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Minimally Invasive Surgery as an Evolving Approach to Limb Salvage
Minimally invasive foot and ankle surgery has made a strong comeback from its origin in the 1970s and it may be here to stay. Key opinion leaders and surgeons in our profession have found innovative techniques and applications outside of bunion and toe surgery due to the invention of a newer generation of less thermogenic osteotomy and wedge burs, and the appeal of offering this technique to patients that are considered high-risk for traditional surgery approaches.
There are many variations of what is considered minimally invasive or percutaneous foot and ankle surgery. Roukis defined percutaneous surgery as having incisions smaller than 3 mm to accommodate the use of a power burr and minimum incision surgery involved having incisions that were 1–2 cm to utilize a saw blade.1 For simplicity, I will define minimally invasive surgery (MIS) as minimum incision and percutaneous foot and ankle surgeries.
Well-known applications of MIS historically involved the forefoot for bunion and hammertoe correction, especially outside of the United States, where there was less debate involving performing MIS metatarsal osteotomies with a low-speed and high-torque power burr.1 Hammertoe corrections were achieved by percutaneous flexor or extensor tenotomies, capsulotomies and phalangeal osteotomies with more than 12 burrs for different indications.2
The appeal of MIS foot and ankle surgery is now widespread amongst surgeons and patients due to the advantages of immediate protected weight-bearing and proposed decreased healing, surgery time, swelling, pain and scarring. Innovative applications now include preparation for arthrodesis of the midfoot, rearfoot and ankle joints, partial ostectomies and osteotomies beyond the forefoot.
A literary search for MIS limb salvage surgeries will produce scarce results. However, there have been case reports with interesting MIS applications for limb salvage and reconstruction. Some notable examples include healing plantar medial ulcerations in a flexible neuropathic flatfoot by inserting a subtalar arthroereisis3 and MIS ray amputation to reconstruct a metatarsal polydactyly through percutaneous incisions to accommodate a specific flute burr.4
Can MIS Help Prevent Amputations and Reconstruct Ulcer-Causing Deformities?
In 1990, Tillo and colleagues published a retrospective study on MIS floating metatarsal osteotomies performed on neuropathic ulcers in which they obtained a 94% limb salvage success rate.5 More recent research by Biz and Ruggieri in France shows promising results for MIS and limb salvage. In 2020, they published an article with online video content of surgical tips and pearls on performing MIS floating osteotomies, as well as outlining the benefits, contraindications and complications with MIS for limb salvage and wound healing.6 The floating metatarsal osteotomy is not a new surgical technique as it was widely used for metatarsalgia; however, the MIS approach and wound healing focus is novel. Absolute contraindications for MIS include severe ischemia/peripheral vascular disease and cellulitis/soft tissue infection, while complications were described as minor with lower percentage of wound recurrence, transfer lesions, malunions and nonunions when compared to conservative offloading treatments and some traditional surgical approaches.6
Tamir and team published a retrospective cohort study in 2022 evaluating for radiographic bone healing with MIS floating metatarsal osteotomies.7 The authors found that 62% had normal union, 15% had asymptomatic nonunions and the remaining had hypertrophic bone callus formation.
I started implementing MIS for limb salvage after utilizing this approach for mild-to-moderate Haglund’s deformities and finding success rates and quicker healing through the smallest incisions as safely as possible. It was an easy transition from MIS for forefoot deformities to surgically offloading wounds through phalangeal osteotomies for rigid hammertoes causing distal digit ulcerations, floating osteotomies for plantar metatarsal ulcers and now, more recently, MIS joint preparation for Charcot reconstruction.
Case Presentations
Case 1. A 64-year-old male with type 2 diabetes, peripheral neuropathy, and a recent amputation of the contralateral lesser digit due to osteomyelitis presented with a concurrent ulcer at the plantar fifth metatarsal head. After standard wound care and conservative offloading, that wound healed uneventfully. The patient ultimately had a recurrence of the wound with infection due to underlying bony deformity of the fifth metatarsal and excessive weight-bearing. After the infection was treated and osteomyelitis was ruled out, the patient agreed to surgical treatment for surgical offloading. A MIS floating fifth metatarsal osteotomy was performed to offload the chronic wound to achieve healing and prevent recurrence.
This patient was weight-bearing in a surgical shoe for 6 weeks and transitioned into supportive sneakers. There were no complications in skin or bone healing at 4 months and no recurrence of the wound. Tamir and team had 96% healing of their ulcers within an average of 3.5 weeks as well, and 38% of their MIS osteotomies involved the fifth metatarsal, with 27% involving the second metatarsal.7
Case 2. A 45-year-old with bilateral Charcot midfoot collapse underwent MIS joint preparation for Charcot reconstruction due to a preulcerative plantar midfoot hyperkeratotic lesion. The patient had prior reconstruction on the left foot by another surgeon and had many complications with skin and bone healing, including osteomyelitis, hardware failure and wound dehiscence with a traditional extensile incision approach performed. The patient subsequently developed Charcot deformity of the right foot. Due to a history of wound healing complications, a MIS approach was chosen to prepare the medial column, lateral column and subtalar joints.
Due to dislocation and necrosis of the navicular bone, a separate incision was made to remove the bone with a saw blade. The other larger than MIS incision was for insertion of the medial column intramedullary nail. The patient has had no wound dehiscence or wound healing complications at the MIS sites, but did have superficial dehiscence at the non-MIS sites.
Closing Thoughts
Minimally invasive foot and ankle surgery can be a great set of surgical skills to have and apply to limb salvage. Recurrent wounds that cannot be offloaded by conservative methods or have failed to heal through standard offloading are perfect indications for MIS. Even if conservative offloading treatment heals a wound, there can be a recurrence rate of up to 57%.7 Advantages of MIS for limb salvage include a very low risk of complications, the option of not using a tourniquet, local block for anesthesia, immediate weight-bearing postoperatively, faster incision and wound healing, minimal scarring and minimal tissue damage.6 There is definitely a learning curve with performing bone work through MIS incisions and with MIS burs. It would be beneficial to have courses taught by experts in MIS limb salvage. Longer follow-up and more research is warranted to continue to improve patient outcomes and advocate for MIS approaches for limb salvage. I look forward to seeing the long-term results of my patients whose limbs have been saved through minimally invasive surgery.
Dr. Saysoukha is CEO and Founder of Premier Foot & Ankle Centers of Tennessee, an AdvancedHEALTH practice. She is board certified by the American Board of Podiatric Medicine and is a Fellow of the American Society of Podiatric Surgeons, a Fellow of the American College of Podiatric Medicine, and an Associate of the American College of Foot and Ankle Surgeons.
References
1. Roukis TS. Percutaneous and minimum incision metatarsal osteotomies: a systematic review. J Foot Ankle Surg. 2009; 48(3):380–387. doi:10.1053/j.jfas.2009.01.007.
2. Botezatu I, Laptoiu D. Minimally invasive surgery of diabetic foot - review of current techniques. J Medicine Life. 2016 Jul–Sep;9(3):249–254. PMID: 27974928; PMCID: PMC5154308.
3. Martucci JA, Migonis AM, Rosenblum BI. Subtalar arthroereisis implantation in acquired neuropathic pes planus: a preliminary report detailing a minimally invasive approach to healing medical column ulcerations. J Foot Ankle Surg. 2020; 59(3):611–615. https://doi.org/10.1053/j.jfas.2019.04.018.
4. Lui TH. Correction of postaxial metatarsal polydactyly of the foot by percutaneous ray amputation and osteotomy. J Foot Ankle Surg. 2013;, 52(1):128–131. http://dx.doi.org/10.1053/j.jfas.2012.09.001.
5. Tillo TH, Giurini JM, Habershaw GM, Chrzan JS, Rowbotham JL. Review of metatarsal osteotomies for the treatment of neuropathic ulcerations. J Am Podiatr Med Assoc. 1990 Apr;80(4):211–7. doi: 10.7547/87507315-80-4-211. PMID: 2324974.
6. Biz C, Ruggieri P. Minimally invasive surgery: osteotomies for diabetic foot disease. Foot Ankle Clin N Am. 2020; 25(3):441–460. https://doi.org/10.1016/j.fcl.2020.05.006
7. Tamir E, Finestone AS, Beer Y, Anekstein Y, Atzmon R, Smorgick Y. Radiographic bone healing in minimally invasive floating metatarsal osteotomy for neuropathic plantar metatarsal head ulcers - a retrospective cohort study. Int J Lower Extremity Wounds. 2022 Sep 14:15347346221126004. doi: 10.1177/15347346221126004. Epub ahead of print. PMID: 36113048.
