Mini-invasive and percutaneous surgery in forefoot
Mini-invasive foot surgery is a surgical technique, which, as the name suggests, is based on limited incisions (not exceeding 1 to 2 cm) to perform surgical procedures usually performed by the surgeon first by broad ways.
This entails, among other things, two consequences: a) he does not see everything he does, and b) must have suitable surgical instruments, ie size and size designed for this purpose.
As a result, this surgery is only performed with these adapted instruments (see Figure 1) and specific brightness amplifier dedicated to this surgery (see Figure 2).
This is a kind of a televisual radiography, which makes it possible to make and follow the effects of each movement in real time. The goal is to control what he does not see.
Several surgical acts that can be done in this way:
- a) Tenotomy :section of the tendons, protrusions under the skin such as the extensors of the toes or embedded such as the flexors of the toes (Short Flexor -CF- and Long Flexor-LF-).
- b) Resection of small bony bones (also known as exostosis or bony protrusions) that create “blistering, also called bursitis” under the skin can also be performed by this technique; (Such as instruments used in dentistry or ENT, or by small size saws mounted on rotating motorized hand pieces such as those used in stomatology)./li>
- c) “capsulotomy” through visual control through the skin, which can be provided by the shine enhancer, by small blunt-pointed knobs, called “beaver”
such as those used in ophthalmological surgery, or “capsulotomies”, thanks to the visual control through the skin that the brilliance enhancer can bring, by small blunt – (See Figure 3), such as those used in ophthalmic surgery. These capsulotomies (see Figure 4) produce arthrotomies (opening of an articular capsule uniting 2 bones as a metatarsal and a phalanx) make it possible to suppress the retraction of the tissue which partially participates in the creation and the maintenance of the deformation as in a hallux Valgus (see Figure 5) or a toe grip (see Figure 6).
- d) axial corrections of the small bones of the foot, these corrections are called osteotomies.
Percutaneous surgery of the foot is a kind of “blind” surgery that is done through the “skin” and is also a “kind” of minimally invasive surgery because it is done by even smaller incisions 1 to 3 mm. To be guided, the Fluoroscopy is very helpful. In some cases both techniques may be used at the same time, in an associated manner. In which kind of case: it depends of the gesture, or the nature of the act or the topography of the bone to be approached, so much so that they can be confused and speak most often of minimally invasive and percutaneous surgery of the foot.
Initially practiced in the USA for more than 20 years, this technique was introduced in Europe and then in France for a decade. It cannot treat all cases of foot and ankle surgery. This is a complementary method to those that already exist. This technique is for orthopedic surgery what the technique of Coeliscopy is to general and abdominal surgery, and in some respects is similar to the mensiscectomy by Arthroscopic in the knee; it brings to traditional orthopedic surgery a new therapeutic arsenal that enriches and complements but does not replace the old one. The patients, in any case, also call it those for whom the term Coeliscopy, seems too technical, “holes” surgery or even “surgery by holes”. And they use the same name for minimally invasive and percutaneous foot surgery.
It should be emphasized and remembered that this surgery can be dangerous and become more aggressive than conventional surgery because the surgeon does not see what he does but through a televised radiography that helps but which (as with the objectives and Laparoscopic and arthroscopic cameras) is dfferent from direct vision and requires a learning curve and quality equipment.
In which pathologies, this technique can be even more advantageous? Whenever a tenotomy, or osteotomy or bone resection is needed. In other words, in a very wide range of pathologies:
- a) Hallux Valgus,
- b) Hammer or grie toe,
- c) Quintus Varus,
- d) Metatarsalgia with fall of the metatarsal heads and formation of an anterior round forefoot,
- e) Prominent calcaneal spine, creating or associated with aponeurosis and other fasciitis,
- f) Periarticular calcifications, in athletes who practice intensive sports and sometimes see ossifications around the joints of the ankle or midfoot or calcifications at the sites of tendon insertion (entesopathies) and in this specific case , Percutaneous surgery may be more effective than traditional open-heart surgery, which, to see what can be done, can create detachments and disinsertions that fine, precise and punctual surgery can do;
- g) Cheilectomy and resection of osteophytes (suppression of bone growths formed at the margin of joint surfaces) in the case of Hallux Limitus or Rigidus;
- h) Evacuation of the often liquid content of “inflammatory bursitis” which are serous bursae created during the rubbing against the shoe, painful and site of risk of ulceration, exposing the bone (!) With a risk d ‘osteitis;
- h)Evacuation of “gouty Tophus”, a painless formation initially occurring in cases of hyperuricemia, which cease to be so if they are a source of friction of associated “bursitis”;
- j) Fractures of the tarsal or ankle bones.
The fixation of osteotomies (in the minimally invasive and percutaneous technique) is generally not carried out, with a few exceptions, by screws, pins or surgical plates, as is the case with the conventional fire technique open. There is simply no fixation. For various reasons, including those which are easily explained by the absence of detachments and dissections of the soft parts, by the type of osteotomies and their orientations and by the necessary immediate support, which consists in asking the patient Immediately after surgery to avoid the frequent Bone demineralisation “and other” algo-dystrophic “complications encountered more frequently in traditional surgery.
The direction of the osteotomy line is made obliquely, from top to bottom and from front to back, in “bevel” which has the consequence of causing during the support, during the march, a “co-aptation “. Of the osteotomy focus, a factor that promotes rapid bone consolidation, ie a rapid cure in 3 to 4 weeks of osteotomy compared to the usual and normal delay for a metatarsal or bone fracture, A phalanx.
Essential role of the dressing the first 3 to 4 weeks. The “Concept” which is the basis of this technique, which is in a way the “philosophy” of this technique consists in the immediate support, without means of fixation, other than the dressing, to consolidate. Conservation of the hematoma formed by osteotomy, around the corrected bone, (not being evacuated as in open-heart surgery), healing takes place more quickly.
It is the “wet” dressing, which, when dry, acts as a restraint, like a “kind of microspray” around the toe, maintains the axial correction obtained by the osteotomy. The arrangement of the compresses which are necessarily woven and unrolled by tying the toes in the form of intertwined “straps”.
The risks are many, although the benefits are many and like any surgical technique, it has its limitations and Risks.