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Percutaneous minimally invasive surgery for HV

Discussion in 'Foot Surgery' started by falconegian, Jan 7, 2009.

  1. falconegian

    falconegian Active Member

    Members do not see these Ads. Sign Up.
    Does anyone have experience with this technique? it is very popular now in Italy. Osteotomy without fixation !!!!
    anyone have results?
  2. Admin2

    Admin2 Administrator Staff Member

  3. Rafa

    Rafa Member

    It is very popular also in Spain,I don´t think it is the best option,I have quiet a lot experience in HAV surgery and with good disection you have less pain and swelling than minimal invasive
  4. Gibby

    Gibby Active Member

    Poor outcomes are frequent. Not recognized among foot surgeons in Orthopedic or Podiatric circles as an option for hallux valgus correction--
  5. Jose Antonio Teatino

    Jose Antonio Teatino Well-Known Member

    It reckoned Dr. Fasick:
    Their statement surprises me, therefore in their own school of Medicine, in the LSU of New Orleans, they have been celebrated meetings yearly, since many years ago and even the misfortune of the hurricane, of the most minimum invasive techniques in Podiatria for orthopedic surgeons of the entire world.
    In Spain, my country, the traumatologists (medical, orthopaedic surgeons) offer these techniques to correct Hallux valgus of a universal and free form for the patients with Hallux Valgus and other pathologies of the foot.
    The own Spanish State supports them and subsidizes, as opposed to its public system of health. The patients have to do no contribute economic.
    The medical scientific companies support the updating in most minimum invasive surgical formation in the foot.
    Years ago they treated as the lunatics to the surgeons that practiced surgery arthroscopic in the knee, but at present all the surgery tends to be most minimum invasive on behalf of the patients. At present applies in orthopaedic surgery of the backbone, endoscopic digestive and in a great quantity of medical specialties.
    Poor results are also frequent in traditional surgery and they are more evident according to certain surgeons.
    In surgery M. I. S. happens equal:
    Not all the ones that practice they have it the same one qualification, and because of it the results always are not equals.
    Are not the techniques the ones that fail, if not the form to apply them.
    You can fight for defending what does, therefore in its sure hands has good results, but will not be able to avoid the natural evolution of the surgery, therefore is a science that continuously progresses.
    Him bearing a grudge that itself not reservoir and continue the evolution of the techniques respectful, although practice not them.
    Jose Antonio Teatino
    Professor of Surgery
    The Academy of Ambulatory Foot & Ankle Surgery
  6. sspeight

    sspeight Guest

    Not sure why this procedure has the HIV tag attached. I treat HIV positive men and am the Podiatrist for the only peer support group for HIV positive men in New Zealand.

    Any reason why this should have the HIV tag attached?
  7. Gibby

    Gibby Active Member

    HV- supposed to be hallux valgus
  8. admin

    admin Administrator Staff Member

  9. Rafa

    Rafa Member

    who thinks that the natural evolution of the foot surgery goes to osteotomies without fixation,drilling bones with poor control,tenotomies all around....?
    Foot surgery,specially forefoot surgery needs to move bones not only in one plane,needs good control and very delicate disection.
    I think the evolution goes to research about new biological fixation devices,more acurate disection techniques,osteotomies with computer support...this is how I understand foot surgery
  10. Dr. DSW

    Dr. DSW Active Member

    This is a VERY old discussion in the U.S.A. The technique of "minimal incision surgery" in the U.S.A. for hallux abducto valgus surgery was very popular among a small group of podiatrists in the U.S. in the 80's and early 90's. The majority of those surgeons did not perform hospital surgery and therefore believed their "minimal incision" techniques were far superior to "traditional" surgery.

    This created quite a war between the traditional open surgeons and the minimal incision surgeons, and ultimately, in my opinion the "traditional" surgeons prevailed since "MIS" is not performed very much anymore.

    Let me make one point VERY clear. Minimal incision surgery and endoscopic surgery in this case are not synonymous. Endoscopic surgery involves visualization of the tissues and anatomical structures via the scope, and does not BLINDLY place a blade or saw blade in the foot.

    My biggest opposition to minimal incision surgery for HAV is that in my opinion it basically breaks the very basic rule of surgery. When I train residents, I tell them to NEVER place a blade where you can't see it, and in minimal incision surgery you are placing a blade where you can NEVER visualize the blade or the tissues.

    Every time I perform a surgery, I'm quick to point out an anomalous nerve, blood vessel, etc, that a minimal incision surgeon could have destroyed when placing in a blade "blindly" or placing in a spinning "bur" blindly to make an osteotomy cut. Who knows if the MIS surgeon is wrapping some anomalous nerve, blood vessel, tendon, etc., around the spinning bur?????

    And in my opinion, in today's age of constantly improving internal fixation, it is utterly amazing that anyone would perform an osteotomy on a patient and NOT use some form of internal fixation.

    Of course the size of the incision is meaningless. Incisions heal side to side, not end to end, so the length of the incision doesn't make a difference.

    Sorry, but after 23 years of performing foot & ankle surgery and visualizing all different variances in anatomy, there is absolutely NO WAY I would let any surgeon stick a blade or power equipment in my foot through a small incision without being able to completely visualize the tissues.

    Once again, that's completely different than endoscopic/arthroscopic procedures where the surgeon is utilizing a scope to visualize the anatomical structures and is not working blindly.
  11. Gibby

    Gibby Active Member

    Thank you, Dr. DSW-
    My thoughts exactly. You are absolutely correct.
    I have seen MIS bunions after "surgery," and it is unusual to find an acceptable outcome.
    Those who argue that LSU School of Medicine has "hosted" MIS cadaver workshops, and, therefore somehow support or validate the practice is false. LSU, Tulane, and other educational institutions often rent space and allow for exchange of ideas, but do not necessarily endorse such ideas. An excellent example is the frequent pharmceutical program- almost weekly at the Medical School. Different drugs being presented, with the School and Medical Center not providing endorsement.
    You should never cut what you cannot see. An osteotomy through the first metatarsal without fixation is not acceptable. I can see limited cases where MIS may acceptable, but not for HAV repair--
  12. Dr. DSW

    Dr. DSW Active Member

    The first several years of my practice, I became very experienced performing "re-do" surgery due to an "MIS" podiatrist down the street from my office. Fortunately for me, it boosted my income, unfortunately for many patients it resulted in a second surgical procedure.

    When I took these patients to the operating room (all the original procedures were performed in the doctor's office), I more often than not, saw a nightmare when I opened up the surgical site. When a high speed spinning bur is placed "blindly" into a foot to make an osteotomy, it's amazing the damage that can be caused.

    No tissue planes are respected, no blood vessels can be retracted, identified or respected and the same holds true for nerves. Any anatomical variances are simply obliterated. Voids in capsular tissue or complete denuding of areas of the capsule were not uncommon.

    Additionally, since no fixation was utilized following the osteotomies, the osteotomy site was often mal-aligned and/or there was often abundant bone callus formation. These procedures were simply filled with complications. But the most IRONIC part was that when I spoke with "MIS"surgeons, I was told that they could perform these procedures "blind"since they knew their anatomy "so well". That's despite the fact that over my years of knowing MY anatomy just as well, I continue to constantly see anomalous vessels, nerves, tendon attachments, etc.

    And of course, I ALWAYS inspect the joint visually intra-operatively, etc., to check the status and condition, which can not be done when performing "MIS" surgery. Similarly, I often perform ancillary procedures such as a capsular procedure or tendon lengthening to enhance my procedure. With an "MIS" surgery, all you can really do is "cut" but you can NOT repair. In other words, you can cut the capsule, but you can not repair or tighten the capsule. You can CUT the tendon, but you can not perform a tendon lengthening, etc.

    Yes, there are a very few indications in my opinion for MIS surgery. If there is a very small bony prominence on the condyle of lesser toe, a small incision can be made basically down to bone and a drill or rasp can be inserted to smooth down that bony prominence. Because basically, there is no anatomical structure there to harm.

    So, the bottom line once again is that blindly placing a scalpel blade and/or high speed drill into a "hole" blindly, through skin, subcutaneous tissue, deep tissue, capsular tissue and bone, and performing an osteotomy, then leaving that osteotomy unfixated is enough to send chills down my spine.
  13. W J Liggins

    W J Liggins Well-Known Member

    I second that!In all my correspondence with 'minimal incision' surgeons, none has answered the simple question 'What do you do when things go wrong'.  The only response thus far is 'Things rarely go wrong'.  I suppose the follow up to that would be 'How do you know?'As far as your second last paragraph is concerned, there are no practitioners who know foot anatomy better than Podiatric Surgeons, and, as you indicate, even the experienced are circumspect about the matter.  Basically, I don't have a problem with (certain) minimal incision techniques, only with minimal surgeons.

    All the best
    Bill Liggins
    Last edited: Jan 12, 2009
  14. drsarbes

    drsarbes Well-Known Member

    I'm on vacation so I'm trying not to get my pulse rate up TOO high as I read this thread.

    IMHO MIS was the single most detrimental factor in alienating the Specialty of Podiatric Medicine from the rest of the medical community (70's and 80's). For this reason; we had podiatrists with little or no surgical skills taking weekend courses and going back to their CNC practice performing MIS surgery.

    They not only had poor outcomes (which anyone could have predicted) but also were not trained to deal with many of the complications they were getting. Thus these found their way to other practices (primary care, orthopedic, etc....) and that's when the CACA hit the fan. How bad our profession looked!!!!!

    ALso, re; comparing arthroscopic surgery with MIS - DR. Dave is correct in what he says, and in addition, when one performs arthroscopic surgery the actual procedure is the same as the OPEN procedure, it's just done arthroscopically. To compare the two is to show a basic lack of knowledge.

    My bottom line here: MIS surgery in Podiatry was created by Podiatrists that either had no Hospital privileges and or no surgical training, taught to other podiatrists with the same limitations. This is no way to create a surgical subspecialty i.e., advances in surgery are made through advances in technology, physiology and experience, not through the lack of training. MIS was NOT a move forward.

    I'd like to go on (and on) but I have a beach chair waiting for me.

  15. falconegian

    falconegian Active Member

    Thanks Steve for reply.
    I'm an Italian surgeon involved in foot surgery. In Italy now MIS is very popular ! and surgeons are creating a lot of confusion expecially for patients that prefer MIS to open.
    My question if to know if any of you has experience with patient that had MIS with complications and what kind of complications: I didn't find in the literature a lot about this.

  16. Jose Antonio Teatino

    Jose Antonio Teatino Well-Known Member

    Dear colleagues:
    No desire controversial.
    I never tried to attack established models. Their forms of work are very respectable, because their results are optimal in their patients.
    If the results in my patients were not equally optimal, would be stupid to pawn on defending techniques to me that gave problems to my patients, and with them.
    The techniques are not those that fail, if it does not form to apply it them.
    There are bad results if they do not do it well.
    This happens in “the traditional” open techniques and in technique also closed, that does not blind.
    In both sides we know because the things were not made well.
    To who aid solicits in technique M.I.S., email can to use my prevailed, because in the forums sterile debates are generated that do not do more than to bother to who does his work extraordinarily, but by a different way.:bash:
    Always to its disposition:

    Jose Antonio Teatino
    Professor of Surgery
    The Academy of Ambulatory Foot & Ankle Surgery.
  17. I had some training in minimal incision surgery (MIS) during my surgical residency at the Veteran's Hospital in Palo Alto. We performed MIS on 5th metatarsal neck osteotomies and lesser metatarsal osteotomies during my residency and the patients seemed to do well, in the limited time I was able to follow-up on them. In addition, we performed these same surgeries on cadaver feet and then dissected down to see what type of soft tissue damage we had caused, and never found any. It looked like someone had just magically performed the osteotomy without any dissection in the cadavers.

    Once I got out into the real world of doing "open surgery", as we called it in those days, I only used MIS techniques for exostectomies, with good results. I never used MIS on metatarsal osteotomies after residency since I never felt comfortable with "floating osteotomies" that would basically heal with an excessively dorsiflexed metatarsal head.

    Also, as Steve and Dave have mentioned, many of the people here in the States doing these surgeries during the 1980's never had surgical residency training. Therefore, MIS was their way to become "surgeons", make a lot of money by billing for multiple surgeries at a time to the insurance companies from their offices, and, from what I saw, these individuals had very little regard for the patient's well-being.

    According to two separate podiatrists that previously practiced in the same city with this individual, one of the podiatrists that post here on Podiatry Arena, was an MIS surgeon in his town for some time, had a number of lawsuits against him, and was basically forced to retire from his podiatric practice. The other podiatrists that I have spoken to that practiced in the same city with him said they were more than happy to get rid of him due to all the harm he was doing in their town to the name of podiatry and to his patients.

    In fact, two very prominent and busy MIS surgeons that I know of, one in the Bay Area and one closer to where I practice, made fortunes doing these MIS surgeries during the 1980s. However, when the HMO insurance transition came about in the late 1980's, and insurance companies started requiring pre-authorization for surgeries, they both developed "disabilities" that "prevented them from doing surgery" since they obviously saw they would never be able to make millions a dollars a year doing surgery again. One supposedly won a huge disability settlement from their disability insurance company and retired. The other one tried to win a huge disability settlement for their fake disability, but wasn't able to lie good enough about his disability to win a disability settlement. He eventually moved out of town....thank goodness! What a bunch of crooks!! :craig:

    I agree with Steve and Dave, the MIS craze that hit the States during that time was one of the darkest times in the history of podiatry in this country.
    Last edited: Jan 14, 2009
  18. Jose Antonio Teatino

    Jose Antonio Teatino Well-Known Member

    Considered Dr. Kirby:
    I cannot doubt its affirmations.
    When I began my walking in surgery M.I.S I had received training with open surgery previously, but the orthopaedic surgeons with whom I shared theatre, were good people, but no-goods surgeons.
    In my city I have stated for more than 25 years, frequent the bad results of these surgeries practiced by orthopaedic surgeons.
    The Podólogos of my country uses “the traditional” surgery mainly since our basic surgical preparation has university formation postgraduate “masters” almost exclusively with techniques “open” developed.
    The podólogos secure therefore a experience in these techniques that allow good results them in the patients.
    Also they are used to seeing with our eyes the surgical anatomy and the anatomical variations to us.
    At present, I have Spanish colleagues who practice excellent “traditional” surgery, with optimal results, that do not envy the one of the best ones of this world.
    For that reason never it could put in doubt to “the traditional” surgery of the foot.
    It becomes impossible to imagine a Keller procedure to me by M.I.S., therefore the M.I.S cannot replace “the traditional” surgery.
    The procedures are the same, Austin is Austin; Reverdin is Reverdin, the metatarsal osteotomía is similar, but in a angulación a little different when not having to use screw.
    The M.I.S is not but that a philosophy that it tries to diminish the surgical damage, to favour the post-operative one and to avoid complications. Avoiding the bell crank use, already the complications fall remarkably.
    You speak of his training M.I.S and the evaluation of anatomical damages after M.I.S., but in my country this has been put under deep study by the departments of Anatomy in the universities.
    Publications of orthopaedic surgeons of recognized prestige like the Dr. De Prado (who like others, had a solid traditional preparation by the habitual routes); next to prestigious anatomists cone the Dr. Golanó, has corroborated this.
    Percutánea surgery of the foot, ISBN: 84-458-1284-X.
    Podólogos Spanish in collaboration with the chair of anatomy of the Independent University of Barcelona is preparation a new and exhaustive publication on the anatomical respect of techniques M.I.S of very next appearance.
    On the evil result of “the floating” osteotomías that you refer, the appearance of transference to the neighboring metatarsuses, I have suffered also it in my practice.
    I was educated with the formula of Leventin, demonstrated criterion today obsolete, because an exhaustive preoperative study that assures the indication the osteotomía, makes this complication infrequent.
    These studies would be recommendable also if our technique were “traditional”.
    On the history of M.I.S in EE.UU I do not have to think, because each knows its house.
    Where there is money, the opportunists always approach; and these “sold” surgery M.I.S like “laser” surgery, with a spectacular recovery, without complications, that allowed continuing working and a normal life… LIES!
    Our surgery is different, neither is easy, nor this free one of complications.
    Its practical one is complex, it requires and a specific university formation long play, and a training very intense and watched over expert monitors. When the academic certificate is obtained that it authorizes to practice this surgical modality, techniques are not due to approach outposts, if that are become familiar with the experience in small exostosis, surgery of simple smaller fingers, and little by little each surgeon does not progress to where its capacity arrives, and there is important the personal ethics.
    The podólogos progress, replacing” traditional” surgical gestures by less invasive others of a gradual form, and to where each thinks that its action is ethically more correct.
    In EE.UU there was podiatras that made much money in the 80 making M.I.S., some honest ones, but other immoral opportunists and discredited these techniques, and this took to the court.
    Between honest, that practiced a new modality, from the today obsolete techniques and mediocre results in multitude of occasions, they suffer a bad fame, product of its curve of learning.
    At present, this specialty has progressed surpassing the errors of its beginnings.
    The reality of nowadays, is that like in my country, there are opportunists who would have to be in the jail, are that still works cone in the 80, but also other honest ones that we tried to suitably improve every day, teaching this practice and that we defend our form to act basing us on the results in our patients.
    In “the traditional” surgery he is not different. Also there are bad surgeons who discredit with their work the most honest colleagues.
    We do not have to fight to that it uses different means to arrive at the same aim, if to which it does not do well its work, harming to the defenceless patients.
    Of this, we are in favour all the honest ones in the same side, have the same enemy:
    The lack of ethics and the use of the medicine like means of material enrichment, instead of the enrichment like person, to help to the needed one with our honest daily work.
    Please: not more controversies.
    If they need information, we are for helping.
    They can know my present work published originally in 1995.
    Present digital surgical techniques. Minimal invasive digital surgery (M.I.S.)
    In Surgical Podología, Cap.8 P. 111-121 to Edit. Elsevier
    ISBN-13: 978-84-8174-915-1 ISBN-10: 84-8174-915-X
    If they do not have interest, because with its practical one they are happy, I only request the same respect that to the others I give.
    Jose Antonio Teatino
    Professor of Surgery
    The Academy of Ambulatory Foot & Ankle Surgery
  19. falconegian

    falconegian Active Member

    Dear Jose,
    I'm really curious to have an experience with MIS. It could be interesting to come in Spain from Italy to see some cases.
    If for you is possible you can send to me a contact (email) to set up it.

    Gianluca Falcone
  20. drsarbes

    drsarbes Well-Known Member

    Hi Gianluca:

    What kind of complications?

    I have seen ALL of the following directly attributed to MIS surgery that, in my opinion, would not have occurred otherwise in these patients;

    Painful scar (fibrosis), Nerve entrapment, hypesthesia, nerve damage (anesthesia), malunion, psuedoathrosis, cellulitis, osteomyelitis, painful bone callus formation, iatrogenic hallux rigidus, iatrogenic subluxed PIPJ (lesser digit), iatrogenic hallux varus, iatrogenic flail toe deformity, and...the most common (perhaps not a complication) continued pain from their ORIGINAL problem.

    In fact I have one on our schedule now; a revision on a man who had a MIS "bunionectomy" and hammer toe repair one year ago. I treated him for his post op infection and now, one year later, his 2nd toe is deviated laterally in the transverse plane due to total disruption of the medial collateral ligaments at the PIPJ and a poorly performed proximal head resection (at east I THINK that's what he was trying to do)

    I'll upload his x-ray Monday when I'm back in the office.

    If you want to perform MIS my 2 cents is this; become the best OPEN surgeon you can be, then, if you feel you can perform these same procedures through a smaller incision, then go ahead.

    one more thought; A Shannon#44 bur can do a lot of damage to soft tissue.

  21. Dr. DSW

    Dr. DSW Active Member

    I would like to echo Dr. Arbes comments.

    Yes, complications can occur with any surgery and certainly occur with "traditional"/open surgical procedures, and there are also plenty of incompetent traditional surgeons.

    However, that still does not distract from the fact that MIS requires the surgeon to place a sharp blade into a small incision and blindly cut structures, and in many procedures, place a high speed drill (and the infamous 44 Shannon bur) into that same small incision blindly and perform blind cuts on a bone.

    I wouldn't make a small hole in my wall at home to make cuts in the frame of my house, just in case there was a wire, pipe, etc., that I may not know about.......and that's the exact same reason I don't place a blade or drill in a patient's foot without visualizing the tissue.

    I'm sorry, you can tell me how many great results you've achieved, but I have witnessed the outcomes of many of the "best" and you'll never convince me that this method has much merit.
  22. Jose Antonio Teatino

    Jose Antonio Teatino Well-Known Member


    Jose Antonio Teatino
    Professor of Surgery
    The Academy of Ambulatory Foot & Ankle Surgery

  23. Frederick George

    Frederick George Active Member

    Dear Jose

    The issue isn't the name of the surgery, but the talent of the surgeon. And certainly minimally invasive surgery is much more difficult than simply opening up the wound area. "Careful dissection" may be quite impressive on a cadaver, but cutting unnecessarily through tissue just causes damage. No surgeon would cut more than he had to, within the limits of his abilities.

    And of course one must be able to deal with any complications that may arise. Certainly there are some bad surgeons out there, but we need to remember that we ALL see other surgeon's problems.

    All of the complications that have been listed occur with surgery no matter what the size of the incision. We all know that.

    MIS surgery on the foot is successful and becoming more practiced throughout the world, done by both foot surgeons and orthopedists, in spite of the hostility of surgeons who can't do it. Why? Because of shorter, easier recovery, and equal or superior results. Patients tell their GP and their friends.

    It's funny to see the ad hominem attacks and carrying of false tales on MIS by "respected" contributors. It seems the real problem with MIS surgeons is that they "made fortunes." Sounds like a bunch of envious old gossips. Not very professional.

    Jose, if you ever get to New Zealand, please let me know. It would be good to have a chat.


  24. drsarbes

    drsarbes Well-Known Member

    HI Fred:

    First, I really would like this to be a constructive, professional discussion. I never want to seem like I'm getting "personal" and If I've come across that way I do apologize.

    That being said, re: your last post; I could not disagree more.
    The complications I listed would not have occurred (in these patients) were it not for the MIS techniques used. I did state that.

    MIS more "difficult?" Are you being serious?

    One point I'd like to interject; When we discuss MIS I assume we are discussing MIS on Bunions (either bumpectomies or metatarsal osteotomies and or phalangeal osteotomies) also lesser metatarsal osteotomies, "removal" of phalangeal heads for hammer toe correction.......
    Not things like simple phalangeal exostectomies.

    To say procedures like a MIS first metatarsal osteotomies "heal faster" than open osteotomies is very misleading and, in my opinion, is a "sell point" used for convincing patients to have surgery. An osteotomy of the first metarsal will NOT heal faster because the SKIN incision is smaller!!! BTW: incisions heal SIDE to SIDE not END to END. We have a MIS "surgeon" who advertises in our local paper...."BACK to work the next day following bunion surgery." Well, over the years I've seen perhaps 75-100 of his MIS bunionectomies. NONE were back to work the next day and virtually ALL needed a revision surgery. (BTW: they ALL had surgery on their INTIAL visit in his office)

    If some of us here seem a little "hostile" (I would call it "offensive") please understand how WE feel when we consistently get MIS complications or poor outcomes in our office and WE are expected to make it all better! When I first started out in practice I was a bit more diplomatic, now I just tell them to;

    1. Contact your original surgeon and let him/her know what is happening and how you feel and
    2. The next time someone wants to perform surgery IN HIS OFFICE on your INITIAL VISIT a red flag should go up!!!!!!

    Last edited: Jan 16, 2009
  25. Dr. DSW

    Dr. DSW Active Member

    As per Steve's post, I find some of the comments made about MIS procedures healing "quicker" to be either ludicrous or irresponsible.

    I had stated in an earlier post, and Steve stated in his most recent post, that if an incision is 3 inches or 1/2 inch, it takes the same time to heal. Incisions heal side to side, not end to end. So an MIS incision or an open incision should not make any difference regarding healing time.

    And would one of our esteemed "MIS" surgeons please explain the physiology of how an "MIS" osteotomy heals quicker than an "open" osteotomy???? As far as I knew, it took a surgical fracture approximately 6-8 weeks to heal. Do the "MIS" surgeons have a magic potion on that Shannon 44 bur that makes osteotomies heal quicker that I should know about??

    In reality, common sense would dictate that an open osteotomy MAY actually heal quicker. When I perform an osteotomy via open methods, I often irrigate with saline during the osteotomy to prevent thermal necrosis from the heat of the blade.

    With the high speed drill entering the foot and the bone, I would have to "assume" there must be some thermal necrosis occurring during an "MIS" osteotomy, which has the POTENTIAL to delay bone healing, not enhance bone healing.

    Additionally, the use of rigid internal fixation which is almost always utilized with open osteotomies has absolutely been proven to enhance bone healing, decrease mal-unions, decrease bone callus formation, etc. Can you say the same for an UN-FIXATED "MIS" osteotomy.

    I have no problem if you sincerely believe if your "MIS" procedure. I have been trained in open surgery AND I have been trained in "MIS" surgery and have made an intelligent decision not to perform "MIS" osteotomies/bunionectomies for the aforementioned reasons.

    I don't know if the "MIS" surgeons on this site have been formally trained in open/traditional surgery, but it's a shame if they have not had that opportunity.

    If you strongly believe if MIS surgery, that's great. HOWEVER, please don't insult me and make statements that "MIS" surgery allows for quicker healing. Statements like that are simply irresponsible and are contrary to medical fact and the laws of physiology.
  26. W J Liggins

    W J Liggins Well-Known Member

    This discussion is rapidly becoming polarised. I am open to persuasion and if a technique is really a huge step forward in surgery then we should investigate it.

    It seems that MIS afficianados are claiming 'more rapid healing' as an advantage of MIS techniques. This should be easy to prove or disprove. Let us take a similar HAV surgery, say a Reverdin Todd Laird Green carried out by formal surgery and another carried out with MIS. The patients can easily be matched for sex/age/ASA level/HV and PASA angle etc, and let pre and post-op. Xrays be published on this site at, say immediate post-op., 2 weeks, 6 weeks and 12 weeks post op.

    Any MIS volunteers?

    Bill Liggins

  27. Bill:

    The only reason that MIS surgery was so popular here in the United States 20 years ago was because those podiatrists doing it were not trained in open surgery so they couldn't do bone surgery otherwise and because they could make a ton of money by doing these procedures in their offices. As soon as the money dried up for these surgeries, then so did the MIS surgery and MIS surgeons. Amazing!

    I knew of only one ethical MIS surgeon that could also do open surgery, and he is the one that trained me on MIS procedures. All of the rest of them, as far as I and most other podiatrists here in the States were concerned, were more interested in the amount of money they could make rather than the well-being of their patients. Unfortunate, but true.
  28. W J Liggins

    W J Liggins Well-Known Member

    Hello Kevin

    A very similar situation exists today in the U.K. Fortunately, recent legislation now prevents any form of invasive sugery being carried out outside an approved operating theatre (room). However, the challenge remains, if one or more MIS practitioners truly feel that they are taking the profession forward and that their claims are legitimate, let them do as I have suggested.

    All the best

  29. podoalf

    podoalf Active Member

    Dear All

    I understand the "two" positions in this issue. Now, I´m training in foot surgery, not Open, not MIS, only "foot surgery". I think that all procedures could be better performed under opne surgery, and of course fixed. However, I perform some MIS surgery, and although is not a randomized study I wrote a baropodometric assement of one procedure :

    Alfonso Martínez-Nova, Raquel Sánchez-Rodríguez, Alejo Leal-Muro, Emilio Sánchez-Barrado, and Juan Diego Pedrera-Zamorano
    Percutaneous Distal Soft Tissue Release–Akin Procedure, Clinical and Podobarometric Assessment With the BioFoot In-Shoe System: A Preliminary Report
    Foot & Ankle Specialist 2008 1: 222-230.

    I will be pleased to send to anybody if you send me your e-mail.

    One of the MIS problems is that don´t exists a body of knowlegde. Not many articles are written about this issue, and sometimes is dificult to show good or poor results.

    Kind regards

    p.d Sorry for my bad english (I don´t use the trasnlators, only my mind !)

  30. Jose Antonio Teatino

    Jose Antonio Teatino Well-Known Member

    They reckoned colleagues:
    I understand and respect its opinions.
    It is evident that the surgery "traditional" they bid for has shown its benefits in the years, and this affirmation is completely valid currently.
    If I used the bad results that have been able to obtain of certain surgeons "traditional" of my environment, to try to discredit its work, I imagine that not even would have an answer of this forum, or this even would not be educated.
    But you are not my enemies.
    The ones that practice a technique without the adequate preparation, rejecting the aid of the experts in her by being considered "upper", whose motivation to practice surgery is its personal financial gain, instead of help their patients of the best possible form, and besides they do it badly, ignoring the damage that with it they infringe. These if are enemies!
    The affirmations as "bony burn" and other, they show the ignorance that still exists on M. I. S. current.
    This technique cannot be acquired in a meeting, neither visiting a colleague during some days, neither through Internet.
    Their traditional surgical formation I seize years of preparation, in universities that give medicine based on the evidence, practical attended by expert monitors and an adaptation of progressive techniques that begins with simple interventions and culminates with some so complex, that not all the surgeons are really qualified for them.
    Surgery M. I. S. is not different.
    In my country, the university offers specific courses for an adequate formation, for professionals qualified in surgery "traditional" and after a year of formation exclusively M. I. S. they are not prepared to practice all the surgical techniques, needing the contribution and assistance of experts during their first years of practice until complete their curve of learning.
    To the experts, we continue learning each day.
    Despite it and sadly, also we have who discredits this technical, doing badly its work and ignoring the formation received, avoiding the updating of its know-how.
    The true enemies of the M. I. S. are the ones that practice it badly.
    If you examine my work published practicing osteotomías in wedge in the phalanxes of the fingers media and using external bindings, they will notify that all the are respected principles of bony healing described by the association for the study of the osteosíntesis, since 1950.
    The treated bone enjoys a stability and compression that does not envy the one that gives a screw, avoiding the damage to the bone originated by the drills in so small bones.
    Neither use internal sutures, neither surgical turnstile, avoiding its complications.
    This does not it give me right to criticize who does a different surgery, if its results are good; therefore in the end, mine they are not so different and also I have in some case results capable of improvement.
    I expect that my words contribute more understanding, that controversial sterile.

    Jose Antonio Teatino
    Professor of Surgery
    The Academy of Ambulatory Foot & Ankle Surgery.
  31. Frederick George

    Frederick George Active Member

    Dear Steve

    You've covered a bit of ground, so let's look at it piece by piece.

    First, I was not referring to you as the gossip carrying false tales.

    Second, you write:
    You don't really expect us all to believe that these complications don't ever happen with surgery other than MIS do you? Isn't it just the ability of the surgeon, and the type of patient that determines this? I certainly agree that there have been notorious MIS "surgeons" who have been inept crooks. But that does not mean that MIS is wrong. All of us want to minimize the trauma to our patients when we do surgery.

    Third, yes, it is more difficult. And I think you agree. Didn't you write
    Don't you do your heel spur surgeries with a mini C arm? Isn't it a bit trickier for you? Why do you think I developed it with NASA? For the same reason that you use it, I think. So that patients do better postop.

    Fourth. "Shorter, easier recovery (as I wrote)," doesn't mean that the bone heals more quickly. Patients don't care when it finally heals. They care about how much it hurts, and what they are able to do while it is healing. Less trauma, and no tourniquet, means less pain. Isn't that why you do your heel spurs with a mini C arm? I invented the XeroSox so my patients could take normal showers, have post op hydrotherapy, or even swim during their recovery.

    Exaggerating (lying) about healing time, is just wrong. And patients know this, and they don't like it. Better for them to be pleasantly surprised.

    I personally have done my surgeries in a licensed surgery center. I suppose an office could be as well set up. Someone who can do same day surgery isn't busy enough. I have always been booked way ahead.

    I have always done "open" as well as MIS (minimally invasive surgeries). As do the orthopods I know.

    Finally, this discussion went way beyond hallux valgus, or first metatarsal osteotomy surgery. As it should.

    Foot surgery today is generally much less traumatic than 30 years ago. And a lot of procedures that we take for granted now; MIS heel spur/plantar fasciotomy, cheilectomy, subungual exostosis, flexor tenotomy, neuroma release, exostectomy, were not acceptable to the old surgeons.

    And not just how the procedure is done, but the procedure as well. Tightrope. Sinus Tarsi stent.

    So, let's move on, move forward, and keep learning and improving our skills.



    And for those who only have gossip about greed and evil motivation to offer, have they ever heard the term "projection?"
  32. drsarbes

    drsarbes Well-Known Member

    Hi all;
    Here are the x-rays I promised.
    This patient had MIS bunionectomy with correction of hammer toe 2nd X 1 year.
    He is scheduled for revision.
    Let me know what you think.
    Thank you

    Attached Files:

  33. Frederick George

    Frederick George Active Member

    Dear Steve

    You wrote:
    Well, so much for that. Since you haven't responded to the discussion, I guess you acquiesce?

    In the same vein of anecdotal poor results, what do you think of this? Patient had bump pain in her shoes, normal ROM.

    stapled bunion preop.JPG
    stapled bunion AP xray.JPG


  34. Jose Antonio Teatino

    Jose Antonio Teatino Well-Known Member

    It reckoned Dr. S. Arves:
    The case that you present, confirms the bad one praxis of who were the author of this criminal surgery.
    For the first radio:
    The patient possessed an angle inter-metatarsal too high.
    The bunionectomy simple does not have indication in a Bunion so evolved.
    It should have been practiced an metatarsal osteotomy capital with displacement to reduce to the same one, or well an metatarsal osteotomy in wedge in its base.
    On the articulation metatarsus-flanges, itself not the P.A.S.A was reduced, that had required perhaps, a procedure Reverdin.
    The tenotomy abductora, or itself was not practiced or was done badly, causing that the rotation in valgus of the finger be impressive, and the relapse iatrogenic very evident.
    Do not present you the pre-operating x-ray, but would not miss me that the post-surgical result were a lot worse than the previous situation of the patient before the surgery.
    For the second finger:
    A technique in disuse, and God know which was the post-operating monitoring of the patient, involves to this result.
    The osteotomy in wedge of the phalanxes of the fingers media, that personally practice, they are very sure and would avoid these disastrous results.
    The technical M. I. S. you would be able to have resolved this case, without problem.
    But it is not the technique the wrong one, if not the sum of many misconceptions in the same case, the one that has caused similar crime.
    Personally I think should be disqualified the author, and to impede that he continue doing damage. Him he should be sent again to the school.
    At times one does it well, but the result he is not the predicted; but when he is done so badly, and not the most basic principles are respected, the surgical practice should be limited to the unconscious, independently they practice their art "traditional" or M. I. S.
    On the subsequent answer of the Dr. Frederick George, I believe that it self should not enter polemics by whom it does worse.
    Possibly the procedure was disproportionate, but perhaps the patient does not sit down badly.
    I have numerous cases with so much, a lot more disastrous results with techniques "traditional" they bid for, as with most minimum invasive practice.
    Is not the technique the one that fails, if not the form to apply it.

    Jose Antonio Teatino
    Professor of Surgery
    The Academy of Ambulatory Foot & Ankle Surgery
  35. drsarbes

    drsarbes Well-Known Member

    Hi Fred:
    "Well, so much for that. Since you haven't responded to the discussion, I guess you acquiesce?"

    I'm not sure what you're referring to, I stated I had a patient scheduled that had poor results from an MIS procedure and was going to post the xray when I returned to the office. This isn't anecdotal, these are the xrays.

    I really didn't have too much more to add to the discussion, I've pretty much stated my thoughts on the subject.

  36. Frederick George

    Frederick George Active Member

    Dear Drs. Teatino and Sarbes

    Re your xrays, obviously the wrong procedure was chosen for the bunion, and perhaps a phalangeal osteotomy was done on the 2nd toe improperly. I personally prefer "open" arthroplasties for nonreducable hammertoes because I had too much post op swelling with the osteotomies.

    It's not the "type" of surgery, but the skill of the surgeon. We all make the smallest incision with the least dissection we can to accomplish the goal. This causes less trauma. Some surgeons can cause less trauma than others.

    I thought I would send along an "open" procedure in the same vein. I think the wrong procedure was chosen, and done improperly, although with a nice new nitinol compressive staple.

    I certainly do more "open" procedures than "closed" procedures. But I also do exclusively outpatient surgery, and often do one foot at a time to minimise post op pain and disability. I want my patients to remain ambulatory if possible.

    30 years ago this seemed outlandish. The only proper way to do bunion surgery was inpatient, bilateral, under general anaesthesia. Things change.

    The xrays I submitted are anecdotal too.

    Wikipedia (emphasis added)

    Although there are miscreants, I think most doctors are trying to do the best they can for the patient. Those that aren't, shouldn't be doctors.

    And we all need to keep our minds open, learning. That's why they call it "practice."


  37. drsarbes

    drsarbes Well-Known Member

    "And we all need to keep our minds open, learning. That's why they call it "practice." "

    Hi Frederick:

    Good points, all. I appreciate the tone of the post. I do always TRY to be objective and professional. The written word does at times come across with a different "tone" than what was intended.

    I think in the final analysis (at least the analysis of the ARGUMENT between open vs MIS) the issue I have is NOT the size of the incision but the procedures themselves.

    ALSO: and you just can't discount this (at least in the USA) the types of Podiatrists that have historically gravitated to MIS are the USED CAR SALESMEN of our profession.

    I'm sure there are lots of qualified, professional and ethical MIS surgeons out there, but in my own little world I have never met one. I don't mean for that to sound cruel or offensive, it's just true.

  38. Frederick George

    Frederick George Active Member

    Dear Steve

    I completely agree. I have talked to MIS "surgeons" who drilled through the skin!

    However we do surgery, the intention is (or should be) to get the best result for the patient with the least discomfort. Even if it is a little more difficult or inconvenient for us.


  39. drsarbes

    drsarbes Well-Known Member

    " I have talked to MIS "surgeons" who drilled through the skin! "

    How about the guys who use a laser for a bunion skin incision then advertise for LASER BUNION SURGERY!!!!!!!

    Yes, the "used car salesmen" of Podiatric Medicine.

  40. Jose Antonio Teatino

    Jose Antonio Teatino Well-Known Member

    It reckoned Dr. S. Arves:

    The salespersons of cars prefer unfortunately the most minimum invasive surgery to sell their product.
    This is lamentable, therefore the honest surgeons we drag this load, that is not ours, but always they place it us.
    The salespersons of the laser should be in the cut by swindling the patient through lies.
    A cordial greeting:

    Jose Antonio Teatino
    Professor of Surgery
    The Academy of Ambulatory Foot & Ankle Surgery

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