THE ROLE OF MINIMALLY INVASIVE SURGERY IN THE FOREFOOT. Miss Sue Kendall PhD FRCS (Orth&Trauma)

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1 THE ROLE OF MINIMALLY INVASIVE SURGERY IN THE FOREFOOT Miss Sue Kendall PhD FRCS (Orth&Trauma)

2 Is Minimally Invasive Surgery of the foot a good idea?

3 Minimally invasive surgery, keyhole surgery entering the skin via small incisions

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5 To produce the least possible damage to structures. At the same time, to achieve the same result as if performed by open or more invasive surgery.

6 Describe the new procedures My experience of the outcomes Advantages and disadvantages

7 Hallux rigidus Metatarsalgia Lesser toes Hallux valgus

8 Hallux Valgus Stiffness Pain Dorsal bunion

9 Classification Grade 0 Grade 1 Grade 2 Grade 3 Grade 4 Mild Moderate Severe

10 Classification of Hallux Rigidus Grade 0 stiffness and loss motion, but no pain or radiographic changes. Grade 1 mild to moderate osteophytes formation but good joint space preservation Grade 2 moderate osteophyte formation with joint space narrowing and subchondral sclerosis Grade 3 marked osteophyte formation and loss of the visible joint space, with or without subchondral cyst formation Grade 3 was further divided into those with advanced arthritic changes but pain only in dorsiflexion or plantarflexion (new Grade 3) and those with pain throughout the range of movement (Grade 4). Originally Regnauld then radiographic Hattrup & Johnson 1988 adapted by Coughlin et al.2003

11 Treatment options Conservative Grade 0

12 Treatment options Injection of steroid and MUA Grade 1

13 Treatment options Cheilectomy Grade2 Grade3

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15 Treatment options Fusion Replacement Grade 4

16 Cheilectomy

17 Hallux Rigidus

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22 MIS Cheilectomy 2 weeks

23 MIS Cheilectomy 6 weeks

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25 Results of minimally invasive cheilectomy Early bleeding Patients do not have a scar and cannot understand why they do not get better quickly Unable to assess extensor tendon, at risk of injury Tethering of scar

26 Good cosmesis

27 Medial bunion

28 Significant bone removed

29 Better scar Better movement Better surgical field for future surgery Better patient satisfaction

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31 Results of MIS Cheilectomy 22 open, 16 MIC Satisfaction 8.6/10 open, 9.1/10 MIC MIS 1 fusion, open 2 fusion 1 replacement Dawe et al JBJS

32 Problems of Cheilectomy Progression

33 Fusion

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41 70% blockage of Femoral Artery

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47 Metatarsalgia

48 Weil s osteotomy

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55 Weil s osteotomy Good for pressure relief Good for offloading poor articular cartilage Good for dislocated toes

56 Results of Weils good to excellent 1yr 84% 7yr 88% Hofstaetter 2005

57 Plantar keratosis 80 feet 6 painful callosities Khwana 2011

58 Elevation of toes

59 Scar contracture

60 MIS Distal Metatarsal Osteotomies

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63 MIS DMO for Metatarsalgia Advantages Less scar contracture Less elevation of the toe Disadvantages Painful Healing time longer Incidence of non and mal union

64 Lesser toes

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69 MIS lesser toes

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72 MIS for Hallux valgus The two-minute Bunion Beater that could put Posh back in her shoes within weeks Mail on-line!

73 Hallux Valgus

74 Scarf Osteotomy Medial side

75 Chevron Osteotomy

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77 Outcome after Chevron 112 feet, 10 year FU constant correction 1 revision Scneider 2004

78 Outcome after Scarf Osteotomy 8% stiffness 10% poor cosmesis 6% varus 4% recurrence 4% metatarsalgia 96% better than before 88% completely satisfied Kilmartin and O Kane 2010

79 Minimum 5 yr follow-up 162 feet 25.9% patients were dissatisfied at 5.2 yr Chong et al. JBJS 2015

80 MIS for Hallux Valgus

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88 Advantages? Less stiffness Smaller scar tissue? Less post operative swelling Quicker!

89 Disadvantages Malposition

90 Recurrence Myerson 2007 study 13 patients Abandoned early 6 of 13 patients had recurrence

91 Uniplanar correction

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93 Correction of foot shape

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97 Outcome after MIS for Hallux Valgus For Less stiffness Less swelling Better scar Against Less correction of foot shape Greater recurrence NICE guidelines on MICA www. Nice.org.uk

98 Prospective Trial of Minimally Invasive Surgery Versus Standard Surgery for Correction of Hallux Valgus (Minibunion) ClinicalTrials.gov Identifier: US Completion due 2018

99 Summary of Minimally Invasive Forefoot Surgery To produce the least possible damage to structures. At the same time, to achieve the same result as if performed by open or more invasive surgery.

100 Cheilectomy Fusion Metatarsalgia Lesser toes Hallux valgus

101 Thank you