction in brachymetatarsia. From an educational standpoint, we’ve learned that correction requiring greater than 1.5 cm in length will likely need gradual correction to avoid strain on the neurovascular structures.⁶ While avoiding neurovascular compromise is a priority in this procedure, I have witnessed acute correction up to 24 mm without postop complication and high patient satisfaction. Do I think 24 mm of acute correction is doable for everyone? Maybe not, but for the skilled surgeon who has experience with this deformity, I think this is a reasonable goal to achieve for their patients.
 
The point of this DPM Blog is not to disregard traditional approaches, but rather to encourage providers to pursue newer techniques to enhance mastery knowledge. I recently attending the Baltimore Limb Deformity Course where physicians from 29 countries from all over the world came together to learn principles of limb deformity. I listened to expert panelists discuss their trials and tribulations throughout their careers, but these challenges inevitably made them into the well-respected surgeons they are today.
 
These innovative approaches that we’ve adopted into modern practice stem from fundamental principles that have originated from integral surgeons in our profession. I encourage readers to stay inspired so we can continue to push the boundaries of our profession.
 
Finally, readers should stay curious and publish as research provides evidence-based medicine that will shift the paradigm of foot and ankle surgery for the better. As Sir William Osler once said, “Medicine is a science of uncertainty and an art of probability.”
 
Dr. Mateen is currently a clinical foot and ankle deformity and Orthoplastics fellow at the Rubin Institute for Advanced Orthopedics at Sinai Hospital in Baltimore, MD.

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