Foot and Ankle Surgery Techniques: 25 Years of Innovation and Evolution

A Resurgence of Minimally Invasive Foot and Ankle Surgery

Brian Loder, DPM, FACFAS, Director of the Michigan Minimally Invasive Foot and Ankle Surgery Fellowship, acknowledges that in the year 2000, minimally invasive surgery (MIS) options in foot and ankle surgery were indeed minimal. 

“The MIS bunion was limited to procedures like the SERI (Simple, Effective, Rapid, Inexpensive) that relied on a percutaneous pin to maintain correction,” he says. “This caused a large amount of pin tract infections and malunions. [MIS] procedures for tailor’s bunions, hammertoes, arthritis and reconstruction were not even on the radar then.” 

Dr. Loder points out that stigma of negative experiences with the MIS procedures of the 1990s was still looming in 2000, which impacted adoption of these concepts until more recent years, when the field has seen a significant resurgence of interest in such techniques.  

“Today we are seeing a whole host of old techniques being revitalized by the MIS approach including in hallux valgus, first metatarsophalangeal joint arthritis, midfoot arthritis, Tailor’s bunions, insertional Achilles tendonitis and Charcot reconstruction,” he notes.

Twenty-five years later, while many are quickly implementing MIS approaches in their surgical practices, and the research is providing important data, some surgeons are proceeding more cautiously, shares William Fishco, DPM, FACFAS, faculty member and previous Board of Directors member of the Podiatry Institute. 

“There is no denying that the MIS techniques available today are advanced and more precise than ever before,” he says. “In the past, small incisions were made, a Shannon burr was used to cut bone and minimal fixation was used. More complications were seen due to the lack of stable fixation. Now, fixation constructs are robust and better outcomes are obtained. Only time will tell if newer techniques will gain (more) traction and become the standard way foot surgery is performed.” 

Dr. Fishco explains that his personal preference is to use tried and true methods that provide predictable outcomes in his practice. However, Dr. Loder feels the future of MIS is very bright for foot and ankle surgeons, citing MIS-specific jigs, and patient-specific instrumentation currently in development. He continues on to say that, from his point of view, MIS adoption will become much easier, and will perhaps become the standard of care over the next several years. 

Charcot Reconstruction 

Dr. Fishco notes that trends in surgical intervention for Charcot has indeed run the gamut over the past 25 years, from deformity correction with plates and screws, to external fixation, beaming screws, and even more conservative surgical intervention such as plantar planing and tendo-Achilles lengthening. 

“Now external fixation is popular again with minimal incision midfoot osteotomies (and) tibio-talo-calcaneal (TTC) fusions with a nail,” he notes. “I think over time, more of the minimal incision surgery with external fixation will become the most common way to address the condition, as large incisions and extensive dissection leads to prolonged surgery times, difficult-to-heal wounds, and potential hardware failure.”

Dr. Loder recalls that, in the year 2000, he saw Charcot reconstruction focused on arthrodesis at the apex of the deformity. He echoes Dr. Fishco’s observation on the potential of wound complications and large incisions in these cases, and shares that in his experience, patients without an existing ulceration preoperatively had better outcomes than those with an ulceration at the time of surgical intervention. Similar to Dr. Fishco’s assertion about TTC fusions becoming more popular for Charcot, Dr. Loder states that the complexity of and risks associated with this condition have spurred surgeons to focus more on proximal management options. 

“The thought process is to let the mobility of the midfoot accommodate the ground forces, while the rigidity of the rearfoot and ankle help prevent the progression of the deformity more proximally,” Dr. Loder explains. The future of Charcot reconstruction, he feels, will focus on new developments in implants facilitating more proximal fusions and helping to avoid proximal amputations, possibly incorporating biointeractive materials.

Total Ankle Replacement

Although some of the implant systems current surgeons know were available and developing prior to 25 years ago, total ankle replacement was certainly not a universal standard at that time. Dr. Fishco recalls that, when he was trained, the implants were not where they are today. Due to the evolution of these systems over the last 25 years, and a likelihood of continued improvement, he feels that in the future, ankle fusion indications will become more limited, such as for drop foot, severe neurological pathology, or as salvage procedures. 

Dr. Loder feels that the most significant development in total ankle replacement during this timeframe has been the introduction of patient-specific instrumentation (PSI), and that we will see even more advances in materials in the future.  

“In the hands of highly experienced surgeons the benefit may be insignificant, but for surgeons who perform TAR at  lower volumes, the PSI provides more accurate implant positioning which leads to longer implant life,” he explains. “The advancement of tibial tray improvements, including biointeractive surfaces and stem options, has made significant improvements in implant survivorship in large angular deformities.”

Frontal Plane Correction in Hallux Valgus

Surgeons certainly continue to robustly debate the role of triplane correction in bunion deformities, a concept that emerged over the last few decades. 

“Previous operative procedures addressed the sagittal and transverse plane, but did not address the frontal plane deformity (observed) with the rotation of the sesamoids,” says Dr. Loder. “In the 2010s, Paul Dayton (and colleagues) advocated for triplane correction of hallux valgus by correcting the deformity at the first tarsometatarsal joint. Since, Dayton and other authors have reported multiple studies in peer-reviewed journals revealing the benefit of correcting the hallux valgus deformity by addressing all three planes.”^1-4 

Dr. Fishco feels that frontal plane hallux valgus correction is among the most significant observations made regarding foot surgery in the past 25 years. Although he personally notes that he has historically achieved congruous and rectus joints from Austin bunionectomies, he does incorporate formal frontal plane correction into more proximal procedures such as the Lapidus.  
Dr. Loder shares the surge in new procedures that address a triplane outlook on hallux valgus correction over the last quarter-century. 

“In 2014, Treace Medical introduced the Lapiplasty procedure, an instrumented arthrodesis of the first tarsometatarsal joint that corrects the hallux valgus deformity on all three planes,” he explains. “Currently, MIS correction of hallux valgus deformity has (also) been developed to allow correction on all three planes. The future will lead to more procedures that will focus on (triplanar) correction.” 

References

1.    Dayton P, Feilmeier M, Kauwe M, Hirschi J. Relationship of frontal plane rotation of first metatarsal to proximal articular set angle and hallux alignment in patients undergoing tarsometatarsal arthrodesis for hallux abducto valgus: a case series and critical review of the literature. J Foot Ankle Surg. 2013;52(3):348-354. 
2.    Dayton P, Carvalho S, Egdorf R, Dayton M. Comparison of radiographic measurements before and after triplane tarsometatarsal arthrodesis for hallux valgus. J Foot Ankle Surg. 2020;59(2):291-297. 
3.    Hatch DJ, Santrock RD, Smith B, Dayton P, Weil L Jr. Triplane hallux abducto valgus classification. J Foot Ankle Surg. 2018;57(5):972-981. 
4.    Smith WB, Dayton P, Santrock RD, Hatch DJ. Understanding frontal plane correction in hallux valgus repair. Clin Podiatr Med Surg. 2018 Jan;35(1):27-36. doi: 10.1016/j.cpm.2017.08.002. Epub 2017 Oct 23. PMID: 29156165.