Name: MIS: A Skeptic's View
Uploaded: 2020-05-01T00:00:00Z
Channel: Arthrex
Description: Jesse Doty, MD (Chattanooga, TN), provides an overview of the adoption of and success with minimally invasive surgery (MIS) techniques in his practice from a skeptic's point of view.

<p>Jesse Doty, MD (Chattanooga, TN), provides an overview of the adoption of and success with minimally invasive surgery (MIS) techniques in his practice from a skeptic's point of view.</p>

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VID1-000766-en-US | A | MIS: A Skeptic's View

Jesse Doty

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MIS: A Skeptic's View

So I've been tasked. I really, truly respect these guys, and I did not include a lot of literature in this, and certainly no mine or George or myself can provide you with literature if you're interested. There are a lot of studies out there, but I'm Jesse Doty, I'm from Chattanooga, Tennessee, and I've been tasked with giving you a glimpse into the approach I took with miss, as I was skeptical in the beginning. And I think there are multiple reasons for that. I think as surgeons, we really it's important for us to act as the gateway between new procedures and new Innovation and our patients when they're in their most vulnerable positions, literally. And so hopefully I can show you how I've incorporated this in kind of my thought process. This first came onto my radar probably about three years ago. I had a patient, who knew my family and requested that I do her valgus deformity correction and suggested that I do it with miss and off the cuff. I said, look, it's not certainly something that I would recommend. I'll be happy to take care of your complications when you get back to town. In jest. But she caught my attention because she went out of state and there weren't many people in the US doing it at the time, and she had both done simultaneously, and she did phenomenal. And so it was it really came onto my radar. And then I began to see more and more things like this pushed by the Europeans initially, even in the third generation and then becoming more popular in the US. And I thought to myself, I'm young enough in my practice, hopefully I have enough of a career ahead of me if I'm going to continue to market myself as a current generation surgeon, offer cutting edge techniques. Is this something that I'm probably going to have to embrace, and would I rather embrace it now and go through the learning curve simultaneously, or have to put myself through the inevitable later? If indeed this continued to stick, I did still have a little bit of reservation. I think the issues were I'm in a pretty small metropolitan area. And you work so hard to gain a reputable relationship with your patients and the community. You don't want to go through a new learning curve when you've done a procedure for so many years, you know what the expectations are. You know what the complications are. You know what to suggest your patients as far as recovery. And then you're going to go through a whole new set of complications or just unknowns. The other thing is I have a really busy surgical practice. And so it was very inconvenient for me anytime I tried to incorporate something new into my practice because I need to get through cases. And they're not all glorious cases. Those are diabetes. Anything. But we all know how busy our lives are. But I continue to see more and more of this. And we've all heard the term don't knock it until you've tried it. And so I thought, well, I probably should at least go to a course and see what the difference is. And so, you know, Doctor Acevedo talked about the earlier generation techniques, Isham in the 80s and Bosch in the 90s. And I think the real difference is those guys did not necessarily stick to the mantra and the original teaching of technique, which had been perpetuated and successful at that point for a couple decades, and those being atraumatic technique, early mobilization and rigid fixation. And so we now have these burs, which are certainly more precise than chisels or saws. And then you can see we have irrigation, which is going to decrease the risk of skin necrosis, which is a new thing. Also the risk of heat osteonecrosis to the bone. It's a It's a lower speed. And so again, less of a heat generator generator just from the BR in and of itself. And higher torque to cut through the bone with the same efficiency just at a lower speed. The other thing really, the BRS evolved in and of themselves with specific BRS for specific procedures, better to effectively cut through bone and less so through soft tissue. A really elegant instrument tray is now available, and we know how important it is to maintain a working portal. So to really elevate the soft tissue, create that working portal where you can access the bone and avoid the risk of wrapping up tendons and nerves. And then even just for the translation of the bone and the 3D orientation correction of the deformity, it's a very simple and elegant instrumentation to do that. The implants also evolved, and this is new compared to what we utilize 10 or 15 years ago. Different options different ways to avoid prominence of the hardware, easier to put the hardware in through smaller incisions with cannulated instrumentation, and also with multiple sizes available for multiple procedures. And so I set out to at least become familiar with the technique. Its popularity seemed to be on the up. And I knew that I would inevitably see these patients in my practice. And I'd already seen some. And if indeed I was going to recommend against it, I think it's important to at least know what I'm recommending against. And perhaps there was something I could learn. And so I think with the calcaneus, it was an easy one that seemed very intuitive to me for positioning sitting at the end of the table. It's easy to bring x ray in and then swing under for Harris axial to check your correction. It's generally a simple straight osteotomy. And if you deviate, you've got quite a large surface area in the calcaneal tuber where you can still obtain a successful correction. And then indeed, there may be some benefit to that compared to an open incision. Looking at wound complications, I've certainly seen in my own, particularly with cave aviaries, foot correction, where you attempt to do a lateral closing wedge osteotomy, address the peroneal tendons and ligaments all through one incision. It can be very difficult and lead to wound problems. So nerve complications, which I've had and it may decrease pain. And so it seemed intuitive and was generally pretty simple to perform. And it also provided a solution to a problem which I felt like I already had in my practice, and perhaps was the way I could improve my current techniques. And so I think the initial intimidation part in the beginning is easy to avoid if you really think through these cases. And I would suggest that the first thing you want to do is think about your ore setup. Where do you want to sit to comfortably access the foot? And it seems intuitive, but we've all done so many cases at this point. It's not something that necessarily goes through our mind. Secondly, once you've determined where you want to sit, where do you want the c-arm to come in from? Because positioning in the O.R. can really make or break you, or really rise the frustration level in the room. And so for this one, this is a valgus. So I always sit on the medial column of the foot for a valgus reach across the whole leg. And then I can easily access the medial column basically for the entire case until I put in the Aiken screw. And then once you've determined where you want to sit, where you want your c-arm, you can establish where you want to put the burr system, because you can really put that about anywhere. Just like Doctor Acevedo alluded to, it's there's no real deviation from the fundamentals of what you've been taught and what you've been successful with in your practices to this point. You can't ignore the fundamentals or you're going to run into problems. And so if you look this is a juvenile patient with a pretty significant Ma. You can always do always do triplanar correction, just based on the estimation that you place your burr, where you place your pivot point and the insertion of the near cortex, and then where you exit. And so in this case, I am a little bit distally, because I know as I do a medial closing wedge to correct the DMA, I'm going to shorten the bone. And then I can re lengthen the bone as I shift. Also doing a more aggressive Aiken, because we know in a juvenile we expect a little bit more recurrence. And so I think if we stick to these fundamentals and we don't ignore things such as length, DMA and angles, we can still safely perform these procedures just through smaller incisions. The same thing goes for the Colectomy. This is another procedure that I've incorporated into my practice, and it seems very simple and intuitive, but you really need to look at an algorithmic approach. Making a working portal to elevate the EHL, the soft tissues, the dorsal medial cutaneous nerve, making a planar cut where you where you can work interosseous within the bone and be much more remote to wrapping up the soft tissues. And this is a look at a colectomy, which you can then fine tune by removing a portion of the proximal phalanx dorsally through a separate portal. And then we go back to those fundamentals. Early mobilization. You have small incisions, so there's less risk of wound problems. In one study, over 80% were in normal footwear with ordinary daily activity at two weeks. I think the key is avoiding frustration. Anytime you take on a new procedure. And how can you anticipate to avoid some of the pitfalls? For me, you have to really think about the osteotomy prior to performing it. And so when I began doing these cases, I wrote down the steps after I left one case, which was strategically scheduled on a Friday afternoon when I knew that I would be in a good mood, my staff would be in a good mood and I would be less crunched for time. I would walk out and make a list of the things that went well, and the things that could that could have been improved upon. And then I would read that before each case in the beginning. So osteotomy location becomes more important. And a lot of that is because implant accuracy is much more imperative. You have to be more selective with your implants because there are less choices to place through smaller incisions. You have to exercise patience with typically easy skills we take for granted placing K-wires and it can be very difficult with smaller, more flexible K-wires, particularly in smaller bone. It's new, so allow extra time for the learning curve. And remember the fundamentals haven't changed. So if you get frustrated, just stick to the fundamentals that you've learned. Have a bailout plan, even if that means you're going to open or reinsert a K-wires, which has been done successfully for decades. And then again, planning and mental playthrough are key. And I think if you stick to that mantra, you can really make it something that you can anticipate a predictable outcome. This is how I go through generally, every single bunion I do for a standard bunion without congruency. I make an incision from a seated position at the metatarsal excuse me at the metatarsal metaphysis distally followed by the proximal phalanx, and then elevate from my working portal. I then perform my osteotomy. Perform the shift. This is one area where, you know this may take 2 or 3 minutes, or it may take ten minutes, but it's a two handed technique to maintain the position of the metatarsal head within the sagittal plane, and then some assistance to advance the wire while you pull the toe into appropriate position. Once you've accomplished accomplished the shift, you can hold it there. And then another portion of the procedure where I know to anticipate this may take two minutes. This may take ten minutes. Insertion of the screws, followed by the Aiken osteotomy and the resection of the medial eminence. And so why would you not try something like this if you feel like you can accomplish the same thing through smaller incisions. And I think it goes back to the original thought process that I had. It's something that was unfamiliar. It's something that I didn't know what to anticipate. I was unsure of the complications and really unsure of the outcomes. And so hopefully if you get a chance or an opportunity to go to one of these courses, you may see that perhaps there is some truth to what you've seen. And perhaps with the third generation techniques, this may continue to evolve and have more applications, particularly in foot and ankle surgery. And so this again, the surgery I did a couple of weeks ago, patient with not very healthy skin. There's a look intraoperatively through hammer toes. And then there's a look. And you'll always see that that bone begins to fill in. And so it's become very predictable. And again I think it's important as techniques evolve to continue to consider different applications, different fundamentals where we can really make a difference for our patients. Thank you.