Is Minimally Invasive Surgery Right for You?
What is Minimally Invasive Surgery?
Percutaneous surgery of the foot, also known as minimal incision surgery (MIS), is a small incision technique. Surgeons call these incisions portals. Typically, no sutures are used. This type of 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 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.
MIS can be performed in the office setting–
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 meticulous technique based on detailed, comprehensive knowledge of the anatomical relationships. Small, specialized instrumentation is used which is different from conventional surgery. As such, the procedures should only be performed by surgeons with expertise in percutaneous surgery.
MIS offers an alternative to open foot surgery. MIS is especially ideal for certain patient populations requiring procedures. These populations may otherwise be slow wound healers such as:
diabetics, those with circulation problems, or other conditions which delay healing time of the skin.
Additionally, the procedures do not take as long to perform. Depending on the procedure, some procedures can take only 15 minutes.
Minimally invasive procedures in the 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 diabetics!
- 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
- 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 present as: 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 to Minimally Invasive 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 3 days as portals heal when no sutures..
- Decreased postoperative pain due to less trauma
- Decreased complication rate and decreased 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 decreased pain to due to bleeding
- Decreased risk of any hardware complication requiring removal–
- (generally no fixation or permanent hardware)
- Can be performed in an office or outpatient ambulatory setting.
- Decreased risks related to anesthesia (most procedures performed using local anesthesia blocks)
- Blood thinners do not need to be stopped for higher risk patients 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 if the desired outcome is not achieved, then a more invasive open foot procedure can then be performed.
Open Foot Surgery Pros:
- Open and direct visualization of anatomy by dissection and use of a tourniquet.
- Fixation such as screw or permanent hardware can be used to provide 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 more ideal for younger patients
Open Foot Surgery Cons:
- Require monitored, regional or general anesthesia due to larger incisional site, and dissection
- Require prophylactic, intravenous antibiotic when bone work is done–(due to larger incisional sites with prolonged bone exposure)
- Both of the above increase the potential for pain and increased procedure time
- Requires medical Clearance, lab work, sometime chest X-ray, EKG due to anesthesia risks
Consideration of the Foot and Patient as a whole:
A detailed systematic analysis of the entire foot should be performed by the podiatrist or medical professional. 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 consideration of the patient as a whole should be considered
- General information such as: age, sex, ethnicity, body type, profession.
- 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–does their essential functions require significant walking, standing or climbing?
Peripheral vascular disease?
Swelling of the legs?
Respiratory diseaseistory of keloid formation?
History of back pain?
Are they a slow healer?
5. Familial history of foot ailments.
Is there a history of anxiety or depression ?Hypersensitivity to pain, confusion?
The podiatrist should consider these questions:
What is the presentation?
Pain quality and characteristics?
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?
Have there been prior foot surgeries? What are the details of past treatments for the foot ailment? Has there been failure of other conservative modalities? Are the expectations post-operatively realistic?
For more details on what physical examination should include, click here to read the doctor’s notes.
If the patient is young, healthy, athletic, and quite active then open surgery may be considered a good option. An example could be a construction worker. When a surgeon performs a bone cut ‘osteotomy’ and fixates the bone with screws, the bone is much more stable and stronger. The downside is it may take longer to heal. Thus there is a greater ability to withstand forces without affecting the correction.
If the patient is older, less active or has other comorbidities such as diabetes for example, then MIS may be more advantageous. This is due to the less risk of infection and faster healing time. Typically no fixation is used and if the bone is cut it will relocate into the correct position. Minimal dissection of the surrounding tissues which will also hold it in place. However, it may take longer for the bone to completely consolidate, gaining its full strength.
That being said, each patient must be considered individually. The surgeon and patient must decide together between minimally invasive procedure versus an open-type proceduremeets their goals and expectations. Additionally, some foot surgeons perform either open or minimally invasive procedures. Dr. Formanek performs 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 procedures of the feet are non urgent and can be conveniently scheduled. Pain is NEVER normal. If pain begins to affect ‘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?
What type of Anesthesia is used?
There are many different types of anesthesia that can be used for foot and ankle surgery. In minimally invasive foot and ankle surgery, ‘fast-acting’ local anesthetic is the most common . This can be combined with a regional nerve block, which numbs the nerves leading to the foot and ankle. This combination provides the best pain relief and allows the surgeon to operate with minimal discomfort. Most foot and ankle surgeries can be performed using local or regional anesthesia
Minimal Incision Based Surgery Eliminates the Need for a Tourniquet
A big benefit of minimally invasive foot surgery is that it eliminates the need for a tourniquet to obtain a blood-free working area. In traditional open incision surgery, a tourniquet is often used to control bleeding and improve visibility. However, in minimally invasive surgery, bleeding actually 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 risks of developing a blot clot. As a result, minimally invasive surgery provides superior outcomes with less risk and less tissue trauma.
Minimally invasive Percutaneous Techniques Are Not New
Current trends in modern orthopedic and general surgery favors the use of MIS. MIS resolves and reduces some of the problems associated with open surgery. It decreases complications, and improves and shortens the postoperative recovery period.
Minimally Invasive techniques for the foot were pioneered in 1945 by Morton Polokoff. This was for small incisions of the nail root for treatment of ingrown toenails. Later, these indications were broadened for removal of bone prominenceswith Foot surgeons adopted 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 developed specifically for surgical use.
Specialized instrumentation in MIS may consist of:
- small blades
- 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 type of 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 reduces the chance of injury during a minimally invasive surgery.
Surgeon use a bur for removing bone surfaces, shaving and re-aligning as well as for cutting bones. Bones are partially cut as in a ‘greenstick’ type fracture to rotate, elevate or achieve better angular position. It is done completely through-and through as an osteotomy to change the position. Surgeons use different types of 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 by using a slow, gentle and sweeping joystick-type motion while operating. Rather than sawing with a blade as in open procedures. This allows the surgeon to maintain complete control over the movements of the instruments. Helping to prevent any accidental damage. Additionally, it is important 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
Fluoroscopy is an imaging tool that makes a real-time video of the movements inside a part of the body. X-rays pass through the body over a period of time. X-rays are a form of ionizing radiation. Fluoroscopy is commonly used in MIS to guide surgeons during minimally invasive procedures .
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 systems. 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 who are concerned about the risks of radiation exposure.
It typically takes 2-3 days for the skin portals 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 postoperative healing course. Pain can be expected for several days which is significantly less than open procedures where there is more dissection. Pain can often be treated with:
- non-steroidal anti-inflammatory medications such as Advil, Aleve or Ibuprofen
There will typically be a period of immobilization in either a rigid shoe or boot, the length of time depending on the procedure(s) performed. It may take bone 4-6 weeks to heal with immobilization whereas soft tissue may require only several weeks immobilization. External dressing is important initially and subsequently in the manner of a strapping to splint the foot or toes. Dress it in the desired position for healing of the soft tissues and bones. Additionally, stretching may be instructed early on in the post-operative course. Office imaging is used to assess bone healing when a bone cut or osteotomy has been made.
There are pros and cons to both 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. Some patients may benefit more from an open procedure–such as athletic patients.
Athletes may need fixation or permanent hardware to return completely to athletic activities.
Ultimately, the best type of surgery for each patient depends on the individual situation. Any surgery, including MIS, should be discussed with a doctor before making any decisions.