Bobby Ndu, MD will discuss new technique that is revolutionizing foot and angle reconstructive surgery. These surgeries used to require large formal incisions and with these new techniques we are able to reduce incisions down to the size of a keyhole. Dr. Ndu discusses these new techniques and the positive impact they will have for patients; this can mean smaller incisions, less soft tissue dissection, less scarring, less pain and swelling, and a faster return to activities.
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Bobby Ndu's, MD, MBA There's a new technique that's revolutionizing foot and ankle reconstructive surgery today. I'm going to show you how we're using it to help our patients here at penn medicine. Hi I'm dr bobby undo an orthopedic surgeon at penn medicine. And I want to share with you some of the new and exciting advancements in minimally invasive foot and ankle surgery. These techniques have allowed us to take procedures that used to require large formal incisions and their subsequent dissections down to being done using incisions the size of a keyhole. Using a smaller incision means that there is significantly less soft tissue dissection which means less scarring, less pain and swelling and often a faster recovery with an easier return to activity for our patients. But like any kind of surgery, minimally invasive surgical techniques still carry risks such as bleeding infection or damage to adjacent anatomy. To name a few. Let's start by looking at one of the procedures you may have heard about a minimally invasive bunion correction. So we first begin by making a small incision on the side of the toe and that's about the extent of the incision that we need to start our procedure after we make this incision that's about the size of the blade. We then take our cutting instrument which is a low speed, high torque burr and verify our position on X ray. We're very particular about the angle at which we make that cut to make sure we get the most optimum correction. We use the burr to make our cut through the bone which allows us to start the process now of correcting the bunion. We then proceed to shift the bone over into its new position and that is highlighted here by our instrument that is passed down the canal of the first metatarsal and represents a block to the metatarsal head, pushing it laterally, creating our correction after we have verified that we're happy with our shift and position. We placed two K wires into position through a separate keyhole incision to help hold the head and its new place. And then we verify on our X ray that we're happy with the position of the bone and the wires before we commit to anything. After we place the initial guide wire we place a second one parallel to it, just to give us additional fixation and to ensure that what we're trying to create is a stable construct. We then measure to determine the length of screw that we will need to pass over the wires to leave in as our permanent implant. We proceed to over drill the wires to make room for the screws and this is all being done through the second keyhole incision, we can appreciate our instruments still holding our metatarsal head shifted and our temporary fixation of our guide wires coming here from the base of the metatarsal. Once we verified that we've drilled to the appropriate depth, we then placed our screws over the wires to give us our permanent fixation and now we can see that we have placed our screws over the guide wire and you can appreciate that the head of this screw is quite specially shaped to match the metatarsal shaft and ensure it will not cause any soft tissue irritation given the trajectory that is required for us to connect the metatarsal shaft to the head in its newly realigned position. And we can see here the relatively small nature of the two incisions that we've had to use now to accomplish this one that can be visualized right here where our screws entered and the second incision up here where we made the original cut to the bone that allowed us to correct the bunion. Now, if we were to do this as a classic open chevron nasty autumn E, the incision would have to be much broader, requiring significantly greater dissection to allow us exposure of the bone to make the appropriate cuts. We need to come through the skin, the underlying muscle as well as the capsule that surrounds the joint to give us access to the bone before we can even begin to make our cuts. And here you can see me moving the tissues aside still before we would have even started the procedure. One of the beautiful things about minimally invasive surgery is we have avoided all of this and we've been able to do the same procedure through a keyhole incision that is significantly smaller than what you see in front of you here now. So now let's look at the difference of that open incision versus what we did earlier with the minimally invasive. You can see here the increased risk, time and effort that's required for an open approach as opposed to the simple elegance of the small incision of an M. I. S. Approach. And that is why we're moving the majority of our patients to a minimally invasive approach because of what it means for them and their recovery. Let's take a look at a minimally invasive hammer toe correction. Now you can see that we have already made our keyhole incision and now we're passing our instrument in because we're already down to bone and our dissection is complete. We enter the bone with a low speed, high torque burr that allows us to then start cutting and removing bone to straighten the toe. And then here we can see that we have now removed a section of bone that is allowing us to now straighten the toe with our toes straightened. We then place a pin from the tip of the toe down to the base to allow us to maintain the straightened position that we were able to achieve. We verify with x ray that the pin is in good position and holding the toe as we would like. We will then typically cut and bend the pin to ensure that it does not catch on any clothes or other items and that completes the procedure for the hammer toe correction. Now we'll see what a hammer toe correction looks like when done in an open fashion. And we can see the dissection being done here across the top of the toe that will require us to move the tendon that moves the toe so that we have access to the bone and joint. This extensive dissection is one of the reasons that a known problem from hammer toe surgery is residual stiffness because of how much the soft tissues have to be moved to gain access to this small joint and the bones underneath. And so here we can see our open incision next to our minimally invasive incision to appreciate the significant difference in the amount of dissection and soft tissue mobilization required, with the minimally invasive incision being so small and so much faster and typically smoother recovery for our patients, giving them the best possible outcome with the least amount of effort. Now let's take a look at a minimally invasive cal Kania, last Iata me while minimally invasive techniques can be used for standalone procedures. They can also be used as an augment to much larger hind foot reconstructions such as we're going to see here in this situation, we're going to be doing an Osti Autumn E. Of the cal Kane ius or a cut in the heel bone. We first begin by inserting guide wires into the heel bone to create borders or to give us an outline of the cut we would like to create. and we can see here the outline of those borders that we're trying to create and that's formed by this pin coming up and this other pin coming down creating the triangle or wedge that we plan to remove. Once we've established that we determined our starting point by trying to come close to the inferior apex of that triangle, where we will make our keyhole incision. As you can see visualized here to be about the size of my blade. We then enter with our cutting burr which is a high torque low speed burr designed to protect our soft tissues but is strong enough to allow us to cut the bone. We first entered the bone and then we start a process of reaming away everything that was between our two wires in that triangle. And as we ream we remove the burr every once in a while and place suction through the same hole to remove any bony fragments. This allows us to keep track of what we're doing while ensuring that we're doing it safely and respecting the patient's adjacent soft tissues. So here we can see the wedge that we have created and the bone that we have removed represented by the clear space that you can see here right in front of the wire and we will continue to make that larger and larger as needed until we have it large enough that we can now begin to mobilize our Osti Autumn E site and close down that wedge so that you can see where it is now shortened and much smaller as we are now able to move this poster tuba ross et anterior early, thus changing the entire angle of the cal cane ius. After we've shifted it forward, we then place guide wires to help hold the position. We then place screws across our Osti Autumn E. Site to bring it together and close down the gap we have created, thus changing how the patient's foot meets the ground, how their achilles meets the foot and how the patient perceives their discomfort going forward with significant improvement of pain. This is our entry site for all of the hardware that we placed to adjust our call cranial angle and we can appreciate here the actual size of this incision being approximately one centimeter, which also matches the size of our surgical site, measuring approximately one centimeter pictured here on the side of the foot. So we have just realigned the entire cal Kane ius as well as this patient's ability for ambulance station through these two small one centimeter incisions. Now let's compare that to what the open incision looks like for the minimally invasive. We've taken it and shrunk it to one centim were on the open approach. You can appreciate that it is at least 4-5 cm and requires me to move aside a significantly greater amount of tissue to get down onto the bone before we would even start making our cuts to remove a wedge and attempt to bring it forward. The need for increased visualization requires increased surgical time and dissection. One of the other differences between minimally invasive and open surgery is the requirement to hold the tissues open. The constant need to apply tension to the tissues to improve visualization also decreases the blood supply to those tissues during the approach and during the surgical procedure, which increases the chances of infection, wound healing, complication or postoperative wound breakdown due to poor blood supply. So here we can see the true difference between our minimally invasive incision versus our formal open incision and the amount of dissection that is required and the amount of soft tissue mobilization that is required. And that's why we're moving most of what we do here to our minimally invasive approach is to help our patients recover faster more comfortably and get back to life more quickly. My colleagues and I here at Penn Medicine are constantly working to provide the latest surgical techniques to help our patients get back on their feet. To contact us about surgical options for your patient or to refer your patient to pen orthopedics, Call our dedicated referral line or visit penn medicine dot org slash refer