MIScellaneous at ACFAS: Practical Pearls on Minimally Invasive Foot & Ankle Surgery

At the ACFAS 2026 ASC, the event kicked off with a roundtable session on MIS surgery beyond the bunion. 

Key Takeaways

• MIS can reduce soft-tissue disruption, but patient selection still drives success. Panelists emphasized matching technique to pathology and risk profiles, not forcing MIS when anatomy, goals, or surgeon experience don’t fit.
• “Minimally invasive” doesn’t mean “minimally complex.” Common pearls included careful fluoroscopic setup, avoiding heat injury with controlled burring, and counseling patients about expected issues like transient neuritic symptoms or delayed skin healing.
• Some MIS procedures are strong “on-ramps,” while others demand more mastery. Percutaneous first MPJ fusion was framed as relatively forgiving with excellent patient satisfaction when positioning is precise, while DMMO and other metatarsal osteotomies were described as technique-sensitive, with postoperative bandaging and swelling control critical to outcomes.

The “MIScellaneous” roundtable at the American College of Foot and Ankle Surgeons (ACFAS) Annual Scientific Conference in Las Vegas was designed as a rapid-fire, discussion-forward session—“everything but the bunion,” as the moderators joked—focused on how minimally invasive surgery (MIS) techniques are showing up in everyday foot and ankle practice. The panel leaned into real-world decision-making: who these procedures are best for, where the learning curve matters most, and what practical habits help reduce complications.

The conversation began with MIS approaches for insertional Achilles pathology and posterior calcaneal prominence, specifically the Zadek osteotomy, and techniques that address a painful “bump” with small incisions, fluoroscopic guidance, and controlled bone work. Several panelists described MIS in these cases as a desirable potential option for patients who can be challenging with open posterior heel surgery, especially those with obesity or higher wound-risk profiles. Their shared theme: once they saw predictable symptom improvement and smoother early recovery, their indications broadened. Panelists repeatedly returned to the idea that MIS can allow earlier mobilization and less soft-tissue disruption, but that the surgeon must stay disciplined about what can (and cannot) be safely removed through limited exposure.

Pearls emerged around managing the posterior spur. Some surgeons described initially being conservative, shaving only a portion of the prominence to avoid destabilizing or inadvertently detaching the Achilles insertion, but then gradually becoming slightly more aggressive as their experience grew. A recurring “judgment call” was whether to choose an MIS detachment/reattachment-type strategy versus a less disruptive MIS decompression or wedge-style correction. The panel acknowledged that the right answer depends on patient factors (age, activity level, body habitus), radiographic anatomy, and importantly, what the surgeon can execute reliably. One clinician noted that in highly athletic patients with minimal risk factors, an open approach may still be on the table; others emphasized that even if MIS is appealing, it must match the pathology and the surgeon’s familiarity with the technique.

The group also flagged adjacent problems that often travel with posterior heel pain, such as plantar fasciitis and plantar calcaneal spurs. Opinions varied on routinely addressing plantar pathology during a posterior heel MIS case. Some surgeons selectively treat plantar symptoms only when the history and exam strongly support it, while others cautioned that aggressive plantar spur work can backfire or simply regenerate over time. The most consistent message: counsel patients that one procedure may not “erase” every radiographic finding, and that symptom-driven targets matter more than a perfect-looking X-ray.

The conversation turned practical when the panel discussed OR setup and fluoroscopy. Positioning strategies differed, but the rationale was consistent: optimize access for the burr and imaging while protecting soft tissue. Panelists discussed working without a tourniquet in some cases, using short, controlled bursts with the burr to reduce heat injury risk. They also noted small-incision pitfalls; maceration or wound irritation from early weightbearing and dressings, for example, underscoring that “minimally invasive” doesn’t mean “no complications.”

When asked about complications, the panel highlighted two that come up frequently in MIS work: transient neuritic symptoms (numbness, tingling, burning) and delayed skin healing. Neuritic complaints were framed as common across MIS procedures, possibly related to swelling, retraction, or heat/irritation near superficial nerve branches, and usually self-limited, but worth discussing up front so patients aren’t surprised.

From there, the session shifted to percutaneous first metatarsophalangeal joint (MPJ) fusion. Multiple surgeons described this as a “game changer” and a forgiving MIS procedure for surgeons building their skill set: tiny incisions, less swelling, less pain, and fast functional recovery, provided the toe is positioned correctly. The panel compared fixation strategies (two screws versus screw-plus-plate or fully threaded constructs), with some surgeons using a dorsal plate selectively in heavier or more deforming cases for added reassurance. They also debated joint preparation and what to do with the “bone slurry” created during burring, ranging from removing it and adding a small amount of autograft to leaving material behind intentionally to support fusion biology.

Finally, the group touched on distal metatarsal MIS osteotomies (including distal metaphyseal metatarsal osteotomy, or DMMO) for issues like metatarsalgia, lesser metatarsal overload, and tailors bunions. Here, the tone shifted: these can look simple, but technique matters. Panelists described DMMO as “art,” stressing cut orientation, planned translation/elevation, and the crucial role of postoperative bandaging and swelling control; especially because many of these osteotomies rely on controlled stability and soft-tissue guidance rather than rigid fixation. The takeaway was candid: start with forgiving cases, learn what you’re trying to achieve biomechanically, and don’t underestimate the learning curve.

Overall, the roundtable delivered a pragmatic snapshot of where MIS fits today: strong potential benefits in recovery and soft-tissue preservation, paired with real constraints related to patient selection, imaging proficiency, heat and nerve awareness, and the awareness to recognize which procedures have a truly straightforward pathway versus those that may be deceptively complex.

Lead image courtesy of Vilayvanh Saysoukha, DPM

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Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of Podiatry Today or HMP Global, their employees, and affiliates.