Minimally invasive foot and ankle surgery

What “minimally invasive” means

Traditional (“open”) surgery exposes the bone or joint through an incision large enough for the surgeon to see and reach it directly. Minimally invasive surgery (MIS) reaches the same target through much smaller incisions:

• Percutaneous surgery uses small stab-like incisions and specialized burrs, saws and instruments, with live X-ray (fluoroscopy) to guide the bone cuts.
• Arthroscopy uses a small camera inside a joint.^[1,2]

“Minimally invasive” describes the size of the incision, not the size of the problem being treated. The operation still corrects the same deformity or repairs the same structure, and it requires the same care in planning, fixation and recovery.

Where it is used

• Bunions. Percutaneous osteotomies of the first metatarsal, including chevron-type cuts, have been developed. A clinical guideline describes indications, contraindications, techniques and postoperative management for the newer generation of these operations.^[3]
• Hammertoes and lesser toes. Percutaneous release of tendons and shaping or cutting of bone. The treatment is sequenced from the base of the toe to the tip.^[7]
• Big toe arthritis. Minimally invasive cheilectomy, and fusion of the big toe joint, have been described.^[1,8]
• Heel-bone osteotomy as part of flatfoot correction.^[1]
• Ankle arthroscopy, for impingement, cartilage injury, loose bodies and as part of ligament repair.^[2,9]
• Achilles tendon repair through small incisions.^[6]

What the evidence shows

Minimally invasive techniques are promising, but the studies do not show that they are better than open surgery across the board.

• Bunion surgery. A meta-analysis of randomized and prospective controlled studies found no clinically important difference in pain, function, alignment or complications between MIS and open surgery. It cautioned that limitations in the studies may have overstated the benefits of MIS.^[4] In a randomized trial, MIS had better early wound healing at six weeks and similar results at one year.^[10] Another randomized trial found equivalent outcomes, a shorter operation and less pain immediately afterward, but more radiation exposure.^[5] A different meta-analysis found better functional scores with open surgery, and suggested MIS was most suitable for mild-to-moderate deformity.^[11]
• Achilles rupture. A meta-analysis of 10 randomized trials found similar function and similar total complications with MIS and open repair. There were fewer superficial wound infections after MIS but more sural nerve injuries.^[6]
• Ankle ligament repair. A meta-analysis found comparable or slightly better function with arthroscopic repair, and lower odds of wound complications.^[9]

Percutaneous techniques require specific training, so the surgeon’s experience with the technique matters.

Is it right for me?

MIS is not suitable for every foot. Severe or complex deformities, stiff joints, poor bone quality, some previous surgeries and some hardware needs may call for an open approach. A surgeon may also need to convert to an open incision during the operation. The right approach is the one that will correct your particular problem safely, by a surgeon who is experienced in it. It is reasonable to ask which approach is recommended for you and why.

Recovery

Recovery follows the same principles as for open surgery: protect the correction while it heals. Some minimally invasive operations allow earlier weight-bearing in a special shoe, and there may be less swelling and less early pain. Bone healing still takes time, and full recovery can take months.^[3,10] See recovery after foot and ankle surgery.

Questions to ask before deciding

• Is a minimally invasive approach appropriate for my problem, or would an open operation be safer?
• How many of these operations do you perform, and what are the risks specific to this technique?
• Will X-ray guidance be used, and what is the radiation exposure?
• How does recovery differ from an open procedure for my foot?

When to seek care