CME OnDemand: Advances in MIS Surgery - Beyond the Bunion-Foot & Ankle Focus: Advances in MIS Surgery

Video Transcription

On behalf of AOFAS, I want to welcome you to tonight's program, Advances in Minimally Invasive Surgery Beyond the Bunion. It will be moderated by Dr. Tyler Gonzalez.  Joining him are Drs. Oliver Schipper, Jonathan Kaplan, Ettore Volcano, and Amitabh Iyer.  You can find their full biographies and disclosures in the program document posted in the chat box and in the AOFAS On Demand Education Center.  To support education programs like this, make a donation to the foundation on our website or by texting GIVE AOFAS to 41444.  I'd like to run through a few housekeeping items before we kick off the presentations. For technical difficulties, please try closing your browser and logging back in the same  way you did the first time. Registered attendees may earn one hour of AMA PRA Category 1 CME credit by completing the evaluation and CME claim form at the end of the webinar.  You can find the link to claim CME in the chat tab, and we will follow up with an email following the conclusion of this broadcast.  The webinar is being recorded and will be available for on-demand viewing on the On Demand Education Center content library in approximately 24 hours.  We encourage you to ask questions during the presentations. To send your question to the faculty, click on the Q&A tab on your navigation bar.  If we cannot get to your question during the live broadcast, the faculty will reach out to you following the broadcast to respond.  Finally, please visit our website to register for upcoming events, including the AOFAS annual meeting for 2023, which is in Kentucky, Louisville, Kentucky.  Tomorrow is the last day to save on registration. I will now turn the program over to Dr. Gonzales to begin. Thank you.  Thank you, Lucas, very much for having us tonight, and thank you to the AOFAS for putting this on. When we were asked to do this session, you know, we were really excited.  The panel here is fantastic. They're not only great colleagues of mine, they're great friends and people who I've  all learned from in minimally invasive foot and ankle surgery, and I think all of us on this panel are very passionate about it and advancing it into all areas of our practice,  and that was why we put together this webinar, really, to show you where MIS is going and beyond the bunion.  We know a lot of people do that, but we use it in all areas of our practice, so I think the goal tonight is to show you guys where we're going with MIS and where we believe  it can go from treating insertional Achilles tendinopathy, ankle arthritis, you know, lesser toe deformities, hallux rigidus, and I think this is a really great opportunity to learn  from some of the best people who have innovated on minimally invasive surgery and really are some of the key advancers in this field.  So I want to just introduce our panel real quick, and then we'll jump right in. We got Dr. Oliver Schipper from Anderson Orthopedic Clinic, Dr. Jonathan Kaplan, now, who's just  recently moved to Duke and is now an associate professor and director of their minimally invasive program in foot and ankle surgery there, Dr. Ettore Volcano, who's the chief  at the Department of Orthopedic Surgery in Mount Sinai at Columbia in Miami Beach, and Dr. Amitabh Iyer, who's the chief of foot and ankle at Johns Hopkins.  So without further ado, you've got a great panel. We're going to start with Dr. Oliver Schipper, who's going to talk about percutaneous zadec  osteotomy for Haggen's deformity and insertional Achilles tendinopathy. Great. I appreciate the introduction there, Tyler.  This is really a great panel, and these are some great topics. You know, outside of minimally invasive bunion surgery, the percutaneous calcaneal dorsal  closing wedge zadec osteotomy has probably had the greatest impact on my practice, and that's what I'll be discussing today. Here are my disclosures relevant to this talk.  So we'll quickly go through the background to the zadec osteotomy. We'll discuss indications.  I'll go through the technique, including a technique video, and then I'll show some cases. So why not open?  Well, you know, we know these patients have an extended recovery, especially if you include a gastrocnemius recession.  It can be very challenging to determine how much time did it take when you're in there. These patients tend to have a long time to return to sport.  Some problems we know are definitely real at the Achilles insertion, and obviously this picture is an extreme example, but again, as you go more plantar into that glabrous  skin, you know, the incision seems to heal slower. These patients tend to have waxing and waning pain and swelling for sometimes six to eight  months after surgery, and it can be kind of a long process for patients to recover from. Patients can have several nerve issues, and there's really not a great revision option.  We can repeat the insertional debridement, possibly use an FHL transfer, but again, there's not a great revision option.  So this technique was actually initially described by Dr. Isidor Zadek back in 1939 as an open technique, and this is a fascinating paper if you're interested.  You can access it online. But this technique's actually been formed open in Europe over the past 10 years, and  some challenges with it have been wound problem and sore nerve issues, as we've seen with open Achilles insertion or reconstruction.  So when we look at the literature, there is, you know, multiple papers on the open technique.  I highlighted this first paper, which had 52 athletes with a minimum three-year follow-up. Again, this was open technique. There were good to excellent results in 96% of patients.  Return to sport was fairly quick at 21 weeks on average. There was one revision for displacement of the osteotomy, and of note, all these patients  did have a concomitant Haglund excision with the Zadek osteotomy. The lower paper here is the first paper published by my colleague, Dr. Balkano, on this panel.  He had a small case series of 26 patients with a minimum six-month follow-up and a mean 12-month follow-up, and again, this was the percutaneous technique.  There was significant improvement in FFI and VAS from pre-op to post-op. There was one revision for nonunion and one patient who did not improve clinically who  also still did not improve with an open secondary reconstruction after. This is our series of 104 patients.  This has just been submitted to JBJS looking at percutaneous Zadek osteotomy for Achilles insertional tendinopathy. Multiple of my co-authors are on this panel.  We have a minimum two-year follow-up and a mean follow-up of almost four years. This study showed significant improvement, again, in FFI and VAS scores with a 98.1%  satisfaction rate. There was a complication rate of 4.1%, which included two screw removals, one nonunion, and one plantar fascia rupture that occurred seven months after surgery.  So again, you can see here with, you know, more kind of short- to medium-term follow-up, again, great outcomes in terms of pain function scores and a low complication rate.  If you've not read it and you're interested in the Zadek-Calcani osteotomy, you have to read this paper by Torn and his team from Europe.  It just really explains the biomechanics and why this technique works. It's so kind of counterintuitive to, you know, us doing a secondary insertional reconstruction open.  But these patients actually have a mean improvement in ankle dorsiflexion of 7.27 degrees from pre-op to post-op.  And so, you know, your first time doing a percutaneous Zadek osteotomy, I recommend you do a silver skull test before and after the procedure, and it's just kind of astonishing  to see how much dorsiflexion they gain. And that's why you don't need to do a gastrocnemius recession with this technique.  Calcaneal pitch decreased from 28.95 degrees to 19.77 degrees, and then the mean XY ratio improved from 2.18 to 2.75.  And this just shows the XY ratio, if you're interested, you can read further in Dr. Torn's paper.  But it's really referring to patients with posterior cavus or high calcaneal pitch as an ideal candidate for this technique.  So in terms of indications, we perform this on any patient with Achilles insertional tendinosis  that can include tagline deformity, calcific metaplasia at the insertion, partial tearing, or retrocalcaneal bursitis.  These patients have typically failed, you know, around four to six months of conservative management. And then based on Torn's paper, they have an XY ratio of less than 2.5.  And again, those are the posterior cavus or high calcaneal pitch patients.  We all perform this technique on patients who have neutral calcaneal pitch or lower calcaneal pitch.  So the objectives of the technique are to remove a one centimeter dorsal wedge of the calcaneal tuberosity.  And ideally, you maintain a plantar cortical bridge of five to eight millimeters. The apex of the osteotomy should be just anterior to the level of the plantar fascial origin.  These patients are set up beanbag lateral, the operative foot is off the bed, resting on the mini CRM with two blue towels underneath.  The contralateral leg is flexed out of the field. You want to use the 10 centimeter calcaneal burr.  And just if you're wondering that the standard burr, the three by 20 is seven centimeters. You want to make sure you ask for the longer 10 centimeter burr.  Depending on the company, it'll be three by 30 millimeters of cutting surface or three by 20 millimeters of cutting surface.  You must use a four in one reducer to reduce heat generation. We typically do this procedure at 6,000 RPMs and then you can use a three millimeter wedge  burr to widen your dorsal wedge as needed. I never use a tourniquet for any MIS procedure and I always use copious irrigation with chilled saline for a bulb syringe.  I don't rely on the little spout on some of the hand pieces. I think it's inadequate to cool the burr. So this is a video showing the technique.  The patient positioned in the lateral decubitus position. We've got the operative leg up and this is best done with a mini C-arm here at Surgery Center.  You can see here we've marked out our wedge on the skin and we'll use that as our guide during the procedure.  You can see at the bottom of the lateral side here, we've marked out the apex of our osteotomy and that'll be our incision.  You can see here that this is the apex of our calcaneal zadec dorsal closing wedge osteotomy. For this procedure, you can see here for this procedure, we use the 3 by 30 millimeter,  10 centimeter long calcaneal burr and you can see this is a much longer burr than the other typical burrs we use.  You can see here that we've now completed the first limb of our zadec osteotomy. We'll now perform a second limb to make the dorsal wedge approximately one centimeter  in length dorsally. You can see here I've now re-angled the burr at the apex in order to make the second limb of my zadec osteotomy.  You can see here there's a small dorsal piece of bone left that we'll remove with a hemostat. This will often come out in pieces.  Alternatively, if you don't want to do this as two separate cuts, you can use a 4 millimeter wedge burr or the 3 by 30 millimeter calcaneal burr to just widen the dorsal wedge.  We've now removed that remaining bone fragment from within the site of the osteotomy. I'm now going to run this on live fluoro so you guys can see this closed down.  It's going to close down with a maximal dorsal flexion of the ankle. There you go. We've now placed the guide wire just inferior to the Achilles insertional ridge across the  osteotomy site to the posterior facet. We've now placed one 7 millimeter headless screw across the osteotomy site. You can see it's nicely closed down with excellent correction.  Alternatively, you can place two screws if you're worried about the plantar hinge, maybe if they're diabetic or if they've got poor bone quality. You can see this is our closure.  We've got one nylon suture here, horizontal mattress for the lateral incision, and then we've got one on the posterior side for the screw insertion.  So a soft dressing will be placed. This patient will be in a short cam boot for the next six weeks. I usually have them sleep in the boot just for the first two weeks.  They'll initiate weight bearing at two weeks, and then they'll discontinue the boot and start physical therapy by six weeks. All right, Tom, wait, I say go.  You can see now we have the knee straight, and if I dorsiflex the ankle, you can see how much range of motion they have. You can see she easily gets past neutral.  That's why gastrocnemius recession is not necessary with this procedure. They actually gain about, on average, around eight degrees after calcaneal ZADAC procedure,  again, without any lengthening of the calf muscle. Thank you again. My name's Oliver Shipper, and again, I appreciate your time.  This is the calcaneal dorsal closing wedge ZADAC osteotomy for Achilles insertional tendinosis, Heiglin deformity, and retrocalcaneal bursitis. Thank you.  All right, so now we'll switch to post-op here. Again, six weeks in a short CAM boot, after I'll hold them off on driving early.  They can start physical therapy, get out of the boot in six weeks, and then they can increase activity, full activity is tolerated, starting at eight weeks post-op.  It's really important, you know, when you first start doing percaneal ZADAC osteotomies,  these patients do have plantar and often lateral heel pain that can last for around six weeks to three months post-op.  I think it's really important to counsel patients on this in terms of guiding expectations,  and in order to reduce plantar heel pain anecdotally, we typically use two 7-0 headless screws with one plantar and one dorsal.  These patients will also receive over-the-counter vitamin D supplementation for three months post-op. So I'll go through a couple of cases here. This is the first one.  You can see there's a Heiglin deformity. There's soft tissue swelling at the Achilles insertion consistent with Achilles insertional  tendinosis, and you can see on the right post-op image, two screws used, nice ZADAC osteotomy  that's healed, and then you can see the Heiglin deformity was easily removed through a small accessory incision.  And again, you know, we don't have literature to say that you have to remove the Heiglin in the short to medium term, but I think for the long term, there may be some value there,  and it's very quick to do. Here's another case. These next two will be some of the worst Achilles insertional disease I've seen, but you can  see significant calcific metaplasia, swelling at the insertion, retrococcal bursitis, and partial tearing.  This is a type 2 diabetic who is 70 years old, and again, she came to her first post-op visit with no Achilles insertional pain.  She did have plantar heel pain for around six weeks, but has since gone on to do great and healed again with a short period of non-weight bearing, and I didn't have to worry about  wound issues with her type 2 diabetes. Here's another patient. Again, severe Achilles insertional tendinosis, partial tearing, retrococcal bursitis, and  calcific metaplasia, and again, this is a patient we did a ZADAC on, two screws, again, went on to do great post-operatively. It's very impressive.  Typically, at two weeks post-op, you'll examine these patients, and the majority of the time, they have minimal or no Achilles insertional pain, which is very impressive.  Again, they will have plantar heel pain, likely related to the apex of the osteotomy being  plantar, just anterior to the plantar fascia origin, which will almost mimic plantar fasciitis.  I believe that's really more bone healing pain, and as I told you, may take up to three months, three and a half months to resolve.  And finally, obviously, there's no perfect procedure for all pathology. You know, this is a patient where there's just significant heterotopic ossification  at the Achilles insertion. This is someone I'm still going to do an open Achilles insertional recon on, so just remember  that, you know, obviously, there's no one procedure that fits all. You know, use your judgment and, you know, use your teaching, but this is still someone I'd do an open recon on.  So in terms of complications, we've discussed most of these already, you know, nonunion, this is really related to the thermal injury from the burr.  It should be exceedingly rare with any calcaneal osteotomy performed percutaneously, but just  as a reminder, if you're in a teaching institution with residents or fellows, you know, they really need to practice before you hand the burr over.  It's just not, you know, intuitive, like using a saw. It's really important that, you know, anyone who's using the burr has had adequate practice  on cadaver or saw bones in a lab before trying to do these procedures. You want to use copious refrigerated irrigation and pause every three to five seconds to clean  the burr flutes and allow the burr to cool in order to prevent nonunion. Plantar fascia rupture, again, we had one patient in our series, you know, that may  have been just related to activity, but nonetheless, it happened seven months postoperatively, so I noted it.  Displacement of the calcaneal osteotomy, this is really related to breach of the plantar hinge. This is why we typically recommend use of two screws.  And then finally, obviously, any calcaneal screw can cause soft tissue irritation, and these screws could be removed, obviously, if a patient develops that.  So in summary, use copious refrigerated irrigation. When you're doing these procedures, pause and clean the flutes every three to five seconds.  You want to maintain a five to eight millimeter plantar cortical bridge. You need to remove about a one centimeter, 10 millimeter dorsal wedge of bone in order  to obtain clinical improvement. The apex should be just anterior to the level of plantar fascia origin.  We recommend using two screws, and for longevity of the outcome, you can excise the haglund deformity through an accessory portal.  But again, at least in the short to medium term, this does not seem to be necessary for clinical effect. So again, I really appreciate everyone's time.  This technique is a great technique and something to consider percutaneously. I think it's made the recovery much easier for patients, and this has really become my  primary treatment for Achilles insertional tendinopathy. That way, I've still got open reconstruction as a bailout in the event a patient doesn't improve with this.  So again, thank you for your time. Oliver, great talk. We have a bunch of questions, as I assume there would be. And so I just want to, I want to get to answer them quickly.  So Oliver, one of the questions was, how do you get at your reduction? You know, people were asking joystick, large pointed clamp, but can you just explain the  reduction maneuver quickly, please? Yeah, absolutely. So you really, again, maximally, and I apologize, it sounds like maybe the audio didn't come  up with the video, but you need to maximally dorsiflex the ankle in order to close down the osteotomy.  And so you're relying on that soft tissue tension from the Achilles insertion for the gastrocnemius.  And if it doesn't close down, then that means you've left too much plantar hinge. So you just go back with the burr and feather that plantar hinge.  Or there may be a small piece of bone, more dorsal obstructing the osteotomy from closing down completely.  Again, you can typically see that on fluoroscopy, but it's maximal dorsiflexion of the ankle to close down the osteotomy. All right.  So another question that was asked, Oliver, I'm going to combine these. And these are common questions we get, guys. So these are great, great questions.  But several of the questions are, is there anyone you won't do it in? Or is it, and you already answered that, right?  It is your primary first go-to for both insertional tendinopathy and Haglund's deformity. And so just, is there anyone you won't do it on?  And then along with that, someone mentioned that you had someone with a very large enthesophy, and they're worried about doing that.  I think all of us are not really worried about that and still do it. So is there anyone you won't do it on, and does the size of the enthesophy concern you? Yeah.  So, I mean, I really differentiate between the enthesophy, right at the insertion. That doesn't bother me so much in terms of choosing ZADAC or open reconstruction.  But if there's significant heterotopic ossification coming up into the distal midsubstance, as  I showed in that last slide, those are patients I'm still going to do an open reconstruction on. Just the amount of diseased tendon is severe, you know, and I'm just not confident.  The reason the ZADAC works is because you're reducing that mechanical irritation on the tendon and detension in the Achilles tendon.  But again, if there's that much heterotopic ossification or calcific metaplasia coming up into the midsubstance, I think you need to do it still open. All right, well.  Tyler, just real quick, I see there's one question here, how are you billing the ZADAC?  It's 28300, which is calcaneal osteotomy, and then if you do a Hagelin excision along with it through a separate incision, you can bill a partial excision of calcaneus, which  is 28120. All right. And real quickly on that, though, you want to add your ICD code, so you don't want to  just say insertional Achilles tendonitis, you want to say Hagelin syndrome and heel spur. The more ICDs you add, the easier it is to attach those secret keys. All right.  So those are, we'll get to, we'll answer some of these other questions through the Q&A,  but we're going to move on to Dr. Ettore Volcano, and Dr. Volcano is going to talk about doing ankle and hindfoot fusions, all MIS.  All right. Can you hear me? Perfect. All right. It's a pleasure to do this with my friends tonight, and thanks to everyone who joined the webinar.  So I will be discussing more about Anqo and Hindfoot fusions this evening. These are my disclosures.  So, you know, our saddle, our communities said that as long as he had a lever and a place to stand he could have lifted the world. Well, I think, with the bird, we can kind of use the same analogy.  The more you use the word, and the more you realize there's so much around the foot and ankle that you can do with it. It's really just a matter of how comfortable you are, and the rest just comes fairly easy.  So, I'm finding myself abandoning more and more open procedures for purely percutaneous, and there's several reasons for that.  Number one, at least in my hands, the speed of surgery. I've noticed that it takes much less time to do the procedures MIS than it is to do it open.  And number two, complications and pain as well as patient satisfaction. These have been published in previous papers and it's been demonstrated that overall post-op pain is less and soft tissue complications are fewer, probably because we're just  doing less soft tissue manipulation, and the bone healing seems to be just as good if not better than open treatment, because we are preserving that vascular,  vascularization of the, of the bone. So let's start with the hind foot.  You know, this is a case of a rigid flat foot in a 70 year old female who obviously had chronic pain, didn't respond to orthotics, bracing, physical therapy and so you know what you do.  The patient's diabetic so you always get all nervous about doing open, larger incisions rather. And so in this case, I went MIS. I prepared all of the, of the joints percutaneous.  The subtalar joint I usually approach through a posterolateral incision, just posterior to the peroneal tendons, you can add a second accessory portal through the sinus tarsae, though I try to avoid it to prevent disruption of the vascularization.  I prepared this using a three by 30 cutting burr, which is the same one that Oliver described for the, for the calcaneus osteotomy.  And then I complete the, the debridement with, with curettes or a bone rasp, and I copiously irrigate using a 60 cc syringe with an 18 gauge blunt needle, it really does a great job to push everything out.  A lot of people say, oh, but how can you take the pieces of cartilage out. The truth is you don't have really pieces of cartilage because the burr is just turning everything into a paste and so you don't need a ranger to take all of that junk out of the joint.  Then we go to the telenovicular joint, and this I approached via two portals, straight medial portal and a dorsolateral portal. I use a two by 12 cutting burr, and the speed is always the same so around 6000 RPMs.  And as Oliver mentioned earlier I never ever use a tourniquet. So the CC joint is pretty intuitive you just go straight lateral.  And as you can see on the right photograph. Those are really the incisions that you end up having.  And so the x rays there were just short, probably I think six, no probably two, two to six weeks after surgery, and the CT scan that I routinely get and all patients three months after surgery demonstrated full healing.  Now I stabilize my fusions with fully threaded non compression screws, with the exception of the subtalar joint.  And the reason is, I believe that fully threaded non compression does provide greater stability than headless compression. And so I just it's just a type of fixation that I trust more but I don't think there's anything wrong with headless compression.  As you move towards the mid foot, you can again, address any joint, the ones I most typically do or the lapidus and TMTs and a little less commonly the navicular cuneiform joints.  So as you can see in this case patient with flat foot alignment and arthritis diffusely in the mid foot. And so in this case, I use the same two by 12 burr.  The lapidus, I performed through a straight medial incision, I don't believe it's necessary to to add a second straight dorsal incision and debris the joint, and I usually you know focus on one bone at a time.  So first I debride the cuneiform then I focus on the metatarsal and I try to remain very consistent. I start dorsal and medial and work my way to lateral and then I start moving plantar.  That way I know that I haven't left out any any parts of the joint.  As far as the second and third TMT joints I essentially go pretty much straight dorsal and use the same technique, and then I perforate the joint by using either the burr or just a two millimeter wire.  And the fixation again is with fully threaded screws because I do allow patients to wait very immediately in a CAM boot after surgery and I just trust the fully threaded screw fixation better.  And this is the x rays of the patient. And in her case I also added a palpanus osteotomy just to correct part of that hind foot balgus.  And these x rays were about eight weeks after surgery so you can actually already start seeing pretty significant bone healing. And these are the two week skin conditions.  So as you can see, very minimal incisions.  So what are the outcomes right I mean all this talk but what are the, what is the data. So, this paper is currently under review in FAI, and on 70 joints TMT joints that are focused on with a minimum of two year follow up.  And in this paper I observed to non unions so that's a 2.8% non union rate which is not too bad in my opinion for those kind of joints, and three complications which were really all related to painful hardware which was then removed.  Interestingly, I did not see any nerve or tendon complication.  ankle and TTC fusions.  So this is really one of the procedures that I enjoy doing the most, not only for the high fusion rate, but because, you know, having having trained with doing these relatively large incisions for ankle or TTC fusions when when you see the same being accomplished  it just feels good. So this patient is 78 year old male with diabetic neuropathy and a foot drop that tripped and fell and got this pretty nasty ankle fracture and so I offered a TTC fusion.  This, the ankle fusion, I do through two portals, and to remedial and lateral just the same way you would do an ankle scope, and I use the three by 30 cutting birth so the same one that I use for the sip Taylor fusion.  The same one you use for the calcaneus osteotomies.  If you have more sclerotic bone so the patient, for instance has arthritis. You might also want to add a three millimeter wedge bird to be a little bit more aggressive and violate that that hard bone.  And then the joint preparation really is the same as for all joints.  The photo on the left hand side is the incisions that I ended up with. There's obviously a smaller incision the poster lateral aspect for the subtalar joint and then the the incisions for the for the rod to go in.  And as you can see at three months, the TTC is fully healed, and no sub tissue complications. In terms of the outcomes we just published on our series on 27 ankle fusions with minimum follow up of two years, we had an 26 out of the 27 healed so that's  with four complications. One was a painful hardware. One obviously was a non union. We had one SPN right is that resolved within three months, and a superficial wound to his sense that also result within a month with without any particular treatment.  So, you know, I think it's time to start bending the need to percutaneous surgery. I know it can appear intimidating to, to, to many people, but the truth is, it, it's actually easier than you would think you have to get started somewhere I think  with an aching osteotomy or calcaneus osteotomy is a good way to get a sense of the tactile feedback that you get from the bird. And then the more you do, the more you realize that you know what I can really apply this to so many other things and once you  start doing it, it's so difficult to go back and you'll just tell yourself why don't I start doing this sooner. Thanks all  great. Great talk. Love it. You've taught me a lot about MIS fusions and your techniques and I think they work really well and really good advice about getting going I think you maintain without that stripping you really get fusion a lot faster.  So a couple questions for you at today. One is when you're doing your ankle prep.  Am I asked to use a distractor, or do you have any tips for getting more posterior in the ankle joint.  Yes. So, no, I never use any kind of distraction, you'll realize that you really don't need it, you and the tighter joints, the minute you go in with the bird.  And you just do a first kind of sweep across the joint that already kind of loosens things up.  So when I'm doing an ankle fusion I usually do add an Achilles tenotomy, just to give me a little bit more, a little less resistance in the ankle. In terms of preparing the joint when it comes to the posterior aspect so the tibia, you can get to very well,  The tail is what I do is I simply just planar flex the, the tail is so planar flex the foot so that the posterior aspect of the Taylor dome is now really in contact with the, with the bird in the joint and so I just sweep all the way across and as I start  from sweeping the posterior aspect of the tail is, I then start dorsiflexing the ankle, and that way I start catching again first the posterior aspect of the dome then the central part of the dome and lastly the interior part of the dome.  That's right, I would just add there too that you know if you're doing ankle fusion for the first time there's no reason not to have the scope right there and then you can just easily pop the scope in and see how you did with your kind of percutaneous joint prep. I think it's a great way to kind of learn how you're doing early on.  I completely agree. So, you know, the very first ones I started, I started doing, I was adding the scope and then I realized that the agreement of the joint was really so pretty good that I stopped doing that.  The reason I didn't suggest the scope in this, in this talk is because I think some people are just not necessarily comfortable doing the scope in the first place. And what I'd rather suggest instead if they're used to doing it open.  Try doing it percutaneous, and then just open and do it, and do it your way. And, you know, see for yourself what you're able to the breed, and what areas maybe you need to work on better in the, in the in the joint for instance, when you do a lap of this,  I think the, the dorsolateral aspect of the joint is the part of the joint that we most commonly don't breed as well. And so I spent a little bit more time in that region of the joint, the same thing with the ankle you might realize that you, you end up always leaving one area of the joint, less the breeded, then, then the rest.  Yeah, I think guys, that's really important. What Dr. Vulcano and Dr. Shipper said, you know, when you're starting this out, either put in the scope, subcalior joint, ankle, even the lesser, you can do it in the MTP joint, or make a small incision and look at your prep, and you'll be surprised at how quickly you'll get good at it and get an adequate prep.  But that if you want to do it, that's the best way to start. And honestly, as Etrae said, you'll get very quick. So it doesn't really take much more time. And then you open and most of your joint is already prepped. So it's really not going to prolong your OR time too much. So great talk, Etrae. We're going to move on. We're going to start with the newly appointed Duke surgeon, Dr. Kaplan, you know, director of MIS surgery. And I actually think this is another area where MIS has really changed.  I know on this panel all our lives, you know, lesser toes are a big problem. We see it all the time. You know, as Bob Anderson used to say, if I could give up forefoot, I'd be a happy man. I think MIS and the lesser toes has changed my practice and my patients. They're happy. And so I think this is one of the really big advances in MIS where we can really provide better care. Take it away, Dr. Kaplan.  Thank you very much, Tyler. Appreciate the kind introduction. So these are my disclosures. I try to refrain too much from bias, but I think like all of us, I do drink the MIS Kool-Aid. So naturally, there's a little bit of all of us to be a little biased towards MIS, but hopefully you'll agree with this by the end of these.  So lesser toes, and they really are the lesser of two evils. I mean, they're still kind of evil, even though they're the lesser of two evils. And it's one of those where I kind of felt like there was a procedure that nobody I ever talked to really enjoyed doing lesser toes. Some people really got into it, but no one really enjoyed it. And now I think with MIS techniques, they're at least a little more enjoyable.  And I'm going to go over the DMMOs, the distal metatarsal metatarsal osteotomies, how to correct hammer toes, whether through osteotomies or soft tissue releases, some varicin vagus correction, bunions, and metatarsus seductus. So why MIS? I think you've heard this over and over again. It's less pain, less stiffness, lower wound complications, better cosmesis, quicker return to activities. And these studies are all primarily for bunions, but the truth is that they apply to lesser toes as well.  So regarding the distal metatarsal metatarsal osteotomy, or the DMMO, my indications can be isolated metatarsalgia, part of my lesser toe deformity algorithm, or bunionettes. A good example might even be like a patient with a cavus foot who comes in with metatarsalgia.  The technique is pretty straightforward. You're either going dorsal medial or dorsal lateral. It is kind of dependent on your hand dominance and which foot you're operating on. You'll use a two by 12 millimeter Shannon burr. You want to angle the osteotomy at 45 degrees to the metatarsal and the sagittal plane, and then finishing perpendicular to long axis to the metatarsal. I was always taught that you must do the second, third, and fourth metatarsal because the inner metatarsal ligament will hold them up.  And by doing all three, it allows them to shorten. But I do think you can get away with an isolated osteotomy or even two. You just have to expect less shortening. No fixation is technically needed, although I have seen some people use candidate screws, but to be honest, these heal really well. And this is an example of a patient who didn't want their bunion corrected, came up with metatarsalgia type pain and pain related lesser toe deformities, went in and did DMMOs and then hammer toe claw toe corrections. I'll talk on that in a second.  But ultimately they heal really well. And this is what it looks like healed.  There are some really good studies looking at this. This study was looking at the first 27 patients. I picked these images because you can really see that 45 degree angle and that sagittal plane.  They showed improvements in their PROs. They showed significant difference in pedobarographs. They did note their learning curve. You have to be cognizant of the angle because if you do the angle of the osteotomy off axis, you can have a malunion or a coccyx deformity or sometimes a nonunion, although I think this happens more often earlier in your practice, mainly just because of heat generation. And then some patients can have some persistent pain.  Moving on, these are a few other good studies. These are my references, but for the sake of time, I just threw them in, but we'll, we'll forego discussing them.  As far as the bunionette goes, you technically could get away with a lateral condylectomy in type one, although it seems to be more and more rare by hands. I'm leaning more towards DMMOs just because of how well they heal and how straightforward they are.  The technique is very similar. Again, you want to angle it. You don't need to do fixation, although I'll show examples of how you can do a cannulated screw if desired. I may use a cannulated screw if I inadvertently make my osteotomy a little bit more vertical than desired, just because I think it helps stabilize it. But again, it's not a necessity. And this is what it looks like as it's healing with good callus formation.  A really good study by Dr. Javier Del Vecchio looking at their patients with this. They had 74 patients. They showed significant improvements in all of their radiographic and clinical outcome parameters. Really good satisfaction, very low complication rates, as you can see here.  As far as the fixation, for those of you who are wondering how you do it, you can do it pretty straightforward. So you'll do your osteotomy as seen here. You want to place your pin. You really need to start more proximal. One thing I'd show you, let's see if I can get the laser pointer working.  Notice how my entry point on the skin is really proximal, because to get into that shaft portion with your pin, you really need to be aware of that. You can put a pin down the middle of the canal. That'll translate the head immediately. That way you don't have to hold it. And then you can advance your pin. Always check it on a lateral. Once you've placed your screw in, then you can shave. However, you really want to be careful here, because if you get too close to that screw, you can cause an iatrogenic fracture. And I'll show you an example of what that looks like. It still heals, but you just want to be aware of it.  Afterwards, once everything's said and done, I'll show you the lateral. You can get really good alignment with that as well. But again, I'm not often using a screw. I'm showing this just an example of how you can do it. And I would think all my co-panelists would agree, these heal really well without a screw. I just show it so that you know you have a bailout option if needed.  This is an example of what can go wrong with this screw. And so this is a patient who had a bunion deformity. It did an osteotomy. This is their first post-op visit.  You can see maybe shaved a little bit too much laterally, maybe got too close to that screw. And on the lateral view, you can see an iatrogenic fracture here.  These still heal really well. When it happens, you wait it out. You don't really have to change your protocol. You just tell the patient that you're gonna watch it.  And oftentimes the screw, if anything, is just a little prominent and symptomatic. And so you can go in and take that out. Moving on to hammer toes.  Most of the time I'm doing a P1 and P2 osteotomy. This is essentially plantar closing wedge osteotomy, the proximal phalanx,  and a dorsal closing wedge osteotomy of the middle phalanx. You don't wanna forget your soft tissue releases, which I'll touch on in a second.  I put here that I'll use a two by eight millimeter Shannon burr, although admittedly I'm trending more towards using a two by 12 millimeter Shannon burr. With the P1 osteotomy,  you have two options for your incision. I like to make my incision plantar and spread the toe flexors with a blunt snap. I feel like this gives me better control of the osteotomy.  The downside is it's a little trickier doing it under floral. You kind of have to mark it out and then move the floral a little bit. You can add a medial or lateral wedge osteotomy  to get biplanar correction. I know other people will go straight medial or straight lateral kind of into that web space. The benefit to this is it's a little easier to get to.  The downside is you just have to be more cognizant of that dorsal apex, because it's a little easier to fracture if you're not paying attention to where you're placing your burr.  Of note with these, you can fix them with a K wire or you can do toe strapping. I was always taught to do toe strapping, although I find myself trending more towards K wires  because I actually think it's less work for the patient. You don't have to worry about the dressing specifically and so on, but I don't think either one's wrong.  Again, you don't want to forget the soft tissues. I'll use a beaver blade. I'll do a dorsal release of the MTP joint under fluoroscopic guidance, a plantar release of the PIP joint,  plus an FDB release. If they have a claw toe, you can add the DIP joint. Also, you can do a percutaneous release of the EDL. In theory, it won't retract and cause a floppy toe  because of the fact that it sits in its sheath, although I personally like to do a little mini open incision, a little Z lengthening.  If needed, I feel like it allows me to dial it in a little bit better, maybe avoid that kind of floppy toe that patients don't always love. This is an example of what it looks like.  So I'll mark out my osteotomy under fluoroscopic guidance. After the bunion's done, I move the lesser toes. Here's where the burr's inside of the osteotomy  to show where I'm going to make that cut. It's hard to see, so I drew a red line there for you so you can see that osteotomy. And then I'll go dorsally right over P2.  Again, check it with my burr, make sure I'm not too proximal or too distal. Some of these are really small bones, and so it's really easy to miss. And then once I've done that,  I usually, again, like to advance the pin. If you're gonna use a pin, you gotta make sure you get down to that subchondral bone so it's less likely to back up.  And this is what it looks like on the lateral.  So for a rigid or really severe deformity, I'll either do an isolated PIP arthrodesis with the soft tissue balancing, or sometimes I'll even add a plantar closing wedge osteotomy  of P1 with the PIP arthrodesis. Otherwise, technique is pretty straightforward, two by eight or two by 12 millimeter shanabur. You can go medial or lateral to the joint,  depending on where you're standing and what hand dominance you have. Again, you can add biplanar closure depending on where you're doing the osteotomy  if you need angulation correction. And again, you can fix it with a K-wire or a screw. I tend to like a K-wire only because if I place a screw, you'd have to go past the DIP joint,  and if it ever has to come out, it's quickly to do. But again, I don't think there's anything wrong with that. Claw toes, I think, are even more straightforward  because you're really just going through the PIP and DIP joints. Again, you don't wanna neglect the soft tissue releases like we talked about.  This is one where I really like to use medullary screws. I like these because they're permanent, they stay in. So in theory, they lower the risk of recurrence.  Also, there's nothing sticking out the tip of the toe and you don't have to worry about dressings. This is a patient who had a calcaneal osteotomy  and post-operatively, or even from the fracture itself, they may have developed claw toes. And so came in and we went in and corrected that.  Various valve-based deformities, real quick. You can correct these by two ways. You can either do Akinets, which I really like to do with a two-by-eight millimeter Shannon-Burr  or a two-by-12 millimeter Shannon-Burr. The nice thing about these is they're pretty straightforward. You're going dorsal, medial, dorsal, lateral, the P1 metadiaphysial base,  and then just doing under fluoroscopic guidance. Here's what it looks like. Admittedly, probably could have added some DMMOs, but ultimately the toes are pretty straight clinically  and you can see significant improvement compared to preoperatively.  This is a good study by Robbie Ray looking at this. They had 40 patients with significant improvements in the angulation. 91% patients extremely satisfied,  no non-unions, no wound issues, and two radiographic occurrences. You can do long oblique P1 osteotomies. I would caution you on this only because they're a little bit more  technically challenging, although they can get a little bit greater correction. You can also allow for some shortening. You just want to be cognizant of where you're at.  This is an example of what it looks like. Patient had an open fusion because ironically the other side was fused to the plate, so that's what they wanted,  but I did DMMOs of 2, 3, 4, and 5 because they also had some bunionitis discomfort. I did an oblique osteotomy of P2, added a middle pharynx osteotomy,  and then I also did some work through the IP joints in the lesser toes and all those healed pretty well.  Last but not least, metatarsus seductus. You can do this one of two ways. You can either do metatarsal base osteotomies or you can do it through the metatarsal-metatarsal joints.  This involves a lateral closing wedge osteotomy for the metatarsal base. I'll usually use a two by 12 millimeter Shannon burr. I'm going dorsolateral to each metatarsal base.  The nice thing about this is you don't really need any fixation. So this is another patient who I had actually fused her MTP joint on the other side before MIS really came along,  and so she wanted that same thing, but this side actually had more metatarsus seductus and lesser toe deformities, and so I did these basilar osteotomies.  It's subtle, but you can see here on the second, the third, and the fourth. I also included this because you want to be cognizant. If you're not checking fluoro enough,  you can notch into the adjacent metatarsal. So this is an example of what it looks like. Fortunately, it healed. Did DMMOs, did a hammer toe correction as well.  Here's where you can actually see where the osteotomy was, not the notched portion. And then this is the pre-op and post-op, so you can actually see that significant improvement  in the metatarsus seductus. Both, I think it occurs through the metatarsal base osteotomies. I think the DMMOs help as well with that.  For those of you who think that, who insist, I mean, we all know it, but some of you insist that the deformities in the TMT, so you have to go there,  or in cases where there's an arthritic TMT, you can do a percutaneous two, three TMT fusion and fourth metatarsal base osteotomies. Very similar technique.  This is what it looks like, and these are the incisions, largest incisions, about one to one and a half centimeters where the implant was inserted.  I know Atrey likes to rag on me for this picture because the sutures are so long, but my cast tech has vision difficulties and used to say that she had a hard time  taking out the MIS incision, so that's why those are so long. I actually took this photo from Atrey, or borrowed it, he gave it to me actually,  just showing how you can use screws as well. And last but not least, courtesy of Chris Miller, I wasn't the greatest at taking clinical photos, so I picked this just so you can see  kind of the deformity preoperatively and postoperatively, how much of that metatarsal seductives you can correct. But really clinically, you can see the big difference there.  These are my references. I wanted to say thank you to my panelists and our moderator, because to be honest, the MIS is not just about  the experience we get to take care of our patients, but also the experience meeting great people and making great friends. Thank you to my family, who's wonderful,  and I do this for them. And last but not least, thank you to the AOFES for hosting this.  Thank you, John, that was a great talk. One question I have for you, do you ever fix your, for your metatarsal seductives, do you ever fix those,  or are they pretty stable osteotomies?  For the most part, the vast majority of time, they're really stable osteotomies.  I think part of your MIS journey, I think early on when you start doing techniques, you tend to lean more towards some fixation,  just gives you peace of mind. So in theory, you could put pins into it. I think it'd be really hard to get screws in there because of the angle, although it's not impossible.  But the nice thing is it's really stable. They tend to heal very well. And so I typically do not use fixation.  Yeah, I just add for the MIS bunion, or sorry, if you're doing MIS bunion as well, that bunion, you're gonna do your lateral closing wedge osteotomy, so the metaductus,  and then with your bunion, it's gonna kind of splint those metatarsals.  You know, in better alignment. You know, the caveat being, obviously, you can still get elevation of the metatarsal if you fracture the medial cortex.  So if you're worried about that, then certainly fixation's reasonable. Well, and going off that too, if you're doing a bunion and metatarsal subductus,  I would advise you to do the metatarsal osteotomies first, and then do the bunion, because you're clearing space for the bunion deformity.  So I know some people that have tried to correct the bunion, and you could do your osteotomies for the bunion first, but I would forego fixation of it  until you've done your lesser metatarsal osteotomy. And I think, guys, as we all see, this is a great place to start, too, if you're thinking of picking up some MIS.  I think these are a lot of great procedures, and patients are very thankful. So with that, let's go on to the closer. Dr. Ayer, who's gonna talk about our MIS treatments  for hallus rigidus.  Thanks, Tyler.  Thanks, Tyler.  All right, thanks. Thanks, everyone, and great talk so far. I really appreciate being here with the group tonight, and thank you to the AOFS as well.  Go ahead, and I have closed captioning on this, so on top of the closed captioning that's provided. Thanks, all of you, for being here, and to my fellow panelists.  Really appreciate everything that I've learned and so here's our basic outline of what we'll be going through as we kind of talk about the journey through open techniques, both for,  not just for chylectomy, but for the arthrodesis kind of aspect of things as well, including some cases. And we all know sort of the basic ideology  of how this occurs, whether it's traumatic, whether it's inflammatory, gout, but regardless, you know, this classic dorsal bump on the great toe.  You know, other risk factors include, you know, osteochondral defects, turf toe, whether it's metatarsus elevatus, historically anyway, even flattening of the metatarsal head.  You know, we know that the dorsal flexion of the great toe is important for general activity. And as we get more impingement dorsally, that bone spur we see in patients all the time  gets bigger and bigger, and it affects shoe wear, amongst other things. The, you know, we see this bump here, and there's been a lot of data looking at this,  including, hey, is there association with various things, including that of hypermobility, or even that of metatarsus elevatus, and the conservative approach is always important  to think about, you know, stiff shoes, carbon fiber plate, Morton's extensions, all these kinds of things. But when you're thinking about ways to approach this,  especially from the traditional aspect, we think about, you know, taking down that bone spur, even considering additional phalangeal osteotomies.  And then of course, you've got your, you know, interposition type treatments, as well as arthrodesis. And definitely data has been out there  to show the value of the chylectomy itself. And this is, you know, really out of some of the older literature that's there, and, you know, kind of scares me out to think  that these are the kind of things that, you know, we've been taught ourselves. But really, what if you could do this minimally invasively? And certainly, you know, the bunion,  just sort of this talk is beyond the bunion, but that's what this has really been about initially, right? Decreasing operative time, decreasing complications,  reducing risk or use of tourniquet and tourniquet-associated pain.  And this is a paper that recently discussed, obviously by some of my co-panelists here, moderator Dr. Gonzalez, about the importance  or, hey, techniques of doing this and irrigating the joint. And when they arthroscopically evaluated the great toe, pretty much everybody had something going on,  some sort of debris. And that's something you've got to be mindful of, that there's probably more going on than meets the eye, just beyond that of the simple bone spur  and arthritis, if you will. This was actually another paper that looked at these minimally invasive dorsal thalactomy patients. They had wound infections and a good chunk of them,  about 10% went on to actually get an arthrodesis at a later time. And really your indications are about the same as for open, right? Grade one or grade two, negative brine tests,  no pain at extremes of dorsal flexion or pains at extreme of dorsal flexion specifically, especially with dorsal flexion, if you will.  So you want to take down through these incisions that you'll see, and we'll kind of go over to that in a second. Put the burr in, it can really pick what kind of burr you want,  kind of depends on the patient, but usually a two millimeter burr, eight or 12, depending on the size of the patient to help smooth that thing down.  And then obviously check on fluoro, how much dorsal flexion you're actually getting. I think you got to be really careful too. It's easy to under resect the thalactomy.  You obviously don't want to over resect metatarsal head either, but you definitely need to be aggressive with regards to this. And this is a very,  this is a great introductory introduction to MIS as a whole. This is some arthroscopic images, actually courtesy of Dr. Gonzalez, showing us debridement of the joint itself  with that scope on both the metatarsal and phalangeal sides, as labeled appropriately here. And you can see the debridement has been taking place  and cleanup relative to what was there before. And here are those portals. You can often use these different portals to scope. You can use the portals themselves  to actually take down the spur as shown here. And then you can actually see the spur coming down and the debridement that's taking place as well. And even softening of the cartilage  that's on the phalangeal side. Another case, bone sore restrictions and range of motion, pain, failure, conservative measures, mark that spur out,  get the burr in down onto bone and debride. And I think another important thing is to make sure you're irrigating the joint, whether you're doing that arthroscopically,  whether you're injecting or lavaging the joint some way, somehow, that's particularly important to get out those inflammatory cytokines that are also probably causing pain too.  So we think about, hey, what if the pain is actually advanced or the not just pain, but the arthritis is advanced, then we think about the fusion.  And while this was described back in the 1850s, it's been evaluated by many in the literature. And especially when we think about the bunion,  we think about the tenodesis effect on the adductor tendon that is a reason why you don't typically need to do anything proximal.  And while studies have shown this through and through, there's definitely some studies that say, yeah, maybe you actually have to do it, but in general, it's actually not necessary.  So you've got to think about prep, how are you going to prep the joint, whether it's in an open way and minimally invasive way as we're talking about.  Some people do flat cuts from a medial approach, some people, most people do kind of a dorsal approach when you're doing open. And this is some of the original descriptions  of the cup and cone lemur system  by Mike Hoffman from years ago. And again, the notion is that the more stability or surface area, the more biomechanically stable it is, but okay, you can still do flat cuts  or use a burr if the bone is soft. You need to be thoughtful about your positioning of that great toe, as I think we're all aware in order to optimize recovery and function.  And then the fixation type is, really can be dealer's choice. What's interesting is that as they've shown that plate and screw constructs are perhaps the most stable,  they actually show that in a more minimally invasive sort of arthroscopic with screw only approach, the screws were actually better.  They had greater stiffness and less plantar gapping compared to a plate-screw construct that was done through a standard open approach. And so in this review or this article,  they found a fusion rate of 93%, proved patient reported outcome scores and satisfaction was quite high. This is a systematic review with a fusion rate of about 87%,  but there were complications, including that of symptomatic non-union. So it's a wave of the future, right? At least that's what we keep all, all of us keep saying,  and we've really incorporated into our practice in different ways as you've seen tonight. And personally, this is cases where, hey, you got to go in and use the burr.  I use a two by 12, I use a two by 12, two by eight, depending on patient. I will sometimes use a three millimeter depending on how much deformity I'm trying to correct,  but you want to be careful not to over resect bone, no matter how you're doing it. This is actually Dr. Kaplan's cases. And, you know, he was using this two by 12 originally  and say, hey, let's put the scope in there to take a look and, you know, use headed screws. And that can certainly work. You can certainly see the joint prep  that's been taking place as well. And, you know, do what you need to do to, you know, penetrate the joint, whether with a wire drill or otherwise,  and get those cannulated partially gritted screws in there  to get some fusion. But you got to be careful not to take too much bone away, especially if you're using a three millimeter burr, because not only can you shorten,  you can also create deformity inadvertently. And this is a case where, hey, again, you know, prep the joints, you know, compress that axially,  get your wires in and then get your fixation appropriately. Specifically in this case, it was headless compression screws.  But the, you know, it looks pretty good,  but then again, it goes on to a non-union. So is it a prep issue? Is it fixation issue? Is it, you know, patient pathology issue? Was it a, you know, biomechanical stability  as a matter of a spread? This is a patient of mine who's from the local area, history of neuropathy. And, you know, I went with the sort of long axial screw  and, you know, DMMOs and DMMOs and also hammer-tail correction at the same time  with P1s. And this patient has gone on to do reasonably well, but the bone was absolutely horrible. So there was some migration over time with that proximal screw on the NP joint,  but she's, you know, doing well, you know, better than she was before as far as the clinical alignment is concerned too. Here's another one.  I adopted this technique from one Dr. Tyler Gonzalez. I actually had seen personally some non-unions or delayed unions. And I said, well, hey,  maybe if I make a very small dorsal incision,  I can actually clean out the joint a little bit better and without having to shotgun and strip all the tissues. And I've definitely seen that be a game changer  in my practice in terms of, you know, being able to clear out the joint, but also at the same time, you know, really limit the amount of, you know, pain as well as, you know,  devascularizing the soft tissues. So it's an easy introduction to MIS techniques with the chiolectomy. You just gotta be careful with the extent of your resection.  Flesh out the joint, you know, arthroscopically or through a mini open approach. With the fusion, don't over resect the joint and cause shortening. If you want to help fine tune,  you're worried about the joint certainly, or the extent of your debridement, make that small dorsal incision to help facilitate that. Cross screws are great,  but, you know, staples can also be inserted through a small incision as well if that's something you wanna do. Thanks very much. Got the same photo there, Dr. Kaplan. Yeah.  Well, guys, we are surprisingly, we're only two minutes over, which is impressive for this crew. You guys all have an immense fund of knowledge and have taught me a ton about MIS  and really helped me become a better minimally invasive surgeon. So I thank all of you. To the people who are here, thank you for listening to us.  All our emails are through the AOFAS. We love talking about this stuff. Feel free to email us, text us, call us. I think the, yeah, good.  This is just showing you where we believe MIS is going. And we do this because we think it is the wave of the future. As Dr. Ayer said, our patients do well. Nothing's perfect.  And I think everyone on this panel showed complications, but it is, we are studying it, we're analyzing it, and our patients are doing well,  and we're having very high success rates. And I think that's what we'll continue to show. So I think it's a journey and you gotta start somewhere,  but it may, it is beyond abundance. So we encourage you to take it up, ask us questions, and just get along for the ride because this is where we're going  and we think it's better for our patients. So thank you all for joining us tonight. Feel free to reach out and we look forward to doing this next time.

Video Summary

The video transcript provided a summary of a presentation on advances in minimally invasive surgery (MIS) beyond bunion treatment. The presentation covered various topics, including the techniques for distal metatarsal osteotomy, treatment of hammer toes, bunionettes, and hallux rigidus. The speaker discussed the benefits of MIS, such as less pain, reduced complications, and quicker recovery. The techniques for each procedure were explained, including the use of specific instruments and approaches. The speaker also mentioned the importance of thorough joint debridement and irrigation during MIS procedures. The transcript included references to studies supporting the use of MIS techniques and their positive outcomes. The overall message was that MIS is a promising approach for foot and ankle surgery, providing better patient outcomes and faster recovery times. The speaker encouraged further exploration and adoption of MIS techniques in clinical practice.

Asset Subtitle

Moderator: Tyler Gonzalez, MD, MBA
Faculty: Oliver Schipper, MD; Jonathan Kaplan, MD; Ettore Vulcano, MD; Amiethab Aiyer, MD

Minimally Invasive Surgery (MIS) is an evolving field in foot and ankle surgery. Many pathologies that foot and ankle orthopaedic surgeons commonly treat can now be addressed with minimally invasive approaches. In this webinar, faculty will discuss advances in MIS foot and ankle surgery that are beyond the bunion to help guide surgeons in expanding their MIS practice. Discussion will include MIS ankle and hindfoot fusions, Zadek Osteotomy, MIS lesser toe deformity correction, and treatment of hallux rigidus with an MIS approach.

At the conclusion of this webinar, you will be able to:

Review indications for MIS foot and ankle surgery
Identify the procedures that are good for MIS foot and ankle surgery
Summarize the risks and benefits of MIS foot and ankle surgery
Discuss the future of MIS foot and ankle surgery

Meta Tag

Minimally Invasive

minimally invasive surgery

Zadek osteotomy

Hindfoot Fusion

Ankle Fusion

Lesser Toes

Hallux Rigidus

Content Type Webinar Recording

Year Published 2023

Keywords

minimally invasive surgery

bunion treatment

distal metatarsal osteotomy

hammer toes

bunionettes

hallux rigidus

reduced complications

quicker recovery

specific instruments

positive outcomes