Percutaneous/minimally invasive surgery

Chirurgie percutanée, mini-invasive Genève

A recent arrival on the scene, this type of surgery has profoundly changed the approach used for disorders of the foot. Percutaneous, minimally- invasive or even falsely described as “laser” surgery, these types of surgery cover a series of specific techniques characterised by minute (1 mm) incisions and the use of dedicated specialised equipment.

Soft tissue (tendons, capsules, etc.) procedures are carried out using very thin scalpels. Procedures on bone use rotary drills for cutting (osteotomy) or abrading (exostectomy).

Fig. 1

Percutaneous drills and motor

The small size of the incision produces an almost invisible scar; however, it does not allow the implantation of larger fixing items such as plates. Whenever possible, the fixation is achieved without materials and is held in place by a special dressing or by a screw inserted percutaneously.

History

Percutaneous surgery was first performed in the mid 1940s in the USA. A group of podiatrists attempted to perform the procedures of that era by the means of small incisions, using dental surgery equipment. Unfortunately, it was totally unsuited for the foot and surgeons very soon came up against a raft of complications and ended up by abandoning the project.

In the 1970s, an American surgeon (S. Isham) took up the baton and modified both the techniques and the equipment, in order to better adapt it to the specific problems of the foot. For 10 years he developed a new approach; however, and despite encouraging clinical results, the surgical community remain somewhat sceptical.

This type of surgery only arrived in Europe in the mid 1980s via Spain (M. Del Prado). Although only performed by a small group of surgeons, the techniques developed considerably between 1990-2000 and it has become one of the major revolutions in the world of modern foot surgery.

Scientific studies are gradually garnering strong academic support for these techniques. Many organisations are now promoting, teaching, and developing percutaneous surgery through the means of international congresses or courses (such as GRECMIP [Foot & Ankle Minimally Invasive Surgery], etc.).
Indications et possibilités
Percutaneous surgery is a tremendous tool. Its aim is not to replace traditional surgery but to provide new options for the treatment of foot conditions.

Correcting forefoot deformities has always been a spearhead for these techniques and still today remains one of the most frequent indications. Traditional deformities able to be corrected with these percutaneous techniques include:
- Hallux valgus (bunion)
- hammertoe
- bunionette (quintus varus)
- pain in the plantar metatarsal region (metatarsalgia)
- Morton’s neuroma
- arthritis of the big toe (hallux rigidus)
Constantly evolving, the indications of percutaneous surgery are developing and expanding to other parts of the foot. It can be used for mid- and hind-foot procedures, though obviously taking into account the limitations of such surgery. In this context, the main areas of interest are:
- talagia (heel pain) and calcaneal spur
- osteotomy of the calcaneus to treat flatfoot or high arches
- calcaneal exostosis (Haglund)
Other indications exist and their number is increasing daily, as a community of passionate specialists are striving to expand its use.
Benefits

Percutaneous surgery allows most procedures to be performed by using one or more 1 mm incisions. Meaning that surgical aggression is minimal and tissues are protected. Theoretically, these techniques mean that pain is limited and therefore recovery and healing is faster; in addition, scars are virtually invisible. Of course, all depends on factors such as the abilities of the surgeon and the type of condition treated. Moreover, the outcome will also vary from one patient to another.

Fig. 3: Scar size after a percutaneous correction of hallux valgus (bunion)

The limited use of implantable material, due to the small size of the incisions, has forced surgeons carrying out minimally-invasive surgery to develop new theoretical and technical approaches, which often implies the use of no external material. This is a real plus, not only from the perspective of health spending, but also due to the frequent complications with such implants (infections, conflicts between the skin and the implant, etc.).

Finally, percutaneous surgery is a real breakthrough in the treatment of patients with specific cutaneous risks, such as diabetics or elderly patients.
Limits and difficulties

Percutaneous surgery is a potentially difficult type of surgery. It requires an in-depth knowledge of standard foot surgery and specific expertise in the field of minimally invasive techniques. The practitioner must be aware of its limits and indications and be able to handle any complications, using either percutaneous or open techniques. Courses and conferences should be organised and attended to train surgeons. These are essential for good clinical practice in the field of percutaneous surgery.

One of the obvious limitations is the lack of direct visualisation during surgery. In fact, the small size of the incisions means that it is impossible to view the structures being treated; radioscopy devices are therefore used to check the correctness of the placement or the correction required. During surgery where direct vision is required, percutaneous surgery is not indicated and open or arthroscopic surgery preferred.

Similarly, these techniques do not permit the placement of voluminous material such as plates.

Finally, in the case of revision or complex surgery or when facing severe deformities, open surgical techniques are preferable as they are more adaptable.
Conclusion

Percutaneous surgery is not intended to replace standard techniques. It offers an array of new tools to orthopaedic surgeons for the treatment of their patients. Surgery may be solely minimally-invasive or hybrid, or a combination of percutaneous and open surgery.

Besides being merely a fad, these techniques represent a real breakthrough in foot surgery, as evidenced by the growing interest among surgeons and patients. Used with expertise and reason, they offer a modern vision, paving the way for a revival in the treatment of foot disorders.

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Percutaneous/minimally invasive surgery

History

Indications et possibilités

Benefits

Limits and difficulties

Conclusion

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