Minimally Invasive Surgery

Advantages of Minimally Invasive Foot Surgery

  • Quicker Solution
  • Faster Recovery
  • High Success Rate

Is Minimally Invasive Foot Surgery Right For You?

Percutaneous foot surgery or Minimally invasive foot surgery, also known as minimal incision surgery (MIS), is a small incision technique–done through portals with typically no sutures. This surgery is less invasive than traditional methods and causes minimal injury to adjacent tissues. During MIS, a surgeon will make one or more small portals, commonly 1-2 mm, in the patient’s skin. Radiologic guidance is necessary for the entire surgery. The surgeon will insert surgical instruments into the incisions and make corrections. Because MIS is less invasive, it often results in a quicker recovery time for patients.

Minimally Invasive Surgery Illustration

Surgeons perform MIS on an outpatient basis. Patients can avoid the costs and inconvenience associated with hospitals or surgery centers.

Surgeons perform minimally invasive surgery when precise percutaneous technique resolves the pathology. The incisions are small and done without injury to other structures. This surgery uses a meticulous process based on comprehensive knowledge of anatomical relationships. Small, specialized instrumentation is used, which is different from conventional surgery. As such, only surgeons who are experts in percutaneous surgery should complete this procedure.

MIS offers an alternative to open foot surgery. MIS is especially ideal for specific patient populations requiring procedures. These populations may otherwise be slow wound healers, such as people with diabetes, circulation problems, or other conditions that delay skin healing time.

The procedures do not take as long to perform; depending on the severity, some can take only 15 minutes.

Minimally invasive procedures on foot can help you fix a variety of different problems:

  • Crooked toes: hammertoes, claw toes, mallet toes, overlapping toes
  • Bone spurs or prominence
  • Ulcers and wounds via alleviation of pressure areas, especially for people with diabetes
  • Corns on or between toes
  • Calluses on the balls of the feet
  • Calluses on the side or underneath the big toes
  • Ingrown toenails
  • Thickened big toenails due to pressure
  • Prominent metatarsal heads
  • Tightness of the toes causing contraction via lengthening or releasing the tendon
  • Bunions and tailor’s bunions
  • Neuroma’s
  • Ball of foot pain
  • Soft tissue masses
  • Tightening of the ligament on the bottom of the foot (plantar fasciitis)
  • Heel spurs or prominences
  • Rebalancing biomechanical loading to the outside or inside of the foot by lengthening tendons

Common symptoms may be localized pain or deformity, callus, corn, blister, or ulceration. These problems are often due to chronic and recurrent pressure from:
adjacent bones, occlusive shoe gear, or ground reactive forces.

What are the Advantages of Minimally Invasive Foot Surgery?

  • Decreased interruption to circulation with minimal injury to adjacent tissues
  • Decreased healing time for patients–especially slow wound healers or immunocompromised (diabetes, peripheral vascular disease, geriatric patients)
  • Able to get the foot wet usually after three days as portals heal when no sutures.
  • Decreased post-operative pain due to minor trauma
  • Decreased complication rate and reduced infection rate–due to quicker procedure time and minimal incision
  • Decreased potential for scarring or keloid formation
  • Aesthetically more pleasing
  • Decreased post-surgical swelling and reduced pain due to bleeding
  • Decreased risk of any hardware complication requiring removal–(generally no fixation or permanent hardware)
  • Performed in an office or outpatient ambulatory setting.
  • Decreased risks related to anesthesia (most procedures performed using local anesthesia blocks)
  • patients do not need to stop blood thinners due to the small portal size
  • Does not require preoperative history and physical with clearance (chest X-ray, EKG, lab work) due to no anesthesia
  • performed in office
  • Significant cost savings for the patient and the insurance companies (hospital fees which could be as much as $20,000)

One of the best pros of MIS is that if the patient does not achieve the desired outcome, the surgeon can perform a more invasive open foot procedure.

Open Foot Surgery Pros

  • Open and direct visualization of anatomy by dissection and using a tourniquet.
  • Fixation such as a screw or permanent hardware can be used to provide a quicker bony healing union.
  • return to athletic or high-impact activities may be quicker
  • potentially more complete return to pre-injury activities–which can be ideal for younger patients

Consideration of the Foot and Patient as a whole:

The podiatrist or medical professional should perform a detailed systematic analysis of the entire foot. Not only the problem that prompted them to come in. There can be alterations in another part of the foot or higher segment that contributes to the symptoms.

Are you a Candidate for MIS?

You and your doctor decide whether MIS is a good decision. A detailed physical examination and patient consideration involve the following factors;

1. General information such as age, sex, ethnicity, body type, and profession.

2. Lifestyle or functional status: Is the patient active or non-active? What are the activities of daily living? Does the patient require transportation and assistance?

3. Work-type–do their essential functions require significant walking, standing, or climbing?

4. Medical history:

  • Diabetes?
  • Peripheral vascular disease?
  • Swelling of the legs?
  • Neuropathy?
  • Unsteadiness?
  • Blood thinners?
  • Cardiovascular disease?
  • Respiratory disease history of keloid formation?
  • Osteoporosis?
  • Arthritis?
  • History of back pain?
  • Are they slow healers?

5. Familial history of foot ailments.

6. Psychological profile:

  • Is there a history of anxiety or depression?
  • Hypersensitivity to pain, confusion?

7. The podiatrist should consider these questions:

  • What is the presentation?
  • Pain quality and characteristics?
  • Location?
  • Onset?
  • Duration?
  • What makes it better?
  • What makes it worse?
  • Has there been any history of trauma?
  • What type of shoe gear does the patient wear?
  • On what type of surfaces do they walk?
  • Associated symptoms?
  • Have there been prior foot surgeries?
  • What are the details of past treatments for the foot ailment?
  • Has there been a failure of other conservative modalities?
  • Are the expectations post-operatively realistic?

Open surgery may be a good option if the patient is young, healthy, athletic, and active, such as a construction worker. When a surgeon performs a bone cut ‘osteotomy’ and fixates the bone with screws, the bone is much more stable and robust. The downside is that it may take longer to heal. Thus, there is a more remarkable ability to withstand forces without affecting the correction.

If the patient is older, less active, or has other comorbidities such as diabetes, MIS may be more advantageous due to the less risk of infection and faster healing time. Typically there’s no fixation, and if the bone’s cut, it will relocate into the correct position. However, the tissue can hold the bone in place due to minimal dissection. It may take longer for the bone to consolidate and gain its full strength.

Each patient will be evaluated and considered individually. The surgeon and patient must decide between a minimally invasive procedure versus an open-type one, depending on which one meets their goals and expectations. Additionally, some foot surgeons perform either open or minimally invasive procedures. In addition, Dr. Formanek serves both types. He is one of a select small group attaining Board Certification in Minimally Invasive Foot and Ankle Surgery.

Consideration of the ideal time for the surgical intervention:

Most minimally-invasive foot procedures are non-urgent, making scheduling more convenient. Pain is never normal. If pain affects ‘activities of daily living,’ surgical intervention may be a necessary option: sooner rather than later. However, some minimally invasive procedures may be considered more urgent–such as alleviating pressure causing recurrent wounds, pre- ulcerations, and preventing infection or loss of bone or limb. Additionally, conditions will likely progress and worsen without intervention.

What happens during a minimally invasive surgery?

Minimally Invasive Surgery is much like traditional surgeries. However, one big difference is that the patient is normally awake and alert during the surgery. The surgery is much quicker, and the use of imaging is always necessary. 

What type of Anesthesia is used?

Many different types of anesthesia are available and used in foot and ankle surgery. In minimally invasive foot and ankle surgery, a ‘fast-acting’ local anesthetic is the most common. This anesthetic can be combined with a regional nerve block, numbing the nerves leading to the foot and ankle. This combination provides the best pain relief and allows the surgeon to operate with minimal discomfort. However, most foot and ankle surgeries use local or regional anesthesia. 

Minimal Incision-Based Surgery Eliminates the Need for a Tourniquet

A significant benefit of minimally invasive foot surgery is that it eliminates the need for a tourniquet to obtain a blood-free working area. A tourniquet is often used in traditional open incision surgery to control bleeding and improve visibility. However, in minimally invasive surgery, bleeding plays a positive role. By cooling the heat of the tissues and washing away bone paste, it helps to improve the quality of the surgical site. Moreover, because of the small size of the incisions or portals, bleeding is not likely to obscure visualization. Additionally, not using a tourniquet lowers the risk of developing a blot clot. As a result, minimally invasive surgery provides superior outcomes with less risk and tissue trauma.

Minimally invasive Percutaneous Techniques Are Not New

Current trends in modern orthopedic and general surgery favor the use of MIS. MIS resolves and reduces some of the problems associated with open surgery. It decreases complications and improves and shortens the post-operative recovery period.

Minimally Invasive Techniques for the foot were pioneered in 1945 by Morton Polokoff for small incisions of the nail root to treat ingrown toenails. Later, these foot surgeons broadened these indications for removal of bone prominence by adopting more aggressive percutaneous techniques. A small group, The Academy of Minimally Invasive Foot and Ankle Surgery continued to use and perfect these techniques. By the 1990s, Stephen Isham described techniques for the treatment of bunions, deformities of the lesser toes, and other conditions. Mariano e Prado and Pedro Luis Ripoll modified and broadened the indications. They reported and presented these broadened indications in scientific meetings and numerous communications.

Common MIS Surgical Instruments

In the late 19th century, dentists began using power-driven instruments for surgery. By the end of the century, electric and pneumatic motors had been explicitly developed for surgical use.

Specialized instrumentation in MIS may consist of:

  • small blades
  • needles
  • curettes
  • freers
  • various types of small burs

Surgeons use these instruments to release tissues and rasps for the removal of bone prominences.

Power instrumentation systems are commonly used in minimally invasive surgeries. These systems convert the speed and power produced into oscillating movements. This motion is ideal for sawing bone without causing too much trauma. The burrs are not to be confused with blades. The burrs are not sharp or naturally cutting and, therefore, less traumatic. This medical instrument reduces the chance of injury during minimally invasive surgery.

Surgeons use a bur for removing bone surfaces, shaving and re-aligning, and cutting bones. Bones are partially cut as in a ‘greenstick’ type fracture to rotate, elevate or achieve better angular position. It is done entirely through and through as an osteotomy to make this change. Surgeons use different burs based on shape (cutting, wedge, oval, fine, or coarse abrading) depending on the procedure.

The “Joystick” Motion

One of the most important aspects of any surgical procedure is maintaining a high level of precision. This is especially true in minimally invasive surgery (MIS). One way to ensure accuracy is using a slow, gentle, sweeping joystick-type motion while operating, rather than sawing with a blade as in open procedures. This motion allows the surgeon to maintain complete control over the movements of the instruments, helping to prevent any accidental damage. Additionally, it is essential to use a low speed with high power-driven instrumentation when performing the procedure. These two techniques decrease heat injury both to the bone and to the surgeon.

During the procedure, a patient may feel pressure or vibration from this ‘Joystick’ maneuver.

Fluoroscopy: Necessary Imaging during MIS

Minimally invasive surgery is performed without a direct view of the surgical field. Instead, procedures are monitored by imaging systems such as fluoroscopy. This type of monitor offers several advantages over traditional radiographic methods. First, it is more versatile in movement, with a C-arm that can be rotated 360 degrees in all planes. This allows for greater comfort and flexibility when viewing the surgical field. Second, fluoroscopy can be fitted without traditional enhancers, which emit a much lower level of radiation. As a result, minimally invasive surgery using fluoroscopy is associated with a lower risk of exposure to radiation. This makes it an ideal choice for patients concerned about radiation exposure’s dangers.


The skin portals typically take 2-3 days to heal when no sutures are used. This allows for getting the foot wet quicker in the tub compared to open procedures with sutures. However, underlying healing is still active, whether it be of the soft tissues, tendon, or bone. Typically, there will be some swelling and bruising in the early post-operative healing course. The patient should expect pain for several days, which is significantly less than open procedures where there is more dissection. The patient can treat pain with:

  • icing
  • elevation
  • rest
  • compression,
  • non-steroidal anti-inflammatory medications such as Advil, Aleve, or Ibuprofen

There will typically be a period of immobilization in a rigid shoe or boot. The length of time depends on the procedure(s) performed. For example, it may take bone 4-6 weeks to heal with immobilization, whereas soft tissue may require only several weeks of immobilization. The external dressing is initially important and subsequently in the way of strapping to splint the foot or toes. Dress it in the desired position to heal the soft tissues and bones. Additionally, stretching may be instructed early on in the post-operative course. In addition, after a bone cut or osteotomy, bone healing is assessed by office imaging.

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Dr. Formanek utilizes the latest and most advanced techniques to perform foot surgery in Baton Rouge. These methods allow patients to walk immediately after surgery, get back to their normal activities, and wear shoes that fit perfectly faster.

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There are pros and cons to minimally invasive surgery (MIS) and open foot surgery. The main advantage of MIS is that it results in less scarring and a quicker recovery time. Additionally, MIS is less likely to damage surrounding tissue. Patients generally experience less pain after the procedure. In addition, some patients may benefit more from an open procedure–such as athletic patients who may need fixation or permanent hardware to return entirely to athletic activities.

Ultimately, the best type of surgery for each patient depends on the individual situation. Therefore, any surgery, including MIS, should be discussed with a doctor before making any decisions.

Foot surgery can be a daunting prospect, but don’t worry! We’re here to help. If you are interested in any foot surgery, Dr. Formanek will be happy to discuss your goals. Reach out to the clinic today and make your appointment!