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Volume 03 / Issue 01 / March 2015
boa.ac.uk
Page 50
JTO Peer-Reviewed Articles
Section??????????????????
Minimally Invasive
Forefoot Surgery
Editorial comment from Fred Robinson
For – Anthony Perera
As in all spheres of surgery, there is always a tension between
our desire to reduce the size of the skin incision, minimising the
soft tissue dissection and the need to ensure that the bony and
soft tissue elements of the surgery are completed with accuracy.
Foot surgery is no different and over the last few years foot
and ankle surgeons have been debating the pros and cons of
minimally invasive forefoot surgery. In the next two articles the
pros and cons of minimally invasive surgery are debated. Of
course there is no right answer but at least it helps to be better
versed in the arguments!
Anthony Perera
Dishan Singh
Adam Lomax
Co-authors Andy Molloy
& David Redfern
The debate as to whether
minimally invasive forefoot
surgery is justified needs a
frame of reference. Pitting
everything done with a
small incision against a few
successful things done with
a large incision, without
consideration of the deep
dissection, osteotomy, fixation,
biomechanics and rehabilitation
is illogical. All of these factors
have much a greater bearing
on the outcome than the
superficial wound. For example,
somewhat bizarrely the
Hohmann osteotomy, rebranded
as the Bosch or the SERI, now
finds itself switching sides. It no
longer counts as ‘open’ surgery,
despite being an open approach
done with a standard saw, just
because it has a smaller cut and
is skewered with a K wire.
For a scientific debate clarity
is essential. This article is not
a defense of the Bosch, SERI
or Reverdin osteotomies, they
did not work through a large
hole and are no more useful
through a small hole. Neither
are they in anyway related
to the percutaneous, fixed
chevron osteotomy (MICA –
minimally invasive chevron
Akin) any more than the scarf is
related to the Wilson, Mitchell
or indeed Hohmann. Such
diverse procedures would not
be treated as a single entity just
because they are all done with
a saw. NICE guidance fails to
recognise such distinctions.
>>
Volume 03 / Issue 01 / March 2015
boa.ac.uk
Page 52
JTO Peer-Reviewed Articles
Section??????????????????
The commonest complaints are soft-tissue
related such as stiffness and swelling.
Nor is this a case for MICA
supremacy. Whilst this is our
preferred technique, bunion
patients vary in numerous factors
and it is therefore just one part of
our armamentarium, which also
includes the scarf osteotomies,
amongst others.
Why can’t we just be
satisfied with what
we know?
To put it simply we have just not
found an ideal surgical solution
yet, far from it in fact. The variety
of procedures and the lack of any
universally agreed ‘gold-standard’
clearly demonstrates this.
The 2014 ‘A Systematic Review’1
found that there was insufficient
evidence to comment on the
effectiveness of both the Scarf
and percutaneous osteotomy
- including the MICA for which
there were no randomised control
trials (RCT). Only the open distal
chevron osteotomy was found
to be “likely to be beneficial and
more effective than no treatment
or orthoses”.
All techniques have
complications. Up to 38%
of Chevron patients had
complications in one RCT. In
another 10% were dissatisfied
with the appearance, 10% had
metatarsalgia and whilst there
was better function and pain
relief at one year there was no
difference in the ability to work
compared with no treatment! The
Scarf fares no better and Coetzee
in demonstrated in his paper
‘Scarf Osteotomy…the dark
side”2.
Nevertheless, we know that
generally problems related to the
bone surgery are uncommon for
any technique that follows the
principles of bunion surgery as
laid out by Barouk and others.
On the contrary the commonest
complaints are soft-tissue related
such as stiffness and swelling.
Unfortunately, these are largely
under-reported as they are harder
to measure. The reliance on
x-ray parameters and the AOFAS
score to determine the ‘success’
of surgery is a major failing of the
literature.
What is the case for the
Percutaneous, Fixed
Chevron osteotomy
(Or MICA)?
There has been very little change
in the soft tissue element of bunion
surgery for some time, if anything
it has become more aggressive
even though, the lateral release
and the medial capsulorraphy all
contribute to the overall insult.
Yet soft tissue preservation is
very important in foot surgery as
it is in trauma surgery and the
importance of this central tenet of
the AO philosophy becomes more
apparent if a first ray osteotomy is
likened to a fracture. Thus a scarf
osteotomy is more like a grade
II or even III injury and the MICA
more like a grade I.
We know that whatever
osteotomy is used the bony
part of the surgery is reliable.
The question is whether the
same basic principles of bunion
surgery can be applied through
a smaller surgical approach.
This is not about cosmesis.
It is about deep soft tissue
complications (swelling, stiffness)
and the superficial soft tissue
complications (in one UK study3
of the scarf there was a 4%
infection rate and a further 31%
scar complication rate).
As MICA is in its infancy
there is very little in print
available for comparison,
much like the scarf in its early
stages. Perera’s series of two
consecutive cohorts of open and
percutaneous bunion corrections
(primarily Chevron) based on
‘intention to treat’ was presented
at BOFAS 20134. This showed
equivalent bony correction but
improved soft-tissue outcomes
including infection, stiffness
and functional outcome scores
for MICA. There was a learning
curve and this was primarily
related to the fixation. Lam
presented his results of a
randomised trial on scarf versus
MICA at BOFAS 20145, again
demonstrating equivalent
radiological results but improved
soft tissue outcomes for MICA.
So what of the future?
Orthopaedics must constantly
strive to improve and one should
not write-off exploration of
percutaneous surgery as the
latest gimmick, or worse as just a
marketing ploy, as this would fail
to recognise the need to improve
what we have. However, patient
safety is paramount and trumps
innovation, thus it is essential that
patients are aware that MICA is
a new procedure and that they
understand the NICE guidance on
the subject. There is a learning
curve and it is not for everybody.
This applies to both surgeon and
patient. Thus it should only be
performed by an appropriately
trained expert and then only
as part of audit and research,
acknowledging the possibility that
MIS may not be the answer.
This will only be possible if
we collect data and monitor
outcomes in scientific study.
It will not come from both sides
brandishing individual examples
of poor outcomes. Of course,
no other innovation (e.g. scarf,
basal opening wedge and
Tightrope procedures) has
been subjected to this level
of scrutiny and therefore it is
clear that the evidence base
of bunion surgery as a whole
and not just minimally invasive
surgery needs work.
Against – Dishan
Singh & Adam Lomax
Minimally invasive surgery (MIS)
for correction of hallux valgus
(HV) is not justifiable. There is
insufficient evidence to support
its use and its historical failures
should not be repeated.
Since the introduction of MIS
for HV correction in the United
Kingdom (UK) in the 1980’s,
three main procedures have
been used. Bosch described
a linear osteotomy at the
metatarsal neck, performed
with a saw through a small
vertical skin incision. An
intramedullary k-wire was then
used to displace and hold the
metatarsal head laterally6. Using
his own modification of this
technique Giannini published
good results, but these results
were not matched elsewhere7.
Myerson abandoned the
procedure after observing
dorsal mal-alignment in 69% of
cases and a recurrence rate of
38%8. Magnan reported a malalignment rate of 25.5%, Huang
showed a poor radiographic
result in up to 63.9% of cases
and Ianno observed an overall
complication rate of 29.4%9-11.
This technique has now largely
been abandoned in the UK.
Volume 03 / Issue 01 / March 2015
boa.ac.uk
Page 53
Section??????????????????
© 2015 British Orthopaedic Association
Journal of Trauma and Orthopaedics: Volume 03, Issue 01, pages 50-54
Title: Minimally Invasive Forefoot Surgery
Authors: Anthony Perera, Dishan Singh & Adam Lomax
A second technique, the
Reverdin-Isham osteotomy
involves an intracapsular
osteotomy performed with a
burr through a percutaneous
incision12. The correction was
achieved through a medial
closing wedge osteotomy of
the head, decreasing the distal
metatarsal articular angle. No
internal fixation was used. The
result was shortening of up to
9mm along with non-congruence
of the 1st MTPJ in up to 47%
of cases13. This technique has
also largely been abandoned
throughout Europe.
A third MIS technique then
emerged; the Minimally-Invasive
Chevron-Akin (MICA)14. This
is advocated by approximately
15 surgeons in the UK today.
Again however, it has a track
record of problems. The fixation,
performed initially with one screw
was inadequate. Subsequent
attempts, next with two dorsal
screws and then with two short
medial screws also proved
insufficient. Now in its 4th
generation, fixation using two
long screws from the medial side
is currently favoured.
There have been articles promoting
MICA in the national press,
generating public interest with
claims of good long-term results,
reduced swelling and pain and
earlier return to function15. This may
be headline grabbing and attractive
to patients, but medicine must
remain evidence based. These
publicised results and early postoperative benefits have not been
substantiated with robust clinical
evidence. Importantly, the good
published results for HV correction
with open chevron osteotomy
should not be transferred to the
MICA technique because the
surgery is very different.
The chevron is used to correct
mild or moderate HV deformity
>>
Volume 03 / Issue 01 / March 2015
boa.ac.uk
Page 54
JTO Peer-Reviewed Articles
Section??????????????????
A lateral soft-tissue release, when
required is always performed before
the osteotomy...
at most, since the head
translation should be no
more than 50% of its width to
maintain stability16.
A lateral soft tissue release,
when required is always
performed before the
osteotomy to allow relocation
of the sesamoids as the
head is translated laterally.
Finally, a medial capsular
plication is performed to
address the attenuated medial
soft tissues. For the MICA
technique, bony cuts are
made percutaneously with
a burr using x-ray guidance.
The cuts that are made are
inaccurate having been shown
to be out-with the surgeons
intended orientation in 100% of
cases17. The burr is thicker than
the saw, meaning that bone
loss is more pronounced and
metatarsal shortening occurs18.
Furthermore, the burr causes
severe damage to the bone
such that bone healing is not
faster simply because the skin
incision is small. Subsequent
displacement of the head is
frequently beyond 50%, even
100% in cases of more severe
deformity. The lateral release
is always performed at the end
of the procedure, after the head
translation and not before19.
The medial soft tissue
attenuation is not addressed.
It is clear that the MICA
procedure is not the same as
the open operation, but for
the fact that the bone cuts are
performed percutaneously and
with a burr. This is a completely
different surgical procedure,
which must be evaluated for
outcomes in its own right. The
only evidence available for the
good outcomes of MICA comes
from short-term follow up (mean
3-7.5 months) of small cohort
groups, without comparison
or control. All of these studies
come from technique-originator
data, in abstracts submitted
to scientific meetings. It
remains unpublished in peerreviewed literature20-22. In
fact, similar unpublished
evidence presented recently
from a non-originator surgeon
who has now abandoned
the technique showed a
complication rate of 27%23.
There are no comparative trials
to prove that MICA delivers
any of the suggested benefits
over open techniques. It is
unsurprising therefore, that two
systematic reviews have failed
to recommend the use of MIS
surgery over open techniques for
the correction of HV24,25.
In summary, assuming
equivalence in long-term
outcomes for MIS surgery and
open techniques is flawed. The
suggested additional advantage
of improved early postoperative
recovery is not evidence based.
The published evidence in
MIS for HV correction shows
an increase in complications
and a record of failure. Until
well-conducted comparative
trials show proven outcomes
and beneficial results from
this technique, we must not
recommend it to our patients.
Anthony Perera is an
Orthopaedic Foot and Ankle
surgeon in Cardiff. He trained on
the Warwick Rotation followed
by fellowship training in Dublin
and Baltimore. He has been
performing minimally invasive
foot surgery for the last 5 years
and teaches on the UK and
GRECMIP courses as well as
conducting audit and research
on the techniques.
Dishan Singh is a consultant
orthopaedic surgeon at the Royal
National Orthopaedic Hospital
in Stanmore and director of
the foot and ankle unit. He is
a Past President of the British
Orthopaedic Foot and Ankle
Society and is a member of
the scientific committee of the
European Foot and Ankle Society.
His research interests include
bunion surgery, hindfoot deformity
and inferior heel pain.
Adam Lomax is an orthopaedic
trainee who completed his
speciality registrar training on the
West of Scotland rotation. He has
undertaken fellowship training in
foot and ankle surgery with Dishan
Singh at the Royal National
Orthopaedic Hospital, and is
currently with James Calder at the
Fortius Clinic in London.
Correspondence:
Email: [email protected]
Email: [email protected]
Email: [email protected]
References can be found online at
www.boa.ac.uk/publications/JTO
or by scanning the QR Code.
References
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