Foot surgery is traditionally done as “open surgery,” meaning the area being operated on has a long incision to allow the surgeon to view and fix the anatomy. In addition, “open surgery” typically involves more tissue disruption resulting in scar tissue and the potential for longer healing. Recently, updated instrumentation has allowed more foot and ankle conditions to be treated with minimally invasive foot surgery techniques.
Because minimally invasive foot surgery (MIFS), does not involve a long incision, it avoids significant damage to the muscles and soft tissue surrounding the foot. In most cases, this results in less pain after foot surgery and a faster recovery.
Foot surgery is recommended only when a period of conservative treatment — such as medications, orthotics, injections, offloading, and physical therapy — has not relieved the symptoms caused by your foot problem. Once the problem is identified the surgeon will inform you of all the surgical options that can be used to fix your foot problem. If you are a candidate for minimally invasive foot surgery then those options will be explained thoroughly.
Minimally invasive foot surgery techniques are beginning to be used for a wider range of foot procedures, and have been used for common procedures like a bunionectomy and hammertoe surgery since the early 1980s. A bunionectomy relieves strain put on the foot by cutting and removing portions of bone and realigning it for better function.
MIFS bunion surgery corrects problems with the big toe joint to alleviate pain that is experienced in a closed shoe and while walking. This educational material focuses on bunion correction utilizing minimally invasive techniques.
Traditional bunion surgery requires the surgeon to make at least a 5cm opening in the skin and dissection of the soft tissue down to bone. With the soft tissue pulled aside and out of the way the surgeon can then see the boney problem needing correction. The surgeon then cuts the bone, moves it over, and places a screw across the bone cut to hold it in place. The surgeon moves the bone over so that the alignment of the bunion can be straight. Then the surgeon will typically close all the layers of soft tissue using absorbable stitches and finally sutures the skin closed with a skin stitch.
The bigger the dissection the more the soft tissue will be inflamed after surgery. This inflammation can result in nerve pain, decreased range of motion, and scar tissue. When the skin and soft tissue is pulled back during foot surgery the surgeon is able to identify anatomy easily. But the pulling back on the soft tissue often causes damage and swelling during the recovery period for the patient. This frequently leads to a longer and more painful recovery period.
Since minimally invasive foot surgery requires very small openings in the skin one can, correctly, conclude that the soft tissue damage is less extensive and therefore the pain and swelling after surgery is greatly lessened. This is very appealing to most of our patients since they desire very little downtime and do not want any inhibition of their lifestyle after surgery. Although minimally invasive foot surgery can be applied to many different foot conditions, it is important to note that not all patients will qualify for the surgery. It is not a solution for every type of foot problem but it does have its place when applicable.
Minimally invasive foot surgery for a bunion is probably the most common application of this technique.
Anesthesia is achieved only through local injections of anesthetic around the surgical site and the numbness typically lasts between 4-6 hours. This is definitely the most unpleasant part of the procedure since the patient is awake and can feel the injections.
Thankfully, at Advanced Podiatry, our surgeons use cold spray and medications to make the patient more comfortable so that the injections cause minimal discomfort. The use of local anesthesia greatly reduces the risks to the patient because it eliminates the need for general or sedation anesthesia. After the patient’s foot is properly anesthetized the procedure can begin. For a typical bunion the first 2mm
opening in the skin will be made just adjacent to the bump. A tiny instrument will be used to create a portal to the bone. After the opening is made an instrument called a freer elevator is used to free up the soft tissue around the bone. Once this space is created a small MIS rotary burr is introduced into the portal and the bump is shaved off.
Next, the surgeon will balance the pull of muscles on the big toe by releasing the tendon responsible for making the bunion worse. This release requires a small 2mm opening through the top of the foot. Once this tendon is released the surgeon will then turn his attention to the great toe. A small portal will be created on the inside of the great toe at its base. Here the surgeon will make a wedge shaped cut into the great toe bone using the specialized MIS rotary burr. This wedge cut is made so that the great toe will sit perfectly straight and the toe joint will be aligned.
After these 3 simple steps the surgeon will clean out the portals with sterile saline and will apply a sterile compression dressing to the foot. This dressing will be kept intact until your scheduled post-op appointment. It is very important to utilize the shoe gear that the doctor dispenses since we do not want the correction to be changed by excessive pressure.
Surgery is typically performed on a Friday so that the patient will have Friday, Saturday, and Sunday to relax their foot before returning to work. The more the patient stays off their foot the better they feel. Pain medication, anti-inflammatories, icing, and elevating also will help to keep the pain to a minimum. The surgeon can also choose utilize local pain patches so that patients will not have to take too many oral pain pills. The side effects of the pain pills may be very uncomfortable for the patient so the patches are a good alternative for relieving pain.
After receiving bunion (MIFS) surgery, our patients can walk the same day. The patient is told to simply keep the dressing clean, dry, and intact so that the surgical site is protected. A CAM walker or boot is dispensed to the patient to aid in the healing process as well. The boot is crucial because it allows the patient to walk with minimal weight on the surgical site. The boot can be cumbersome at first but our patients quickly adapt to their new shoe gear. The first post op visit is typically 3-4 days after the surgery and at that visit the surgeon will simply make sure that there are no issues or concerns that need to be addressed. The patient will then come back 10-14 days later and during that time they will continue to be in the boot. After the 2nd post op visit the patient will be instructed on how to dress their toe to ensure the alignment of the toe is secured. The skin by this time is healed and the patient is allowed to get the foot wet. The patient will return 14 days later and will be assessed for switching to a regular supportive shoe. If the patient can tolerate a regular shoe the patient will gradually increase their activity as tolerated. All of these steps are contingent upon the healing of the bones and the patients’ symptoms. That being said, every patient can have their own unique post-operative course. The consistent factor of all the patients is that pain and swelling is minimized and that they are able to carry on with their lives immediately after foot surgery.
Utilizing state of the art techniques to correct foot pathologies has always been a priority at Advanced Podiatry and now with minimally invasive foot surgery techniques we are effectively treating bunion pain with better results and minimal discomfort. Please call and make an appointment with Dr. Cruz today to help get you on the road to pain free walking.