Good morning, I'm Dr. Errol Bailey from Resurgence Orthopedics in Atlanta, Georgia, trained at Massachusetts General Hospital and Foot and Ankle Fellowship in Hospital Suppressor Surgery with the late, great William Hamilton, who I owe everything to. I want to thank you for coming this morning. It's a little bit of an odd time slot, but we want to close this thing down in a really great way. We're going to talk about something that's different in MIS. We're going to actually stay away from bunions today and talk about all of the other wonderful things that you can do with burrs or small saws in the foot and ankle. So we're going to start with our first talk by Dr. Rosalind Miller, who comes to us from the UK. She's done extensive work in minimally invasive surgery and diabetics and Charcot foot reconstruction, and her talk is when small incisions actually matter, MIS for Charcot. So good morning, everyone, and I understand this is the closer session. And whilst MIS for chialectomy did not convince all of you to start doing minimally invasive surgery, hopefully by the end of this talk, you might see that this is the home run as far as where MIS really comes into its own. So why should you be interested in MIS at all, actually? And probably it's because of this statistic and this population group. So the World Health Organization has recently revised its figures, and when I first started doing MIS for Charcot nearly 10 years ago now, it was predicted at that stage that there would be somewhere in the region of around about 500 million people globally that would have diabetes. And that figure has now gone up within 10 years to 700 million by 2040 will have diabetes globally. And so it affects all of us because it affects our practice, regardless of whether you actively seek out diabetic patients or not. And we talk about diabetic foot disease, but as far as I can see, this really is the cancer of orthopedics when you look at our death rates that are associated with it. I've said this many times before, but the combined five-year risk, the five-year risk of death is higher than the combined risk of prostate and breast cancer if you have a diabetic foot ulcer that recurs. So it is a problem and it's getting worse. Charcot neuroarthropathy, it's either neurovascular or neurotraumatic, but ultimately the problem is that these patients have lost their feedback mechanism, so they don't know that they've had an incident to the foot and that they're potentially at risk of developing a diabetic foot ulcer. On the one hand, you have increased blood flow, osteoclastic activity, inflammatory molecules. On the other hand, you have decreased bone density and osteoblastic activity, so the bone is not normal. And the most common deformity that they get with Charcot is the mid-foot rocker bottom. And we all know how this presents with a swollen hot red foot that tends to be painless. So there are a group of patients that can present with pain. But often the first time the patient may come into your office is because the fact that they feel that their foot is swollen, the shoe doesn't fit. They have normal bounding pulses in the majority of them, because this is not usually the vascular group. So it's not the vascular surgeons that tend to see these patients. We all know the different classifications that they are, broad-scale type 1, 2, and 3, concentrating on where the deformity happens. And we all know what is the standard treatment for these patients. It's total contact casting to redistribute the pressures so that you alleviate the pressure on the skin and the ulcer will heal. But the problem with the total contact casting and conservative treatment is that unless you've changed the biomechanics and the actual architecture of the foot, that ulcer will recur. And our treatment goals are still the same as they have always been, to take a chronically deformed, unstable foot. And in that situation, that foot requires surgical reconstruction, because anything short of that, it's just going to lead to re-deformation and re-ulceration. And what we're trying to achieve is not necessarily a normal foot, but a braceable foot, a foot that will go into a shoe that it's not going to re-ulcerate. And so for me, midfoot charcoal is all about mechanical overload. And the surgical techniques that we've used have evolved over the last 10 to 15 years, and we're now very familiar with the idea of the super construct. So this is where you essentially span the deformity and correct the deformity using beams and bolts, and it can be very effective. But these often utilize big, large incisions. And for me as a surgeon, that was just causing too much anxiety in the middle of the night, wondering what these wounds were going to be like the next day. It puts a lot of tension in the skin, you get a lot of swelling afterwards, and you're just never 100% sure whether or not this wound's actually going to close. So when I started doing MIS, and it was for chiolectomies, it was for bunions, it then suddenly became very clear to me, I have this big diabetic population, maybe I should start doing it for something that would make a bigger difference. But it's using exactly the same instrumentation. So it's percutaneous instrumentation, a Shannon cutting burr, and a wedge milling burr. And the burr machine is low speed, high torque. So this isn't big, fancy equipment that you need. The setup's almost exactly the same. And for most of my diabetic patients, I'm still doing these as day case procedures. My anaesthetist likes to be able to give them a day case spinal, because that means things are far less problematic for them at the top end, because a lot of these patients have multiple comorbidities. And if you're going to start anywhere with MIS for the diabetic foot, then start really simply with a percutaneous Achilles tendon lengthening and an exostectomy just to flatten off the base of that foot. You do need to be slightly careful when you do the exostectomy, because you can sometimes destabilize the foot a wee bit more if there's a lot of ligamentous involvement. But the thing for me, and the thing that revolutionized my practice, was the rapidity with which these wounds healed. And typically, within six weeks, you will get an ulcer to heal with the minimally invasive technique. And critically, once they're healed, they stay healed. So essentially, the technique is a triplane closing wedge osteotomy. I use fluoroscopy throughout. I use guide wires so that I can essentially close down the wedge once I've taken across the, first of all, starting with the Shannon Burr to cut the whole way across the foot. If you don't do that, you find that you get a hinge on the lateral side, and it can make reduction a wee bit more tricky. And then you use the milling wedge burr to basically create that wedge and make it into a bone piece, which you can squeeze out through the percutaneous stab incisions. And similarly, with any fixation, thinking about midfoot pathology, the second TMT joint is the keystone. And this is the one that you do need to concentrate on first to make sure that you're going to get any sort of sound reduction. And essentially, what you're doing is breaking the foot in half, making it mobile so that you can then reposition it and hold it with percutaneous fixation. When I started, it was with screws because that was all that I had available in my practice at that time. And for many patients, actually, this was sufficient for them. And it was a triplanar correction which managed to realign the foot. And this patient, the only thing I had to actually go back and do was to release his extensor hallus, his longus tendon, because his toe was still cocked up down the line. But the bit that then started to surprise me, and I have to say I was just looking to get the foot plantigrade, was it wasn't that it was just plantigrade. It was the fact that I was able to now start to recreate the medial arch. So then over the years, I started to look at the different types of fixation. Beams and bolts are probably my go-to standard at the moment. But I have also incorporated the MIPO technique, which you can do with this technique because you have taken essentially all that redundant skin and made a lovely skin pocket that you can slide hardware down. And it's a bit fiddly. It takes a wee bit of time to learn how to do the technique, but ultimately, it's definitely much more doable. And critically, you feel less stressed about the end of the operation because you know that that skin's not under any tension. You can also use MIS for going further up the foot and for doing intramedullary nailing. You can do it either in isolation with an MIS burr, or you can do it with arthroscopy as a coupling technique so that you can debride the bone. But critically, again, you're not disrupting all of that skin. And again, you can get fairly substantial deformity correction and better positioning of the foot alignment. And then why not combine it with internal and external fixation, and both have been done. The only thing that I don't do is a circular frame, and that's for practical reasons within our facility. But I do have colleagues nearby who do do a lot of framework, and I think MIS as a tool lends itself very nicely to intramedullary fixation and circular framing. So what else can you do to try and get these bones to heal? Now, I'm not looking necessarily for a solid fixation, but fibrous nonunion is acceptable in these patients. But certainly, the addition of biologics does make the bone much harder and the construct more rigid. But the thing that then changed for me is really this question about timing. We very much have always been taught that you need to wait until the charcoal is burnt out. That can take anywhere between 18 months and two years. Now, 18 months and two years, or two years for this group of patients, is a lifetime of misery. The incidence of depression is extremely high in diabetic patients. And we've all seen this group of x-rays where you kind of see that the foot is starting to drift, and you just know where it's going to end up. And so for me, the question is, if these techniques are more straightforward, give less risk of infection, then why are we not intervening slightly early to try and prevent the big deformity that's then much harder for us to correct? So this is a patient that, she was a very well-informed patient. She had her own thermometer and measured her temperatures, and we got her fixed and stabilized. And then she came back to me 18 months later and said, you know, my temperature's gone up in the lateral side of my foot. And sure enough, her cuboid had started to show signs of charcoal. And pain can happen afterwards. I have had some patients that once we've corrected their foot deformity, ironically, they actually come back and they've had some pain afterwards. This lady had got a lovely correction, and on the other side, I'd done the MIPO technique. And for her, the pain was because actually her foot was now too rigid. And so we took out the plate on the other side, and that gave her just a jog of movement, and her pain subsided. Fixation failure can happen. It tends to happen at the tips of the bolts, and it can happen in the midpoint, at the apex of the deformity with the bolts. But again, do you have to do anything about it? I don't often go chasing this if there's not a major issue for the patients. And if there is a problem whereby you get a bit of infection, you can take out the screws and the deformity remains corrected. Infection I've had a couple of cases of that, but for me, the thing that was most interesting was that when I took out the beams and bolts and irrigated with antibiotics, the deformity remained corrected, and they didn't have a recurrence of their deformity. So you might not want to do MIS for your coelectomies, but I would actually implore you to at least try thinking about doing it for your diabetic population. And if this isn't the home run of MIS, then I'm not quite sure what is. Thank you. Thank you, Ross. I failed to mention my co-moderator. That's on me. We have with us Gregory Guyton, who is a leader and innovator in MIS foot and ankle, well known for all of his calcaneal osteotomy work and establishing anatomic safe zones for where to put our saws and burrs when we're doing these minimal incision calcaneal osteotomies, and also has done extensive work in minimally invasive lapidus procedures. So welcome. Our next talk is by Victor Dubois-Ferriere. I practiced that about a hundred times listening to Rosalind's talk to make sure I could get that right. He's from Geneva University and also did fellowship work here in Canada at McGill, and he's going to talk to you about incisions are small, but non-unions are just as big, and believe me, we do. Hello everybody. Thanks to be here this morning. Thanks for the introduction and for the good French you speak for my name. So my name is Victor Dubois-Ferriere and I come from Geneva, Switzerland and I have to thank the AOFAS to inviting me here today. It's an absolute honor. So the topic I have to present is about mini-invasive surgery. It is a field I'm doing for more than six, seven years. First in the University Hospital of Geneva as a head of foot and ankle unit and now in my private practice. Here are my disclosures. So over the last 20 years foot and ankle surgery has evolved tremendously with the evolution of surgical procedures, development of adapted instrumentation and growing of minimal invasive surgery. MIS has gained popularity in all field of orthopedic and trauma surgery. It is one of today's main trending topics in foot and ankle surgery and in the last 20 years it has been growing in popularity due to its reported advantages and to the improvement of surgical procedure and instrumentation. MIS is just not about bunion. It includes percutaneous surgery mostly used for osteotomies like calcaneus osteomy, bunion, lesser toes. We can also use it with computer-assisted surgery which allows us to do mini-invasive procedures and of course arthroscopic and endoscopic techniques. Theoretical and potential advantages of MIS are reduced surgical time, decreased recovery and rehab times, less soft tissue stripping, less pain and decreased complication versus open techniques. So what does the literature says? During the last decades a growing number of comparative studies between MIS and open procedure have been published. MIS showed a tendency to offer better clinical outcome but we still need an higher level of evidence and what is really lacking is discussions about complications. They are very scarce. That's why it's really difficult to answer to this question. Are complications different? Are they just as big or not? So let's go through some cases to try to find to answer to this question. Here is a 46 male having pseudo gout of the ankle. He presented persistent pain and failure of conservative treatment. At the end we decided to perform a fusion, an arthroscopic fusion. This is the post-op x-rays and at six months he presented with pain, persistent pain, swelling, weight-bearing, possible mild equinus and so we did a CT scan which confirmed an union with a malposition. So we went to open revision with bone graft and we can see now a successful fusion with less pain, better alignment. So in arthroscopic and endoscopic surgery complications are not so different as in open approach, probably just as big. The main difference is that arthroscopic approaches will preserve soft tissue envelope and should be easier to solve. I couldn't find any study confirming this hypothesis comparing the outcome of treating arthroscopic or endoscopic complication versus open complication but this is my personal opinion. So if I have to choose between treating an arthroscopic complication versus an open one, I would definitely choose the arthroscopic one. Another problem we can have with MIS is that there are just not the same complication could be unexpected. Like in this patient presenting a nocerectal lesion of distal tibia and where we decide to perform a computer-assisted navigated drilling with an arthroscopic control, here is what we discover one week later, a cutaneous necrosis. In fact, the skin was burned during the installation of the navigation tracker and the problem did go pretty deep as you can see on the MRI. Finally, unfortunately, he complete healing. We obtained a complete healing after two months of wound care and close follow-up. That was difficult for the patient. This is the type of complication that are just different and this is only due to the specific setup that some MIS procedure requires. We have to learn from them and to know that they could occur. Sometimes complications can be just big. Here we can find a 49 year old lady with a severe Alex valgus metatarsal jaw of the second and third metatarsal. The patient had the first surgery with an open chevron, percutaneous DMMO and something to the fifth. Sadly, she had a poor surgical selection, a poor surgical technique which led to an early recurrence. So, the surgeon went for a second surgery and performed a scarf, redo DMMO and fifth percutaneous osteotomy. And guess what? The nightmare continued. So, again, early recurrence and an union of second, third and fourth metatarsal. So, finally, she was referred to us and we decided to do an MTP fusion and revision of lesser MTP joint. Unfortunately, she recovered with a stable first ray and a physiological weight-bearing pattern under the foot. In percutaneous surgery, complications are not only just as big, but they can be more important and difficult to treat. They represent a new challenge and can be difficult to solve. Unfixed osteotomies can lead to complex malunion and non-unions, but correcting the biomechanical problem at its origin would be the key. So, there is a way to decrease them. I think it is really important to have proper surgical technique that requires participating in cadaver course, doing fellowship and having a mentor during the learning curve. It is also really important to improve reproducibility of procedures, in example, by using specific jigs. And finally, we have to know the limits of these techniques. Complications are unfortunately part of our daily work. We spend a lot of mental energy to try to manage them and solve them. Even when solved, complications will influence negatively patient experience. As we can see in this retrospective review of 171 patients who had foot and ankle surgery, they reported 11% of post-operative complications. And they look at the patient's willingness to recommend surgery or willingness to repeat surgery, and the overall satisfaction with surgery and complications, and in particular infection and re-operation, were associated with lower fulfillment of patient expectation. And this is true despite resolution and recovery from initial surgery and complication. So, this enlightens the importance of preparing the patient for an eventual complication. And this is whatever approach you will choose, MIS or open. So, MIS has evolved as an alternative to traditional procedures, but complications remain challenging. We must ensure that these procedures are performed safely and effectively with predictable clinical outcomes. There is a need to undergo specific training, and mentorship during learning curve is essential to avoid critical complications. And even with small incisions, complications are just as big. Thank you for your attention. Thank you, Victor. We're going to move right along so that hopefully we can have a few questions at the end. Next is Christopher Miller, who's orthopedically Yale-trained and also did fellowship work in Boston at the Brigham and Women's Hospital, and is currently at the Beth Israel Hospital where he's chief of foot and ankle in Boston. He's going to be talking to you about Achilles tendinopathy. There's some really exciting things happening here, and I think we're going to push the needle forward with minimally invasive surgery. Hi, thank you, and thanks for having me. So, I'm going to focus on insertional Achilles tendonitis here, and sort of focus on some case examples and then talk. So, open versus MIS, and I love what Dr. Miller was saying here about MIS being a tool. We don't have to give up our open surgeries if you don't want to. I think a lot of us have gone as much as we can to MIS, but as with anything, you can still always fall back on what you're comfortable, what you're used to. We know that an open Hagglund's has great outcomes, very effective, and you can see and address the pathology. So, this is certainly how I learned to do it, and so the question is, if you're comfortable, why make a change? And for me, despite having, fortunately these aren't my patients, I took it from a paper, but I've had patients with serious wound heal complications, and I think we've all seen similar patients to this, and when you have this after an insertional Achilles, you just feel horrible for the patient, and it gets very complicated to handle. So, if I can, you know, find something that will let me avoid some of the wound healing problems in a fairly tenuous part of the body, relatively bad blood supply, but still allow me to do the surgery and have something that's reliable, that's what I'm most attracted to about the MIS options. And so, we've seen the wound healing problems, you can have, you know, several nerve injuries. Patients will complain of stiffness of the scar in my practice. Maybe it's just a Boston thing, but I doubt it. So, what else can we do? I'm going to talk about two options here. So, we have sort of an endoscopic Hagglund's, with or without an Achilles repair, and then this Zetac osteotomy, and I think these are two of the tools that I think we should be thinking more about using on a more regular basis. So, I said I don't, I haven't given up open surgery. Somebody like this coming in is going to still get an open approach in my hands. I know that there are some people who will still try to do this MIS, but I still think that no matter what we do, there's going to be a role for open surgery. So, this is for somebody with severe tendinopathy and a large insertional spur that maybe can't access with the scope and the burr completely. But, so this is my first case. This was a 60-year-old with diabetes. Pretty typical presentation and farewell conservative treatment was having pain at the Hagglund's and at the spur. And so, I talked to him about his various options. I wasn't doing Zetac at this time, so I really just talked about the open and endoscopic options. And with his diabetes, I decided I would give a try with the endoscopic approach. And so, what I like about the Hagglund's reconstruction is that with the endoscopic approaches, we're trying to do the same surgery. And so, if you're looking to consider switching, this, for a lot of patients, well, a lot of surgeons, sort of resonates because you know what you're getting with your open, and so you're trying to reproduce that, but with a less smaller incision. And what I've noticed is that I stopped having wound issues and had significantly less pain. You're just trying to recreate the same kind of contour that you would with an open procedure. So, how do I do this? I mark where the pain is preoperatively. I make four portals around the center of the posterior tuberosity there, and I then plan out my debridement. I use my wedge burr to come in, using those portals to access, and then I, as I debride the Hagglund's and then come down, rotate my hand to get down to the spur, I'm actually elevating the tendon footprint as well and creating a working space. So, I start off with the burr, make my space, do my bony resection, and then I'll put the scope in at that point. So, I'll put the scope in, and I'll shave, and I'll remove all of the bone slurry that's in there. At the same time, if there's some anterior tendinopathy in the tendon, I can use the shaver, press the tendon down onto it, and remove that and resect the tendinopathy as well. And then, using those same portals, I'll put in my double row repair. And then, so this is the technique here, and I'm placing the anchors, tapping them through the portal sites, and passing the sutures percutaneously with a suture passer of some kind. And again, trying to recreate that same X pattern with the double row repair. And this is what it looked like. I also did an endoscopic straighter on this patient, and then they end up being very pleased. But here's a slightly different one. So, this was a younger patient, very healthy, runner, and was having pain just anterior to the tendon, wasn't able to get back to his sport. We have an MRI here showing the retrocalcaneal bursitis, some edema in the posterior tuberosity there, and really focally tender at the bone, and just anterior. And so, for this one, especially with the very minimal tendinopathy, I elected to just do a endoscopic resection. And so, for the fellows out there, I can remove everything that I marked with blue, and not disrupt the Achilles footprint whatsoever. And so, I mark it with a K-wire, and this way I can let my residents and fellows remove all of that and not get into the Achilles insertion site. I come in from the side. I'm right-handed, so I'll come either medial or lateral, depending on which side we're on, using the wedge bur, and resect down to the wire. And then I make a small trans-tendinous insertion, and I just do a little sort of windshield wiping to clean up and smooth out the contours. And then, endoscopy, same thing, remove all the slurry and resect that sort of inflamed bursa in the retro, in the, just anterior to the calcaneus. But, in this case, because I haven't actually removed or elevated any of the tendon, I don't have to do anything else, which lets me rehab them quite quickly. I let them weight-bear right away, and we start PT as soon as the wounds have healed. So, the advantages, only worrying about the soft tissue healing, I'm not disrupting the tendon. If you're not instrumenting, you can actually do the supine, which makes your anesthesiologist very happy and facilitates just the flow of the day. But, if there is significant tendinopathy, or if you're worried about that insertional spur, and you have to elevate a large portion of tendon, I do like to repair it in that case, and that's, that would be my personal bias. Although, when we look at some of the studies, and this is a meta-analysis from 2021, most of the cases that they, studies they evaluated in this one, did not actually repair the tendon down, and they still had very good outcomes. And so, the AOFAS scores were, you know, basically equivalent here. But, what we saw with the endoscopic group in this study is that the complications were much lower, and that was a combination of wound healing and nerve issues. And then, again, faster return to ADLs in sport with the endoscopic approach. So, why, if they do well without augmenting it with a repair, why repair at all? And, I would argue that we know that if you do it open, and you repair it down, the double rows at 2 to 3x strength of the repair, and this was done by one of my fellows, Dr. Mikulski here, but he looked biomechanically endoscopic versus open, and showed that the endoscopic, even without repairing it back, had higher load to failure, and probably because you're not disrupting all those investing soft tissues around the site. So, outcomes for this, this was from Dr. Vega in Barcelona, and this is one of the only ones I could find looking at the repair of the tendon as well, but you can see the significant improvements in patient-reported outcomes here. Okay, so, something completely different, and if you're, this is, I think, a really interesting operation that is getting a lot of traction now, but this is the Zedek, and so this is my last case here, but a 55-year-old woman painted the insertion, and this was the first one I did. So, she had already had Hagans on the other side, and hated it, and really wanted something different. I was like, well, this is perfect. I got something very different for you, and so, for the setup for this, I go lateral. I like the large C-arm. I use a calcaneal burr, and this is what we're trying to do here, and you can see we've taken a dorsal closing wedge, and in this case, I placed two screws because I did crack the posterior, sorry, the plantar cortex there, but usually I just place one, and let's see if this works. So, a little distorted, but what I'm showing here, this is my fluoroshots, and I'm marking out my resection, my start point, my screw trajectories here, and I'm clearing the periosteum off the side, and I drill my pilot hole, and I come down. I'm going to sweep, and I'm just going to make a standard cut through the calcaneus, and now I dorsiflex up. You can see it closed down, and what I do is sort of, I'd call it reciprocal planing. I close it down. I put the burr back in, and I just swipe again. I do that about three times, so I resect, you know, hopefully about three widths of the burr, and then I keep it closed, and I can place my screws in there, and these are the incisions for here, and so for this, these patients, they have very little pain, and essentially no wound healing issues yet, but the goal is to take about a centimeter of bone at the top, leaving a bridge at the bottom. It's not a new surgery, so this is described in 1939 by Dr. Zadig, and he describes this. This is a nice paper here, but they describe sort of the mechanics of why this works, and so what the patients that I'm trying to do this for are ones who maybe have a slightly higher calcaneal pitch, have a long calcaneus that's defined by this X to Y ratio, and then the goal, once you do the closure, is you're trying to open up that angle between the Achilles tendon itself and the haggling spur in the back, and at the same time, you elevate the heel, and you end up with getting a lot more ankle dorsiflexion. I think the combination of those mechanical factors are what then leads to the decrease in pain. So, very similar indications in my hands for doing this as doing the endoscopic, and this has become a little bit more of a favorite of mine, and outcomes return to sports. This was done in athletes in Europe. By 21 weeks, they were getting back significant improvements in FFI and VAS scores, and you can see sort of the post-op recovery in terms of improvements in the PROMIS scores, not PROMIS scores, patient report outcome scores noted here. So, this is my post-op protocol, and I let them wait there about two weeks, and this was, for anybody, if you're looking, this is a great review article here by Dr. Syed in 2016, but he lays out kind of a rationale for what to do at which stage, and so for severe, he's still doing open. For more mild, either the resection or... Thank you. Next up, we have Rebecca Serrato from Mercy Hospital in Baltimore, trained with Mark Meyerson as a leader in this field and a superb lecturer, and without further ado, we give you Rebecca. Thank you, Harold. Thank you, Casey and Daniel, for the invitation to speak on the final day at 7 in the morning. Thanks, Casey. So, I'm gonna speak on something like we talked about, not bunions, a little bit different, MIS, and can we use this in our fusion cases. So, I'm gonna kind of go through a little potpourri of some of the cases that I have done this on and maybe give some insight on to maybe some techniques on how to do joint preparation with this. Here's my disclosures, and I do want to highlight I am a consultant for Stryker, specifically in their ProStep MIS line. So, what are our goals for fusion surgery? So, it's like I'm talking to my residents and my fellows again, but first things first, you got to get rid of all of the articular cartilage. As Dr. Younger would say, cartilage is the anti-graft. So, you got to accomplish that. You need to then prepare the bone surface. So, we want to do a perforation, a preparation of that subchondral bone surface, and then at that point, we want to compress and obtain stable fixation. And voila, you can have a fusion, and that'll apply to the ankle, the big toe, wherever you're going. So, I guess the question we've been asking ourselves over the years is, all right, can we obtain these same goals while minimizing soft tissue insult and complications? And I think we've already started to do that, and you can see that in arthroscopic fusions. we've already been speaking on that. Fusions with arthroscopic visualization has been shown in the literature, particularly ankle and subtalar joint, to have excellent results and oftentimes advantages over the open. If you compare arthroscopic ankle fusions to that of open, numerous level three articles comparing both of them have shown less complications, better clinical scores. If you admit them, less hospital stays, less blood loss. And probably one of the other things we've seen is a shorter time to union. And again, meta-analysis looking at all of these articles, both in 2017 and then recently in 2020, again, highlighted all of the advantages of doing an ankle fusion arthroscopically. So why aren't we all doing it? Well, there's challenges to doing this. And any of you guys that have done this, same as myself, it can be a bit time-consuming and frustrating. You know, when you're in there and you're debriding it with the scope, there's very large pieces of articular cartilage, particularly if patients still have some, and that's going to affect your visualization. So you're constantly shaving, the shaver's clogged while you're doing that. You've got your little graspers and pituitaries in there. And this can take a long time. I always would tell my patients, it's almost like building a model ship in a bottle. So this is going to take us longer. But are there techniques, there's ways, are there tools that we can implement to this that will get the advantages of a less invasive joint preparation, but maybe not all of the work that we have to do and the time? And I think this is where the BRRRR and using the percutaneous techniques can help us. And this also is not new. So this was a publication in 2014 where they reported their level for a retrospective study looking at 25 patients that they did percutaneous TTC fusion. And what they used, as you can see, I put in the photos from the article, is they used a large chisel to open it, start the initial debridement, and then they put one of those wedge BRRRRs on a traditional motor handpiece. I'd be a little concerned with that because as we all talk about, you want to use that very special equipment where you have that high torque, low speed so that you're not generating the heat that a BRRRR at a normal speed with normal power can do. But they described that they obtained a bone union up to 86%, which when you compare it to the open literature is similar. And obviously you're looking at fewer wound complications. And then all of us keep coming back to the same foot and ankle clinic. So I definitely, if anybody's interested in starting to read and understand, I think that the 2016 foot and ankle clinics, it was all on minimally invasive foot and ankle surgery. I think it's a really great read. So this was Dr. Bauer and he described percutaneous hindfoot and midfoot fusion. And he walks you through the techniques of his ankle subtalar triple percutaneous fusions, including the portal positions and the use now of the conical BRRRRs that we use, the wedge BRRRRs, and alternating it between rasps and soft tissue MIS rasps and stuff like that. And what he also describes with this is there are some pitfalls. And it's no different than any other new technique, but you've got a BRRRR in a joint with very little visualization. So probably the first thing that new surgeons with this technique can run into is probably inadequate resection. So you didn't do the goals that we talked about in the beginning. Or you can also run into asymmetric resection. So if you aren't careful and you're not aware and learning where you are, you can actually resect too much, particularly, for instance, on the subtalar joint on the lateral side. And he even acknowledged probably one of the more challenging of the joints to prepare and prepare safely and well is the talonevicular joint for its obvious shape. Dr. Zhou and Chris Miller's group just published a cadaveric study just this year in FAI where they walked us through the different joints from the ankle all the way to the IP joint of the hallux, their portal positions, and they did five open debridements and five percutaneous, and then they opened all of these joints up and they looked at the quality and the percentage of joint preparation. How well can we obtain completely debriding all of these joints? And what they found is that there's a similar percentage of joint preparation in all joints except for two. So at the talonevicular joint, the talar head actually had, and at the CC joint, the cuboid, had better joint preparation with the MIS technique than actually with the open technique. So walking you through some examples. So hallux-MTP fusion, we all know why you do it and why it works, but I would say the indication for MIS approach is, again, I'm worried about the skin. I don't want to make that incision and put a plate right underneath it. So here's a patient of mine who, unfortunately, over many years talked multiple providers to provide her lots of cortisone injections. And I don't think many of us would want to be making an incision and putting hardware across this big toe joint. So this patient went in MTP arthrodesis. There's two basic ways you can do it, and you can marry both of these. You're arthroscopic-assisted or just straight percutaneous. And so, real quickly, this is kind of the described portals that you can use, both from the arthroscopic. They're very similar portals for placing your burr. Bauer also described using the portal that we use for dorsal chylectomy, kind of more proximal and dorsal medial to resect the spur as well. Again, as long as you're respecting the anatomy and the danger zones in your nerves, you really have multiple ways to access these joints. For arthroscopic-assisted, surgeons will use either a 1-9 or 2-7 scope. You're going to go in there and do the goals of fusion surgery, get rid of the cartilage, prepare the joint, and usually I'll use for my perforation, to perforate the subchondral plate, I'll use awls, K-wires, chisels, everything to just make it look like nooks and crannies. And then, with the percutaneous, I will have my patient foot over the end of the bed, like I do for all of my four-foot procedure, and this allows me to bring my mini-fluoro out to the bottom of the foot, and it's gonna guide me. Those are my eyes, just like the scope is your eyes. I use a three-millimeter wedge burr, and the soft tissue rasps, and just carefully prepare the joint and remove the cartilage, excrude that bone paste, you can irrigate it. I like to complement all of my percutaneous fusions with, even if it's a dry scope, I want to put my eyes in there and make sure that I've done an adequate debridement and preparation of my joint. And there have been some studies on Hallux MTP fusion. This was a meta-analysis looking at six studies, all level four or five, but two were arthroscopic-assisted and four percutaneous, and what they were able to find with all of these is the clinical outcomes improved and were comparable to open. And the fusion rate was the same, so at least we can say, if you guys are willing to take this, you're certainly not gonna do harm by your patient. But, as we all have been alluding, there's some technical techniques, it's demanding, it's a high learning curve, so you have to commit to this. But I do think that these are benefits. This is a patient who came back eight weeks out from her MTP fusion, and this is that patient I showed you who's six weeks out from the MTP fusion. Very quickly, MIS Lapidus, which has been described. Most recently have had publications looking at outcomes, including comparing open versus MIS Lapidus, seeing fewer non-unions, fewer wound complications. Some of my technical tips for percutaneous, avoid a tourniquet. Well, actually, I don't use a tourniquet for any of my percutaneous surgery, but certainly for this. You wanna minimize that heat that you're generating at the joint when you're debriding it, and also at the skin. You don't need visualization, so it doesn't matter if you have a little bit of bleeding. Distract your joints. So by distracting it, you're gonna be able to introduce that wedge burr, introduce the cutting burr without resecting too much bone, which some of us have, initially, we were most concerned with. And you can distract each joint. This is an example of a hinterman that I'm using to distract at the second TMT joint, or distraction. This is non-invasive at the HALX MTP joint. Use fluoro, use it a lot. We talk about that when you're learning how to do bunions or lesser toes. This is your eyes if you're not using a scope. So constantly using that to just make sure that you're in an accurate position for where your burr is at that joint. And again, like I had mentioned, use a scope, whether you're using it wet or dry, so that you can assess how adequate you've got this joint prepared before you start throwing your fixation. And with this comes evolution. Technology starts to complement what we're looking for and what we're asking for. There are now cartilage removal burrs. So you can remove the cartilage, and these are designed with less aggressive flutes, so you actually can remove the cartilage without the burrs taking too aggressively the bone down. And so our concerns before, where we might be losing too much of a bone when we're doing this, these can kind of protect you as a surgeon with that. And they can be used, there's all kinds of shapes and sizes, so you can use that for whatever joint you need, the smaller ones, tail and avicular joint. And also, some of these come with dedicated saline infusion cannulas. So you're actually irrigating within the joint at the time that you're performing it. So again, you've got some newer tools to help you do this safer. So this is an example from Dr. Steinlauf, where he did an arthroscopic ankle fusion. And I talked about the frustration before about the cartilage getting in the way, and you can put these cartilage removal burrs in, and it does a very efficient and safe job removing this cartilage. And then he just used one of the others to sit there and walk around the joint to perforate it. So again, using your principles and update your techniques. As I alluded, there's risks of this. Well, there's risks of any surgery. And I think a lot of this has to do with skill, training, and technique. So incomplete joint preparation, and that's on you to make sure that you've either looked in there or you have your comfort level to know that you've prepared that joint well. Asymmetric joint preparation. In the ankle, probably more likely anteriorly. Subtalar, it's gonna be lateral, so you could potentially put that hind foot in valgus. At the CC joint, again, it's lateral, so you may give an abduction deformity at the transverse carceral joints. Excessive bone resection. Again, consider using a Hintermann distractor or any other technique that you're using. Heat generation. Again, principles of Burke, keep it low speed. But there are serious advantages to this. You're limiting your soft tissue stripping. Obviously, we'll have reduced wound complications, as we've seen with the arthroscopic ankle fusion, faster time to union. And once you're comfortable, good, and you've been performing this for a while, it's certainly a much quicker surgery. So we've talked about the evolution approaches that we go from open, minimally invasive, arthroscopic, now percutaneous. Long ago, we used to make saw cuts, flat cuts for our fusions. We don't do that. We maintain anatomy. So now with cartilage removal, we've evolved, as you can see, from not even just our cutting wedge burrs, but these cartilage removal burrs. Thank you. Last we have Emilio Wagner who's going to talk about lesser toes and hopefully we have about five minutes for Dr. Guyton to sum up and give his thoughts if we have time left. Thank you so much. It's an honor to be here. So I have nothing to disclose relative to this presentation. So we have to agree that lesser toe deformities is the most difficult pathology to address in foot and ankle literature. I think that's true. It's painful to try to treat this. So we should stop talking about mallet, claw, or hammer toes. We should analyze every toe position, the joint, how it is deformed, and its stiffness, if it is flexible or not. And the classic method to see how stiff a joint is, is, for example, for the MTP, to push with your hand under the MTP heads. Or if you cannot straighten out the toe, that is not a flexible deformity. So I was trained to do open surgery. And we were doing, for flexible MTP extension deformities, some dorsal release. We were adding gear stone tailor transfers. Or we did also modified while, like a mass area type osteotomy, when it was more rigid. Now, in these cases, we had a lot of complications. We even reported this in 2019. We got up to 57% of floating toe deformities, although it was not a functional problem. It was a cosmetic problem. Regarding PAP flexion deformities, we did gear stone tailor again. And if it is really rigid or rigid, we would add or do a debris arthroplasty. So we all know that gear stone tailor transfer is a very good one. But it leaves the toes stiff. And finally, regarding MTP instability, lately we were doing plantar plate repairs. And for the varus valgus of the toe, we would be doing some capsular reefing or some soft tissue tensioning. And you could even play with a while. If you move it medial or lateral, you could address the valgus or varus deviation of the toe. Now, what do we still do open? For me, the DAP joint flexion deformity of the toes is very easy and fast to do it open. And it's very fast and easy. And I think it's very reliable. And regarding MTP instability, when you have a dorsally dislocated toe of the MTP joint, I think in that case, we should still go open and do a while to be able to reduce the toe. If it is a very low physical demand patient, you could compensate the deformity with MIS, although the toe will remain dislocated. So what do we do now with MIS? You can do almost everything in a closed fashion. Obviously, we need longer term follow-up studies for this specific issue. So tenotomies, they are done as usual. You've heard already how we do osteotomies. They can be complete or incomplete. You know all of you how to do flexor or extensor tenotomies. I wanted to share with you just some more small videos. If you do a partial osteotomy, for example, to get the toe down, if you have an MTP extension, flexible, or if you have a PAP joint, flexion deformity, from the bottom, you can do a limited osteotomy of the plantar aspect of the proximal phalanx, and you leave a dorsal hinge, and then you get a nice plantar flexion of the toe, and you get rid of these flexible deformities. For example, if you want to take care of varus or valgus deviation of the toes, just one plane of the deformity is very easy. You just perform, again, an incomplete osteotomy, going, again, from the plantar aspect is the most easy way for me, and then you just crank the toe against the deformity. So these are very useful and easy operations. So as I was saying, these are x-rays of a clinical example of a patient with a PAP joint deformity, flexible. So in the upper images, we're performing this incomplete plantar osteotomy of P1, and you can perform a plantar flexion movement of the toe, and that resolves these flexible deformities. If you have more than one plane of the deformity, so let's see this case, you will have a valgus deviation of the toe besides a small elevation. You can see here in the lateral x-ray, I'm drawing how the toe was really deformed with valgus and hammer toe deformity. So in these cases, as you can see there in the x-ray, you do a two-plane deformity, so we have a complete osteotomy done MIS, and you can get a very nice, good-looking foot at the end of the operation, just with MIS on the toes. So if the PAP joint is more rigid, if it is semi-rigid, or besides doing a plantar flexion osteotomy of that toe, you could add a dorsal condylectomy, so I'm drawing the contour of the toe, and that gives you a nice cosmetic result You are compensating the deformity, you're not correcting it completely, but you get a very satisfying cosmetic result, and also a functional one. So if the PAP joint is rigid, we still perform arthrodesis, but in an MIS way, and we prefer to use screws at this time. Frequently, if the PAP is rigid, you need to add a plantar flexion component of this correction. So I'm going to show you this case, that's the clinical picture and the x-ray. So we would do a PAP fusion with a very short MIS bur, so just prepare the joint and then you wash it, and then you use cannulated screws from the tip, so you leave these screws holding proximal phalanx to the intermediate phalanx, so you get rid of the PAP joint flexion deformity, and then in an MIS fashion, you go plantarly, and you perform an osteotomy on that proximal phalanx, just proximal to the tip of the screw. So you have, on the left, the pre-op, and on the right, one year post-op, a very nice looking foot, and a very well-satisfied patient. And that's how the x-rays look. And regarding the toes, you saw how deformed they were, and you can see following the direction of the screws that we got rid of the deformity. Regarding the MTP joint, we still do extensor tenotomies, but if it is semi-rigid, we would add a P1 plantar flexion osteotomy, so a partial one, as I just showed you, and if it is associated with metatarsalgia, which is not the topic of this presentation, we would add an MIS distal metatarsal osteotomy. So for the various values of the toe, I think this is a very nice indication to go MIS. It will depend how many planes of correction you wanna do, you want to correct. So in this case, we're just correcting one plane, I'm marking there in the slide, which is the wedge I created with my MIS burr, and then with bandages, you hold the toe in the corrected position, and this heals nicely. You have to keep the toes in the corrected position for about four to six weeks. And as I said, if you have more than one plane of deformity, this is somewhat similar to the PAP joint deformity. In this case, you need to do a complete osteotomy of the proximal phalanx, and again, hold the toes with bandages for four to six weeks and you get very nice corrections. So in summary, I think MIS approach, it allows more motion to the toe, and I've seen that in my patients. If you avoid soft tissue procedures like the GT transfer, we're compensating the deformity rather than correcting the toe back to its original position. I was not convinced at the beginning, as I said, I was trained to do everything open, but this really achieves similar and very satisfying functional results. And it's less aggressive, so you will get less soft tissue complications. real potpourri and a run across all of the, many of the possibilities, not all of the possibilities that we can do MIS. I think we can take just a couple of minutes for questions. So if anybody has questions, please come up to the microphones and as people move or if they move, I will start off briefly and just throw a question out. Chris, I'll ask a question of you. So I do endoscopic work on the Achilles much like you do. I also started off the way that some of our sports colleagues doing, which is just trying to get a scope in there without using the Burr first. And I would ask you is number one, is that still a viable technique for our sports colleagues that aren't familiar with the Burr? Because I found it very hard and using the Burr to create a working space is an awesome technique. The other question is we have some other people that aren't so thrilled with arthroscopy that just use the Burr. Is that a viable technique? Yeah. So I think I found what you found is that it's hard to do the resection with just the arthroscopic Burr. So I think it is, I would encourage our sports colleagues if they wanna do it, using the Burr in the back on the Haglunds is actually pretty easy. It's of the many of the MIS techniques is not the hardest one to learn. Using the Shannon Burr. Shannon Burr, yep. And so I would encourage them to try it, but if they're getting good results, you don't have to change. And I think this is a tools and option. I was just talking with Dr. Wagner here and he doesn't use the scope very much when he's doing the endoscopic resection or just a MIS resection in that case. As long as you're getting, have a way to get all of the debris out, I think that's totally reasonable. So I think both are good depending on your skillset. I think that's fair. There's a lot of ways to skin the cat. Looks like we have a question over here. My name is Magid from Doha, Qatar. Could I ask, could you do Zadig's osteotomy if you have pain at the insertion of the tendoachelles and the x-ray showed ossification and the patient is tender over this ossification. If you do Zadig's, you don't have to touch the tendon? Is this work? So yes, I've done that. And I think I showed my patient had a fairly large spur. For me, if it's over 50% of the tendon, if it's maybe more than 15 millimeters, that's gonna be where I start thinking about wanting to resect it. But if it's, as long as it's not a very large spur, I will still do the Zadig and my patients have been happy. And I think that's what Dr. Vulcano's study has shown as well. And the pain disappear after you do Zadig's? At the insertion? Yes. All right, well, my apologies. I think we are out of time. It's a little past, so we're gonna have to wrap up. Thanks, everybody, a lovely session.

minimally invasive surgery

foot and ankle conditions

arthroscopic ankle fusions

percutaneous hindfoot and midfoot fusions

MIS Lapidus procedures

MIS correction of lesser toe deformities

advantages of MIS

patient selection

surgical skill