Minimally Invasive Surgery in Modern Podiatry: Insights from the APMA Panel Discussion

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At the 2025 American Podiatric Medical Association (APMA) National conference in Grapevine, TX, a lively roundtable discussion led by moderator Kelsey Millonig, DPM, MPH, alongside panelists Rachel Gerber, DPM, and Christopher Juels, DPM, explored current perspectives and challenges in minimally invasive surgery (MIS) versus traditional open procedures. Their session delved into key surgical applications including hallux valgus, insertional Achilles pathology, lesser metatarsal osteotomies, and complex midfoot and hindfoot fusions.

Hypermobility and Hallux Valgus: Where MIS Fits

Panelists debated the management of first ray hypermobility in the context of bunion correction. Traditional approaches often lean toward first TMTJ fusion, they noted, especially when instability is suspected. However, the panel emphasized:

• Transverse Plane Stability as a critical factor in recurrence risk. MIS approaches can realign the mechanical axis and offer stabilization benefits without requiring TMTJ fusion in all cases.
• Selective Use of Fusion: While MIS can restore stability for many, fusion remains a valuable option when significant hypermobility is evident or conservative MIS correction fails.
• Learning Curve: The team acknowledged a steep early curve for MIS hallux valgus procedures, with studies suggesting up to 35–40 cases needed to gain proficiency, but this is based on longer OR time and fluoroscopy time, and not on worsening outcomes or complications, says Dr. Juels.^1,2

Insertional Achilles Tendinopathy: Tailored Application of MIS

The panel reviewed surgical strategies for chronic insertional Achilles pathology, noting that:

• Patient Selection is Key: They generally felt that younger, active patients with discrete insertional pathology are better candidates for MIS.
• Instrumentation Nuances: MIS offers reduced soft tissue disruption but demands attention to heat generation and precision burr usage.
• Complication Rates: The panel noted that recent data suggests complication rates for MIS approaches may be half that of traditional open methods. 
• Limitations Still Exist: Larger spurs or complex Haglund deformities may still require open exposure for complete decompression, in their experience.

Lesser Metatarsal Osteotomies: Avoiding Elevation and Shortening

Minimally invasive lesser metatarsal procedures drew significant interest for their evolving role in forefoot reconstruction. Pearls and pitfalls that the panel discussed included:

• Isolated vs. Multiple Osteotomies: Avoiding isolated procedures in the presence of transfer lesions was emphasized, as the panel noted this may lead to unintended elevation.
• Controlled Correction: Panelists overall favored techniques that minimize shortening and dorsal displacement, especially in the second and third rays.
• Postoperative Outcomes: MIS in this context has demonstrated improved cosmesis and lower hardware complications, though careful intraoperative technique is crucial.³ 

Midfoot and Hindfoot Fusions: Innovation Meets Complexity

As the panel turned to rearfoot reconstruction, several key thought processes emerged regarding MIS versus open fusions:

• Subtalar and Tibiotalarcalcaneal (TTC) Fusion: MIS shows promise in reducing soft tissue trauma and wound complications, especially in high-risk or previously operated patients, panelists added.
• 3D Anatomical Understanding: Successful MIS fusion requires precise knowledge of joint orientation and fluoroscopic technique.
• Joint Preparation: Methods like windshield-wiper burrs or osteotomes were discussed as potentially effective means of joint preparation with MIS.
• Scope-Assisted Fusion: Arthroscopic tools can aid in joint debridement, especially for surgeons early in their MIS fusion learning curve.

Panel Reflections and Takeaways

Throughout the session, the panelists underscored several recurring themes:

• Adaptation and Patient-Centered Planning: MIS is not universally superior and should be tailored to anatomy, pathology, and patient goals.
• Candid Discussion of Complications: Cases with delayed healing, hardware irritation, or inadequate correction were reviewed, reinforcing the need for realistic expectations and follow-up.
• Training and Proficiency: The surgical learning curve remains a challenge that interested surgeons must undertake. Experience, mentorship, and repetition are key, said the panel. 
• Future Directions: Ongoing comparative studies and long-term data will be essential to continue to define and refine best practices and indications for MIS across foot and ankle surgery.

References
1.     Baumann AN, Walley KC, Anastasio AT, Gong DC, Talusan PG. Learning curve associated with minimally invasive surgery for hallux valgus: A systematic review. Foot Ankle Surg. 2023 Dec;29(8):560-565. doi: 10.1016/j.fas.2023.07.012. Epub 2023 Jul 27. PMID: 37524619.
2.     Lewis TL, Robinson PW, Ray R, et al. The learning curve of third-generation percutaneous Chevron and Akin osteotomy (PECA) for hallux valgus. J Foot Ankle Surg. 2023;62(1):162-167. 
3.     Neunteufel E, Krenn S, Chraim M, Amann P, Greiner F, Kranzl A, Bock P. Minimally Invasive Distal Metatarsal Metaphyseal Osteotomy of the Lesser Toes: Clinical, Radiologic, and Pedobarographic Outcomes. Foot Ankle Int. 2022 Feb;43(2):153-163. doi: 10.1177/10711007211034849. Epub 2021 Aug 17. PMID: 34404241.