Minimally Invasive Surgery (MIS)

[DexterMorganSK]

I thought of making this thread for a while now. Is anyone here doing any MIS? Either for a bunion, HT, or Achilles repair? If you are, how are you doing it, and what special tools are you using? Did you learn about MIS during residency or through a fellowship? Do you think MIS is the future for HAVs/HTs/etc.? I hope to post YT videos and research articles on this in the coming week! Is there any source you recommend for the young residents and students interested in MIS?

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[dtrack22]

I do MIS bunions and have done some MIS/perc fusions, HT, calc slides, met osteotomies and a weil (that i didn’t really like but patient did very well), etc.

I pretty much exclusively do a midsubstance repair for the achilles though I still make a longitudinal incision instead of the transverse one often shown with PARS type procedures.

I used the PARS jig as a resident but it was for end to end repair. I only pull the proximal stump distal and anchor into the calc. I no longer bother with any end to end anastomosis because it isn’t necessary.

I learned all of it out in practice on my own. Watched videos, did a lab or two. No formal residency training on any MIS stuff other than a few cases with the PARS jig.

 

[Shiyuan]

I just stick with Osteomed Kobygard for morton’s neuroma decompression or plantar fasciotomies.

 

[HardRoadPaved]

I've been honing in on my MIS craft... Cant wait to get my ABFAS CAQ in MIS if the fees are low

 

[wakaflocka88]

My MIS are smaller incisions and extend as necessary, such as in a lapidus. I only need about 6cm over the TMTJ to do my work. If you respect the soft tissue it will in turn heal predictably for the most part. Don’t retract like you’re the hulk, don’t crush tendons and ligaments, watch your tourniquet time, close appropriately. And most importantly - patient selection. MIS doesn’t mean now every single patient is eligible.

 

[GreenHousePub]

I see no reason to do MIS bunions. My incisions for bunions are tiny for the most part and I close with monocryl subcuticular so the incision heals nicely.
Additionally for the latest MIS bunions you're putting two specialty headless screws in there that jack up the cost of the surgery immensely.
I get by with one 100 dollar (at most) screw just fine.

 

[GreenHousePub]

I just stick with Osteomed Kobygard for morton’s neuroma decompression or plantar fasciotomies.

I just looked it up on their website as I have never used it. It was kind of the manufacturer to provide the 360p video filmed in 1995 to show me how to use it.

 

[CutsWithFury]

Did a couple Arthrex courses and a local cadaver lab. Never did it in residency. It’s all feel. Once you learn how to handle the burr you can literally do anything with it. Bunions are easy. Hammertoes are easy. Calcaneal osteotomies are awesome to do MIS.

My first MIS surgery was actually a Charcot recon.

Patient had previous recon done by someone else with ex fix but they fused the patients forefoot in Varus. Patient had chronic lateral column ulcer which could not be offloaded or healed. The residual deformity was too severe. Since entire midfoot was fused solid and in Varus I did two stab incisions on either side of the foot and did MIS burr midfoot osteotomy and derotate did foot out of Varus and perced large caliber screws for fixation.

 

[Pronation]

I see no reason to do MIS bunions. My incisions for bunions are tiny for the most part and I close with monocryl subcuticular so the incision heals nicely.
Additionally for the latest MIS bunions you're putting two specialty headless screws in there that jack up the cost of the surgery immensely.
I get by with one 100 dollar (at most) screw just fine.

Do you do a bunionectomy skin to skin in 15 mins? Add an additional 5 mins for the akin.

Takes about 10 of these to get the proficiency.

Do a majority of your post op bunionectomies report taking pain meds for a couple days and then not needing them?

Just some things to think about on the appropriate MIS candidate.

 

[dtrack22]

Do a majority of your post op bunionectomies report taking pain meds for a couple days and then not needing them?

I’ve noticed a decrease in reported pain and I also don’t worry about undercorrection like I would see with an open chevron routinely. Either my own or another providers. You also get a 1st MPJ that functions normally within a week or two of surgery. If anyone tells you they are opening up the MPJ and don’t routinely have significant post-op stiffness, even to the point of patient needing PT following a bunion…they are lying.

 

[Scrantonicity]

I’ve noticed a decrease in reported pain and I also don’t worry about undercorrection like I would see with an open chevron routinely. Either my own or another providers. You also get a 1st MPJ that functions normally within a week or two of surgery. If anyone tells you they are opening up the MPJ and don’t routinely have significant post-op stiffness, even to the point of patient needing PT following a bunion…they are lying.

That's the one thing that is starting to sell me about MIS bunions...the stupid 1st MPJ stiffness after an Austin. I never saw the need for MIS (besides Achilles/retrocalc work), but if it eliminates the stiffness I may have to look at it again...

 

[CutsWithFury]

That's the one thing that is starting to sell me about MIS bunions...the stupid 1st MPJ stiffness after an Austin. I never saw the need for MIS (besides Achilles/retrocalc work), but if it eliminates the stiffness I may have to look at it again...

With MIS you are not opening the capsule therefore no scarring. With MIS you are not opening the capsule and performing a v-shaped osteotomy which causes bleeding which increases the strength of the scar tissue formation as the capsule is healing over that. It's a no brainer.

You can put the capital fragment wherever you want with ease. I've seen some people do lapiplasty and dorsiflex the entire first ray pretty bad because there is no freedom with the jig. Looks good on AP but terrible on lateral.

 

[air bud]

I've been honing in on my MIS craft... Cant wait to get my ABFAS CAQ in MIS if the fees are low

Excellent

 

[shadesofgrey]

This past year I started doing MIS bunions and the patients have done quite well with them. I can walk them immediately postop in a surgical shoe, less pain, good MPJ motion and good correction of the deformity. However, as another poster mentioned the screws are ridiculously expensive... like obscenely expensive... like I'm waiting for the surgery center to say no more of these expensive. Additionally the learning curve was steeper than I expected. I did a couple of labs and figured, hell its got a jig it's probably idiot proof. Nah, its tough to throw the wires with the jig on. Takes a while to get used to it; after the first one, I swore no more MIS bunions, but I had several more already scheduled so had to go through with them. It does get easier each time, but ya have to stick with it.

My suggestions: 1) go to several labs 2) block out more time than you think you will actually need for it

 

[dtrack22]

This past year I started doing MIS bunions and the patients have done quite well with them. I can walk them immediately postop in a surgical shoe, less pain, good MPJ motion and good correction of the deformity. However, as another poster mentioned the screws are ridiculously expensive... like obscenely expensive... like I'm waiting for the surgery center to say no more of these expensive. Additionally the learning curve was steeper than I expected. I did a couple of labs and figured, hell its got a jig it's probably idiot proof. Nah, its tough to throw the wires with the jig on. Takes a while to get used to it; after the first one, I swore no more MIS bunions, but I had several more already scheduled so had to go through with them. It does get easier each time, but ya have to stick with it.

My suggestions: 1) go to several labs 2) block out more time than you think you will actually need for it

The burr and 3 screws should be easily under $1k. It’s definitely more expensive than 2 stainless steel solid screws, or a buried k wire. But the facility has several vendors to choose from (unless you absolutely need to use Arthrex vs Stryker vs Novastep). I’m at a critical access hospital so cost isn’t an issue, but when Arthrex tried to sell the power unit, hand piece and screw trays to the hospital, the screws weren’t more than $100-150 a piece. Stryker put it all on consignment and so I use their system (technically Wright products until it all gets rebranded).

You can always do a lapiplasty that will cost the surgery center $5k…

 

[shadesofgrey]

The burr and 3 screws should be easily under $1k. It’s definitely more expensive than 2 stainless steel solid screws, or a buried k wire. But the facility has several vendors to choose from (unless you absolutely need to use Arthrex vs Stryker vs Novastep). I’m at a critical access hospital so cost isn’t an issue, but when Arthrex tried to sell the power unit, hand piece and screw trays to the hospital, the screws weren’t more than $100-150 a piece. Stryker put it all on consignment and so I use their system (technically Wright products until it all gets rebranded).

You can always do a lapiplasty that will cost the surgery center $5k…

Wow, we are getting screwed (pun kind of intended)... I've been using the Arthrex kit, but I saw the invoice for the hardware and they were going for over $500 per screw. I've been able to justify it to myself by saying well it's cheaper than a lapidus plate/screws. How's the Stryker set up compare to Arthrex? I wanted to be loyal to my Arthrex rep, as they helped get me to some courses but apparently she been getting hers...

 

[CutsWithFury]

Wow, we are getting screwed (pun kind of intended)... I've been using the Arthrex kit, but I saw the invoice for the hardware and they were going for over $500 per screw. I've been able to justify it to myself by saying well it's cheaper than a lapidus plate/screws. How's the Stryker set up compare to Arthrex? I wanted to be loyal to my Arthrex rep, as they helped get me to some courses but apparently she been getting hers...

Call your rep out. He owes you some steak dinners.

 

[dtrack22]

So sexist.

Sexist would have been actually reading the post and asking if “she” was hot…

 

[Pronation]

Sexist would have been actually reading the post and asking if “she” was hot…

So transphobic.

 

[air bud]

Just trying not to get this off topic this was a good thread. I have no immediate intention of starting MIS. Open to it, will do some courses I have the time....has it's role but I still love me some lapiplasty.

 

[heybrother]

I'm enjoying this thread. I left residency absolutely confident that what I had been trained in - 1st MPJ fusion and lapidus for all - was absolutely right. I was very, very wrong. Dead stupid wrong. There's absolutely a place for osteotomy.

-The rehab is much faster
-If you need to resect the eminence/medial joint remodeling its far preferable to do it through 1 incision/procedure ie. I hate a lapidus where I have to both resect/remodel the 1st MPJ and do the fusion too.
-Small bunions are absolutely appropriate for osteotomy. If you are as crazy as I was and only thing lapidus is appropriate you are going to be missing out on a lot of surgery / telling patients their bunion is too small to be worth fixing.

Obviously osteotomy has limits. If the patient also has a flatfoot/instability/2nd MPJ symptoms/metatarsus adductus I'm inclined to believe something will still go wrong. I think the biggest miss people can make is trying to push an Auston on someone with substantial metatarsus adductus.

Small random thing. I've never heard someone discuss this before / bring it up (probably because of where I trained) - but post-op Austin's and post-op lapidus don't look the same at all. Totally different sort of expectation. Lapidus is theoretically all about closing the IM to position the joint under the great toe and narrowing the foot. You end up with a hallux next to the 2nd toe. The perfect Austin has no eminence but also maintains the space between the hallux and 2nd toe while still producing a straight toe. When I first got out I initially had this feeling of confirmation bias seeing overly aggressive Austin's that failed. However, since that time I've seen so many perfectly satisfied people. Not even people where they are still in valgus but they are ok - just satisfied people with good toe correction where I found myself looking at it thinking - wow, this worked.

That said. I've never seen a opening/closing whatever base wedge procedure work. Uniform dissatisfaction.

Anyway. Thanks all for the thoughts on MIS. I'm attempting to embrace the osteotomy but the benefits of less trauma/less dissection / less incision / easier healing / less scarring seems like a win. Every incision is an opportunity for something stupid to happen.

 

[Feli]

I'm enjoying this thread. I left residency absolutely confident that what I had been trained in - 1st MPJ fusion and lapidus for all - was absolutely right. I was very, very wrong. Dead stupid wrong. There's absolutely a place for osteotomy...

I would say you were actually right.
The literature on recur rates and IM loss and revision rates is not fiction (fyi, I probably did 65% austin and 10% cbwo in residency!).
Osteotomy indication is a veeery thin place.

Follow up is the enemy of "good" surgery. Don't mistake getting something done fast or quick recover for getting it done optimally.

I swear that I see at least a half dozen patients weekly avg who had bump-n-run or base or distal osteotomy and now have recurrence complaints of various types (1-2 impinge, IM/medial pain recur, lesser met pains, arthrosis 1st MPJ, etc). Some of them survived 20+ years, some not even a couple years. Most people plan to live a lot longer than 20yrs after bunions. These are powerful forces deforming (adductor, 1MC instability, etc). I would say less than 5% of my bunions taken to OR are met osteotomies anymore, but probably a third of mine overall are also revision (so a lot of MPJ1 fusions compared to most ppl?). I basically only use 1st met osteotomies for middle aged and older ppl who have primarily lesser met/digit pain. A lot of things look great on the table and fall apart later.

I just don't understand what is so wrong with normal open surgery (forefoot... tendon releases or some RRA or other I kinda get MIS approaches). It's not as if a shorter incision heals faster... as mentioned, it's tissue handling (and pt education/compliance) more than anything. Minimal or no tourniquet makes a big diff on post op rebound perfusion and pain/ecchy/edema also. It's not as if drilling a bone won't hurt since the incision is 5mm versus 35mm. We can stay out of the joint capsule with MIS or open osteotomies or Lapidus if we want (I very seldom choose to). It's not as it we are less likely to hit nerves doing screws blind stab/drill vs dissect + retraction with visualization. I don't find the 5-10mins of suture being especially consequential. I do WBAT and MPJ1 ROM by pt on nearly all of my forefoot once incisions heal in ~2wk, but that's jmo. I think podiatry (and industry) often looks to improve and fix stuff that's not broken?

 

[NatCh]

Do a majority of your post op bunionectomies report taking pain meds for a couple days and then not needing them?

I can say "yes" to this one, for pretty much all of my forefoot cases. I typically prescribe #18 (3 days worth) of Norco 5/325 and have only had two people need a refill for the past several years. Add 30-50 mg/kg of magnesium sulfate (MgSO4) IV over 20 minutes in pre-op holding. If you don't feel like doing the calculation for every patient then just order 2g. Edit: I also order 1g APAP, 400mg Celebrex, 600mg Gabapentin.

You're welcome.

Magnesium: a versatile drug for anesthesiologists

Magnesium sulfate has been used in preeclampsia patients in order to prevent seizure. It is also used for the treatment of arrhythmia and asthma and as an anesthetic adjunct in patients undergoing surgery for pheochromocytoma. However, its potentiating ...

www.ncbi.nlm.nih.gov

 

[GreenHousePub]

I can say "yes" to this one, for pretty much all of my forefoot cases. I typically prescribe #18 (3 days worth) of Norco 5/325 and have only had two people need a refill for the past several years. Add 30-50 mg/kg of magnesium sulfate (MgSO4) IV over 20 minutes in pre-op holding. If you don't feel like doing the calculation for every patient then just order 2g.

You're welcome.

Good tip, thanks

 

[wakaflocka88]

I can say "yes" to this one, for pretty much all of my forefoot cases. I typically prescribe #18 (3 days worth) of Norco 5/325 and have only had two people need a refill for the past several years. Add 30-50 mg/kg of magnesium sulfate (MgSO4) IV over 20 minutes in pre-op holding. If you don't feel like doing the calculation for every patient then just order 2g.

You're welcome.

100% agree. I do not refill norco 5 and rarely do as long as you set proven scientific expectations of post-surgical pain inflammation curve, which usually tapers off by day 3-4. Combine that with IV toradol and a good block, patient only really needs narcs 1-2 days for me personally.

And patient selection is paramount when it comes to this. Don’t be the pod that does #90 oxy 10s or refill at every post op visit.

 

[Feli]

...Don’t be the pod that does #90 oxy 10s or refill at every post op visit.

I'm seeing "that" guy's patients on a once almost daily... then weekly... now roughly monthly basis. It's a joy to see them on the schedule.

...Great tips by @NatCh ... I do same except #30 or #10 on norco 5mg (depending on the procedures). Very few norco refills ever needed. Toradol for all without contra, gabapentin once in PACU also. I do NSAIDs pre-op and through unless there's a contra... the inhibits bone healing thing is hocus compared to cost/benefit. I may have to look into MagSulf. I think the biggest pain/edema help on most forefoot/midfoot/Achilles/scope/etc is with no tourniquet (on but not ever inflated).

For some of the RRA, you do have to leave room to go up on pain meds, though. I might do oxy short supply or sed hypno short supply if they are struggling with just norco for major recon/trauma. Muscle relaxers are great in recovery or ongoing for tendon work. Gabapentin ongoing for a few weeks is good for amps or major recon also. I have mixed feelings on pop blocks... leave them up to anesthesia... seems they're 0 pain for a day or two and then you usually get the phone blown up?

 

[deleted1138023]

I'm seeing "that" guy's patients on a once almost daily... then weekly... now roughly monthly basis. It's a joy to see them on the schedule.

...Great tips by @NatCh ... I do same except #30 or #10 on norco 5mg (depending on the procedures). Toradol for all without contra, gabapentin once in PACU also. Very few norco refills ever needed. I do NSAIDs pre-op and through unless there's a contra... the inhibits bone healing thing is hocus compared to cost/benefit. I may have to look into MagSulf. I think the biggest pain/edema help on most is no tourniquet (on but not ever inflated).

For some of the RRA, you do have to leave room to go up, though. I might do oxy short supply or sed hypno short supply if they are struggling with just norco for major recon/trauma. Muscle relaxers are great in recovery or ongoing for tendon work. Gabapentin ongoing for a few weeks is good for amps or major recon also.

the inhibit bone healing thing isn't hocus

 

[wakaflocka88]

I'm seeing "that" guy's patients on a once almost daily... then weekly... now roughly monthly basis. It's a joy to see them on the schedule.

...Great tips by @NatCh ... I do same except #30 or #10 on norco 5mg (depending on the procedures). Very few norco refills ever needed. Toradol for all without contra, gabapentin once in PACU also. I do NSAIDs pre-op and through unless there's a contra... the inhibits bone healing thing is hocus compared to cost/benefit. I may have to look into MagSulf. I think the biggest pain/edema help on most forefoot/midfoot/Achilles/scope/etc is with no tourniquet (on but not ever inflated).

For some of the RRA, you do have to leave room to go up on pain meds, though. I might do oxy short supply or sed hypno short supply if they are struggling with just norco for major recon/trauma. Muscle relaxers are great in recovery or ongoing for tendon work. Gabapentin ongoing for a few weeks is good for amps or major recon also. I have mixed feelings on pop blocks... leave them up to anesthesia... seems they're 0 pain for a day or two and then you usually get the phone blown up?

Yes to flexaril/gabapentin also. I usually prescribe those before refilling a Norco. But again, too many providers have the reflex of “refill”.

I do not believe in NSAID inhibiting bone healing. I tell anesthesia to give IV toradol without hesitation. To me the benefits outweigh the potential risk.

I do my own ankle/foot blocks since I feel I have better control over the regional distribution that I want to cover, no issues so far and much lower risk of skewering the tibial nerve and getting a drop foot, or the notorious rebound pain after a pop/adductor block. I used to do Exparel, found it wasn’t any better than lido/marcaine.

 

[dtrack22]

the inhibit bone healing thing isn't hocus

It’s weird how fractures all over the world heal with patients taking ibuprofen for weeks…

I used to do Exparel, found it wasn’t any better than lido/marcaine.

I still use exparel on forefoot cases. I also don’t get any pushback and only operate at a hospital so cost isnt an issue. Usually have patients state that they did not have any post-op pain until sometime the following day at the earliest. I don’t get 48 hours of anesthesia often but I have had a few patients where they reported zero pain from a Thursday surgery until Saturday. I don’t get long lasting anesthesia when I do a circumferential ankle block with exparel. I’m doing it blind (no US for any of the areas) so maybe I’ve just been inadequately anesthetizing the tibial nerve? The rest are so superficial that I don’t think I’m missing them.

 

[wakaflocka88]

It’s weird how fractures all over the world heal with patients taking ibuprofen for weeks…


I still use exparel on forefoot cases. I also don’t get any pushback and only operate at a hospital so cost isnt an issue. Usually have patients state that they did not have any post-op pain until sometime the following day at the earliest. I don’t get 48 hours of anesthesia often but I have had a few patients where they reported zero pain from a Thursday surgery until Saturday. I don’t get long lasting anesthesia when I do a circumferential ankle block with exparel. I’m doing it blind (no US for any of the areas) so maybe I’ve just been inadequately anesthetizing the tibial nerve? The rest are so superficial that I don’t think I’m missing them.

Good point but I’ve found either 0.25% or 0.50% marcaine plain to be working for me for at least 12-24 hours. I tend to put prob 10-15cc in the tarsal tunnel area and then sometimes I’ll put 5-10cc at the fibular neck as well. Again can’t hurt to go wild on using local - safe, effective and just works. I usually give before and after the case if it goes for more than 1.5 hours

And yes to NSAIDs and fractures 😂 the benefits of toradol is wonderful for post op pain and so is my ibuprofen/meloxicam

 

[PointyNippers]

For those that have done MIS bunions - what's your standard post-op protocol?

Looking to get familiar with it and see if it's something I wanna start doing. I was trained in residency to basically Austin/Akin everything or a Lapidus if IM angle is big enough. But I've been noticing a lot of post-op MPJ stiffness like mentioned before

 

[dtrack22]

WBAT in surgical shoe post-op, transition to regular shoes as tolerated at 4 weeks. Transition back to high impact activities/sports at 8 weeks.

My first post-op is at 2 weeks for suture removal and I do have them start manual ROM of MPJ at home (dorsiflexion, plantarflexion, Adduction away from 2nd toe) at that visit. See them at 6 weeks for Xray and make sure transition to shoes is going ok. Usually final post op at 3 months for xray and make sure they are back to pre-surgery activities. Bone will continue to remodel past that and I will often times schedule a 6 month post-op for xrays just for board purposes, but many don’t show up because they have no complaints so they figure they don’t need to come in which I’m fine with but some ABFAS dingus will likely ding me for that despite notes detailing return to activity without complaints at the 3 month visit.

 

[Pronation]

For those that have done MIS bunions - what's your standard post-op protocol?

Looking to get familiar with it and see if it's something I wanna start doing. I was trained in residency to basically Austin/Akin everything or a Lapidus if IM angle is big enough. But I've been noticing a lot of post-op MPJ stiffness like mentioned before

Mine is pretty conservative for now.

4w heel WB in surgical shoe, then 3w WBAT in surgical shoe, then transition to sneakers. No high impact until 12w.

 

[air bud]

Mine is pretty conservative for now.

4w heel WB in surgical shoe, then 3w WBAT in surgical shoe, then transition to sneakers. No high impact until 12w.

Jeepers that is a lapidus protoc for some...

 

[air bud]

WBAT in surgical shoe post-op, transition to regular shoes as tolerated at 4 weeks. Transition back to high impact activities/sports at 8 weeks.

My first post-op is at 2 weeks for suture removal and I do have them start manual ROM of MPJ at home (dorsiflexion, plantarflexion, Adduction away from 2nd toe) at that visit. See them at 6 weeks for Xray and make sure transition to shoes is going ok. Usually final post op at 3 months for xray and make sure they are back to pre-surgery activities. Bone will continue to remodel past that and I will often times schedule a 6 month post-op for xrays just for board purposes, but many don’t show up because they have no complaints so they figure they don’t need to come in which I’m fine with but some ABFAS dingus will likely ding me for that despite notes detailing return to activity without complaints at the 3 month visit.

Oh they are totally going to get you for not having a healed osteotomy at last x-ray.... Although this although this certainly does raise some interesting questions as more and more people are going to be doing mis bunions

 

[dtrack22]

Oh they are totally going to get you for not having a healed osteotomy at last x-ray

There is bony consolidation and cortical bridging at the osteotomy site at 3 months in the location where the medial met head and lateral met shaft are in contact. You just don’t see that lateral bony remodeling that occurs outside of or lateral too the shaft of the first met. It’s technically a “healed” osteotomy, but there are still bony/adaptive changes that occur on xray past 3 months. Another great example of how dumb the ABFAS case review process is.

 

[CutsWithFury]

There is bony consolidation and cortical bridging at the osteotomy site at 3 months in the location where the medial met head and lateral met shaft are in contact. You just don’t see that lateral bony remodeling that occurs outside of or lateral too the shaft of the first met. It’s technically a “healed” osteotomy, but there are still bony/adaptive changes that occur on xray past 3 months. Another great example of how dumb the ABFAS case review process is.

ABFAS will get you on that. Promise you.

They will also audit you for the years you worked in private practice and ask for a letter from the hospital you were privileged at to confirm you did the cases you recorded during your first 3 years in private practice. Count on it.

 

[dtrack22]

They will also audit you for the years you worked in private practice and ask for a letter from the hospital you were privileged at to confirm you did the cases you recorded during your first 3 years in private practice. Count on it.

They select a single month from a single facility and it is universally a month from the same calendar year that you are registering for the case review. Meaning, you register this Dec (or whenever they lock the logging system) your audit is going to be from a facility you worked at in 2022. Seems to also be pretty universally May-Sep of that year. I was going to at least do case review for the foot exam during my second job and they asked for my logs from the hospital I was operating out of in either June or July of that same year. I ended up not sitting because the hospital didn’t send whatever certified affidavit they were supposed to in time…

I did speak with someone at ABFAS after my first job where I asked about the possibility of having to track down cases from a hospital that was hours away that I no longer had privileges at and they were pretty adamant that they will select your most recent cases whenever possible. So unless you only have one rearfoot case from your new job, and they are forced to pick older cases, they will generally select more recent cases and not cases from your first month out of residency. And that’s even if you are the same facility the whole time. We’ll find out if there is any truth to that…

 

[Pronation]

ABFAS will get you on that. Promise you.

They will also audit you for the years you worked in private practice and ask for a letter from the hospital you were privileged at to confirm you did the cases you recorded during your first 3 years in private practice. Count on it.

This is exactly why I avoided MIS bunions and also only did straight forward TARs during the board collection period.

 

[Creflo]

My postop pain protocol: I don't see the need for toradol if I block the area with marcaine. They both have a similar duration of action. I generally go with nwb with foot elevated, 3g tylenol per day, if still painful add ibuprofen, and if still painful narcotic as last resort. They rarely need narcotics with this protocol. If they are hurting after the first couple of days postop, I treat with activity reduction instead of pain meds.

 

[CutsWithFury]

I’m doing my wife’s bilateral bunions via MIS one day. I’m not letting some other dumb podiatrist touch her.

 

[air bud]

I am lazy can anyone point us in the direction of good literature abput long term success of MIS bunions?

 

[deleted1138023]

I am lazy can anyone point us in the direction of good literature abput long term success of MIS bunions?

it doesn't exist.

 

[DexterMorganSK]

I am lazy can anyone point us in the direction of good literature abput long term success of MIS bunions?

Agreed with ToeFather, not much info on the long-term success of MIS bunions. However, in the video below, he talks about several papers (from 19:40 mins) showing some of the positives of doing an MIS.

 

[air bud]

it doesn't exist.

As I suspected....

 

[dtrack22]

As I suspected....

Not sure what Siddiqui‘s longest published follow up is. But Bosch has 7-10 year follow up study. They’ve been doing percutaneous met osteotomies in Europe with temporary k-wire fixation for 30-40 years. So they exist despite ToeFather’s response to the rhetorical question you thought you knew the answer to… and they get published in a real journal like Foot and Ankle International. I’m sure Treace has a sponsored study with long term follow up in FAI or JBJS though right?

 

[Dr. Little Foot]

My MIS are smaller incisions and extend as necessary, such as in a lapidus. I only need about 6cm over the TMTJ to do my work. If you respect the soft tissue it will in turn heal predictably for the most part. Don’t retract like you’re the hulk, don’t crush tendons and ligaments, watch your tourniquet time, close appropriately. And most importantly - patient selection. MIS doesn’t mean now every single patient is eligible.

What are your top criteria for MIS eligibility/patient selection?

 

[wakaflocka88]

What are your top criteria for MIS eligibility/patient selection?

I don’t do the 1mm MIS stuff. I just meant that my style of MIS is still open incisions but I keep it as small as I need for visualization and still do the work, such as a lapidus, brostrom, ankle fractures, ankle fusions, Achilles’ tendon repair. You don’t need a 20 inch long incision for an Achilles’ tendon. Start small and extend as needed. Whatever style works for you. But again doesn’t matter what you do. If you don’t pick your patients wisely then you have to deal with the aftermath. Too many pods are cut happy. But complain of post op headaches. Duh?

 

[Pronation]

What are your top criteria for MIS eligibility/patient selection?

A pulse and commercial insurance.