I consider the term ‘minimally invasive surgery’ (MIS) to represent a wide range of techniques directed at achieving a surgical objective with less collateral tissue damage. The surgeon choosing to employ such techniques may aspire to achieve improved or more consistent outcome for their patients but is this so? What are the complications? In certain areas of surgery the concept of MIS is well established (e.g. knee and ankle arthroscopy). In forefoot surgery the concept has been met with interest but also skepticism. Much of this skepticism pivots around concerns that the loss of direct vision (maintained in arthroscopic techniques) may increase the risk of complications. In other words, there is a concern that due to the loss of direct visualization (replaced by intra-operative xray imaging), any benefit that might arise from the less invasive technique of the operation will be negated by either poorer quality of surgical correction or higher risk of injury to adjacent structures. All surgery is associated with a degree of risk and in considering the complications specifically associated with MIS of the forefoot we must try to separate out those complications related to the specific MIS technique involved and those that are not. In other words, we need to identify whether the complication has occurred as a result of incorrect surgical planning (e.g. wrong choice of osteotomy/flaws in surgical objective), poor execution of the surgical technique, or as a result of the MIS instrumentation/equipment. I will discuss the above in relation to my experience of complications encountered whilst employing minimally invasive surgical techniques in the treatment of forefoot pathology over the last 2 years.

In recent years the Weil osteotomy has become the dominant technique employed by most surgeons for distal metatarsal osteotomy. This is generally a reliable technique but problems with stiffness can frequently occur in the operated metatarso-phalangeal joints. We present our experience with a minimally invasive distal metatarsal extra-articular osteotomy technique. This technique utilises a high-speed burr via a tiny skin portal to perform a distal metatarsal extra-articular osteotomy under image intensifier guidance without the need for fixation.

A consecutive series of 55 osteomies in 21 patients were included in the study. All osteotomies were performed for metatarsalgia/restoration of metatarsal cascade. The mean age was 49 (38-78), and 20/21 were female. The senior author performed all surgery. All patients were allowed to weight bear immediately in a postoperative shoe and then an ordinary shoe from 4-6 week post-operatively. Mean follow-up was 8 months (4-13) and patients were assessed clinically and scored using the AOFAS scoring system and a subjective outcome score.

The mean AOFAS score improved significantly postoperatively. All patients were very satisfied/satisfied with the outcome. Two patients had minor superficial portal infections, which resolved with oral antibiotics. One patient reported irritating numbness and stiffness in toes (1st case performed). Most patients reported swelling persisting to 3-4 months. There was one symptomatic delayed at 4 months treated successfully with short air boot immobilisation. There were no mal unions.

This series suggests that MIS distal metatarsal osteotomy results compare well with outcomes reported with modern open techniques such as the Weil. We now favour an MIS distal metatarsal osteotomy technique for most indications due to the minimal stiffness observed postoperatively as well as much reduced surgical time without the need for tourniquet.

Introduction

Chronic ruptures of the Achilles tendon pose a significant management challenge to the clinician. Numerous methods of surgical reconstruction have been described and are generally associated with a higher complication rate than with immediate repair. We report our results with a single 5cm incision technique to reconstruct chronic Achilles tendon ruptures with transfer of FHL. This simple technique also enables easy tensioning of the graft/reconstruction to match the uninjured leg and early mobilisation.

Introduction

We describe our experience with a minimally invasive Chevron and Akin (MICA) technique for hallux valgus correction. This technique adheres to the same principles as open surgical correction but is performed using a specialized high-speed cutting burr under image intensifier guidance via tiny skin portals.