Top 10 Innovations in Podiatry 2022: SmartRelease Endoscopic Soft Tissue Release System by MicroAire Surgical Instruments

Dr. Tozzi discloses that he is a consultant for MicroAire International.

My name is Dr. Mark Tozzi, board certified foot and ankle surgery since 1982. Graduated from the Ohio College of Podiatric Medicine, stayed on as an instructor of faculty. And over the decades taught many residents, enjoyed teaching residency training. Started the process of product innovation about five years ago, actually 10, and have founded three separate companies, all of which have to do with medical surgical safety, I would say, in addition to the MicroAire system, which we're going to talk about shortly.

MicroAire International is located in Charlottesville, Virginia. In the 90s, I did a whole decade of sports medicine with a group of orthopedic surgeons. The system itself used to be called the AG system. It was FDA approved for carpal tunnel. I was doing plantar fascial releases with a double portal system and experimented with the SmartRelease MicroAire system, which I've been using now for over 20 years. The company heard about the fact that I had been doing this off label. They flew their product managers in, observed me do one of these in 2019, and I am now a paid medical consultant for MicroAire. It is the fastest FDA approval they've ever received for an instrument in the history of the company.

So the MicroAire system was recently, as of last year, FDA approved for plantar fasciotomy. And this is partial plantar fasciotomy. We only release the central and medial band, never a complete release and also gastroc recession. Since I began using the system for gastroc recession, I am probably never going to do another open one. It's a one stitch incision for both procedures. We also avoid the lateral incision, which could end up inadvertently severing the sural nerve. So we don't need that double portal incision that comes typically with trochar systems and hook blades. The procedures are done with general anesthesia, highly recommended, with hemostasis, mandatory to get an excellent image, and the most important part that I would like to pass along to all my surgeon colleagues is I no longer make incisions in the heel. I typically will tell my residents this is more of an arch procedure than a heel procedure. And that came from trial and error.

When I first began to use the SmartRelease system 20 years ago, I would make incisions into the fat pad of the heel. And I would encounter adipose. I would be suctioning out healthy fat that really is a shock absorber for the heel. So it does have an anatomic function. And as I began to move the incision more distal toward the arch, the visualization is like night and day. So to MicroAire's credit, they don't allow the system to be used until there's a training session. And the surgeons are then comfortable, not only with the equipment and the ease of which you can introduce the equipment to the heel or to the gastroc, but it really points out the differences between making an incision back in the heel area and moving that incision more distal.

When I do cadaver labs, I'll typically do these remotely and I will ask the surgeon, show me where you would make your incision. And nine times out of 10, it's in the fat pad. And the reason that it's so much easier to move distal is the visualization is 100% better as you scoop the incision further distal down the foot.

I actually have a white paper ready to publish sitting right next to me. We did a five-year retrospective study on my patients 10 years ago. Because the product was not FDA approved at the time, I never submitted the article. So we're just getting ready now to send it to the Journal of Foot and Ankle Surgery. The success rate, and that was using the Orthopedic Foot and Ankle Society's scoring system is 94%. So the patient satisfaction rate is just superb. I mean, I'll take 94% success rates, excellent results, and this was 25 questions that we asked patients from pain relief to is your arch collapsing, and are you sorry you had the procedure done and that's been my experience.

For patients that fail conservative care, I think this is an optimal way to approach plantar fasciotomy. And we emphasize the importance of not doing a complete release, which is another part of the SmartRelease system. You can't sever the lateral band because you're not taking the blade assembly far enough lateral to catch the lateral band. So this ensures that you don't run into an inadvertent, complete release like you can with a hook blade. And again, I speak from personal experience. Once you have incisions on each side of the heel or each side of the gastroc, it gets a little dicey when you stick the hook blade in, and sometimes you wonder am I cutting the whole thing? And, that's inadvertent, of course, because we don't want to weaken the arch by severing the whole plantar fascia.

I elaborated on general anesthesia. So I typically will recommend an LMA. The reason is you try to do these under local and the patients are moving around. You'd like to have the tissues completely relaxed when you do the procedure. And we actually have a video available through MicroAire of me doing both the EPF plantar fascial release and the gastroc recession. And I think that will help surgeons that want to try this for the first time, become more comfortable with the system.

Evolution of gastroc recession being done endoscopically is happening now. I would never consider in the rest of my career ever opening a plantar fascia with an incision. And I know some surgeons are actually still doing it. I think once the endoscope is introduced, the gastroc recession is going to follow suit.

I think most of these are incisions that are three centimeters plus in length on the back of the calf. If we can reduce it to a small stab incision, that too is a big advantage of the SmartRelease system over the traditional open approach. And gastroc recessions are actually being in the literature recommended for patients with chronic plantar fasciitis also. So that I think too is going to be an ongoing study that will be looking carefully at moving forward that not only should we consider the bands of the fascia involved, but the gastroc itself can factor into the chronicity of it. And I think that more studies are going to support the fact that an endoscopic release via the gastrocnemius or gastroc-soleus aponeurosis is going to be a really big plus for patients that have chronic heel pain that's recalcitrant.