06/28/2013    Stefan Lorincz, DPM

MIS For Bunionectomies? (Randall Brower, DPM)

Until recently, I was also quite skeptical of the
use of MIS in foot and ankle surgery. I had not
been trained in it nor did I hear positive input
from those that mentioned it. So, I did what any
curious person would and attended the recent MIS
seminar in New Orleans, LA.

After listening to the lectures and spending a
full day in the lab I can say that I am putting
what I learned to use already. As with any
surgical technique, not every patient is a
candidate. There are hundreds of different
procedures described in literature on how to
correct a bunion. The case you specifically
mentioned can probably be treated 10 different
ways by 10 different doctors.

If it was a severe hallux valgus in an "older"
patient, I probably would have just fused the
joint by plate/screw fixation and let the patient
walk on it post-op. My point is that MIS has a
role in addressing many foot deformities if done
correctly and in my opinion, if appropriate
patient selection is observed. If your patient
had "bump" pain only, exposing the joint,
reflecting all the soft tissues and drilling the
chondral defect probably did not accomplish more
than MIS could have.

Many specialties are strongly focusing on MIS
(ortho, neuro, cardiology, gen. surgery, etc.)
but for some reason in podiatry it seems like the
longer the incision, the better the surgeon.
Again, I'm not discounting all of my training and
experience in traditional surgical technique, but
rather approaching MIS with an open mind and a
desire to see if this is something beneficial to
my patients. I perform many endoscopic and
arthroscopic procedure. Why do I not do them
open? Because we know patients recover faster and
do better if we make smaller incisions.

So I would encourage anyone wanting to actually
learn more about MIS techniques in the foot and
ankle to read current literature, attend a MIS
meeting and see that it can be a useful addition
to an already competent surgeon.

Stefan Lorincz, DPM, Eau Claire, WI.
Lorincz.Stefan@mayo.edu

Other messages in this thread:

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06/29/2013    Michael Lawrence, DPM

MIS For Bunionectomies? (Randall Brower, DPM)

I read the post of Dr. Brower and his thoughts
now would accurately reflect my thoughts not that
long ago. And looking at his intra-op photos, I
could name names of patients whose joints looked
just like that; and I performed the same
procedures as Dr. Brower on them. I have every
reason to believe that Dr. Brower is a fine foot
surgeon and a credit to our profession. With
that said, I would like to make a few points.

Are we absolutely sure that the chondral defect
has to be repaired in a situation as presented?
I'm sure we all come across some bad-looking
joints either in reality or on x-rays that are
asymptomatic. Many of them are really bad bunions
with chewed up met head cartilage from the base
of the proximal phalanx being badly out of
alignment, while still being non-painful!

I truly believe that denuding the head of the
soft tissues is unto itself injurious. I have
always said that surgery is injury by design to
patients and others. Reducing the amount of
injury seems to me to be a most noble and
beneficial effort in our attempts at correcting
the problems we see and treat.

I have virtually no real-world experience with
MIS, but I did attend the same cadaver seminar in
New Orleans as did Dr. Lorincz, and had a very
similar experience. It was an energizing and
exciting one actually. And not just podiatrists
were in attendance and made presentations, but
several orthopods did so as well. Cases were
presented very well with long-term follow-up and
both good and not so good results. The cadaver
lab was exceptional.

If I can kindly say that all too often it is not
the incision that needs more opening, but rather
our minds. Admittedly, it took mine a long time
to do so.

Michael Lawrence, DPM, Chattanooga, TN,
ftdoc@joimail.com