Taking on the controversy of open versus minimally-invasive surgery (MIS) techniques for distal metatarsal osteotomies, Jeffrey E. McAlister DPM, FACFAS acknowledges that disagreement exists. Citing a 2018 study, he shares that open versions of this procedure yield overall moderate patient satisfaction, low complication rates and a moderate rate of recurrence.10 Specifically, Dr. McAlister notes recurrence rates for various procedures, including the Scarf and Chevron osteotomies, ranging between 25 to 78 percent across multiple studies in the literature.11-14 Overall patient satisfaction over a 14-year follow-up in one study comparing the Scarf and Chevron osteotomies was 30 percent.11
Minimal incision surgeries appear to be favorable in comparison to open techniques for mild hallux valgus deformities, states Dr. McAlister. In a 2020 study evaluating 287 patients over a seven-year period, Yassin and colleagues found similar changes in the intermetatarsal and hallux valgus angles.15 Researchers in this study also found the MIS technique to be safe if the surgeon was running the burr at low speed and with short pulses. There was also significantly less pain in the percutaneous correction group, according to the study authors. Dr. McAlister notes similar findings in other studies and in his own experience.16,17
In his 1989 book, Johnson characterized minimally invasive foot surgery as a crippling procedure, influencing most podiatrists and orthopedic surgeons to abandon the technique.18 However, in more recent years, one can note a resurgence of MIS procedures in many aspects of foot and ankle surgery, says Dr. McAlister, who is in private practice in Scottsdale, Ariz. He asserts that MIS techniques in forefoot reconstruction are here to stay but challenges do still exist.
Dr. McAlister explains that following proper indications for the procedure, ensuring prudent patient selection and understanding that there is a learning curve will help surgeons avoid mistakes made in the past. Additionally, improved techniques and technology may also contribute to a better MIS experience than in past generations, according to Dr. McAlister.
In his experience, Dr. McAlister employs MIS for mild to moderate hallux valgus cases, Coughlin/Shurnas grade zero to two with no metatarsus adductus and reducible deformities. Alternately, he tends to choose open tarsometatarsal rotational fusion for moderate to severe cases. For patients with significant arthritis, Dr. McAlister favors a first MPJ fusion.
In his experience, Dr. McAlister says MIS techniques cause less stiffness, risk of infection, nerve damage and pain in comparison to open counterparts. But in order to optimize outcomes, he says surgeons should focus on patient selection, proper operating room setup, accurate sesamoid rotation measurement, rotation of the capital fragment and thorough washout of bone debris from the surgical site.
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