Expert Insights on Minimally Invasive Bunion Surgery
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Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of the Foot and Ankle Surgery Institute or HMP Global, their employees, and affiliates.
Transcript
Tyler Gonzalez, MD, MBA, FAAOS: Thank you, everyone, for joining us tonight. My name is Tyler Gonzalez. I'm Assistant Professor of Orthopedic Surgery focused on foot and ankle at University of South Carolina. Tonight we're here with HMP Global Foot and Ankle Institute to do really the first of many series of minimally invasive surgery discussions. Tonight we're going to focus on minimally invasive bunion surgery and we have two world experts here tonight. Dr. Brian Loder out of Michigan and Dr. Oliver Schipper out of the DC/Virginia area. They're two really good friends of mine and two real experts in the field of minimally invasive foot and ankle surgery in general and minimally invasive bunion surgery. So it's a real honor to have them tonight, and I think we're going to learn a lot from them.
How have you integrated MIS bunion surgery into your practice?
Dr. Gonzalez: You know, Dr. Loder, you've been doing MIS along with Dr. Schipper, probably more than, somewhat in the longest in the country. Can you just give us a little background about kind of how you got into MIS bunion surgery and how that has really integrated into your practice over the last few years.
Brian Loder, DPM, CWS, FACFAS: Originally, I don't know, somewhere in about, you know, the 2014 age, I started to get extremely bored with the outcomes of bunion surgery—just didn't like the recurrence rate, didn't like the outcomes, didn't like the patients’ outcomes and not coming back to the other side because it was so painful. So I dug into the literature and I came across some of the literature in Europe exposing the minimally invasive technique and I bought onto that. Now I started doing it prior to any instrumentation, so I had to kind of work my way through it, making the incisions smaller and smaller, and then I got lucky enough to get hooked up with a group of surgeons including Oliver and Holly to bring the new instrumentation to the United States and then start doing it.
And that was the big game changer for me in my practice. Once I started doing MIS, my patient volume went up, patients traveled to come see me more, farther distance, and it just started to explode. And then I started to look for more and more avenues to use that technique in other foot and ankle surgery procedures.
Dr. Gonzalez: I mean, I think it's such an incredible journey and I think now the AOFAS just this year released a position statement accepting minimally invasive surgery as an acceptable bunion solution. But so many people are still scared of this despite so much literature and acceptance and being involved in both the podiatric and the orthopedic communities. I mean, Dr. Shipper, you started very early on, one of the early adopters of this, right out of your fellowship. I mean, how did you say, "Okay, I'm just going to do this," when no one else was doing it at this time, being a new surgeon, now you're in your first decade of practice and one of the leaders in the space? But for those people who are listening, who are still nervous about it, I mean, you did it before there was any of this data. Anyone was doing it. What motivated you to jump on board it? And what were some in the beginning, your biggest hurdles you faced in starting this new type of surgery?
Oliver Schipper, MD: Yeah, so for me, when I was going through training—and I train with some incredible surgeons, really had blessed to have some really great mentors down at Ortho Carolina. But when I went through fellowship and even in residency too, by mentors in residency, everyone always talked about, when could I stop doing forefoot surgery? And especially because of the bunion surgery itself, right? There's a big cosmetic component. Everyone always said 90% did well, 10% did not. No, doesn't matter who you are, doesn't matter how good you are. And then they always talked about what a, you know, painful surgery it was for patients, long recovery, right? So it just didn't sound that great. And again, these are some of the best surgeons I think in the world, right?
And so I thought there's gotta be a better way. You know, probably like most surgeons, I don't wanna hear patients complain after surgery, right? I wanna do a great job, you know, get them through. So it's a nice, quick, easy clinic visit. So I just thought there's gotta be a better way. Happened to see, just see this from Stryker because this was right when they were considering bringing the burrs into the country and Ortho Carolina was at the time the Wright Medical mothership. So I had kind of seen the burrs. I'd seen the technique. It was so different from kind of a lot of what we'd seen. The fact that you didn't have to do a (inaudible) was so different, right? And you think, is that going to really work when we do that on pretty much every bunion at the time.
And so you know it's an election year so the thought was kind of how make bunions great again right and I just started doing it early and you notice the difference very early, right? I mean, these patients came back, at two weeks they were complaining about pain, sometimes they took no narcotics, which was fairly uncommon with open bunion surgery but it just was a very different recovery. And I kind of took that we say the leap of faith, right? I said, hey, I'm gonna commit to this and do it, right? And, you know, I haven't looked back, right? We started joined with industry and then started training kind of very small groups at first—one person, two person, three person labs. And it just kind of has grown over the past really eight, nine years, the point where now we've got labs, we're doing (inaudible) in San Diego with, I think it's like 50 surgeons, right? And now we've created a minimally invasive foot and ankle surgery textbook.
So it's just kind of grown over time as acceptance has increased in this country. And it was the best decision I ever made. I mean, selfishly, I made it initially because I thought, Hey, I got to differentiate myself in a saturated DC Metro marketplace. But again, best career decision I made and, and for my patients’ sake it's really been incredible.
What are the factors driving your embrace of MIS for bunions?
Dr. Gonzalez: You made so many good points there. And I think one thing is somewhat of that leap of faith, but I think when we look at all areas of surgery, right, from general surgery, orthopedic surgery, ENT, everything has gone from open to mini open to minimally invasive or laparoscopic, arthroscopic, right? The lap hole used to be open, then it went to mini-open, then it went to laparoscopic. Rotator cuff went from open to mini-open. So this is a natural trend in surgery. So it's nothing crazy, right? This is what people do. And I think one thing that's interesting is there are a lot of fads in foot and ankle surgery, as both of you know. And I think with minimally invasive surgery, things come and they go, but as you alluded to Dr. Schipper, like in minimally invasive, more research is coming out, more industry is getting involved, more money is being put into it, more textbooks are coming out, more people are doing it. So, and the reason is, in my opinion, is patients are doing better. Dr. Loder always mentions patients are patients are asking for it.
So Dr. Schipper, one thing I want to ask you, in your evolution of doing this, and for the audience who may have not started or is getting going, what percentage of your bunions are minimally invasive? And why is the real reason? Because you alluded to that patients do well, but we know you can still get a good correction with an open chevron, you can do a good correction with a 3D modified Lapidus procedure. What's your reason? And I wanna hear Dr. Loder's reason after. You know, why you haven't, what percentage are you doing and why that percentage is not more divided? 'Cause I kind of know what it is already.
Dr. Schipper: This is like leading me here. But no, I mean, for me, it's 100% MIS at this point. I mean, going back to doing an open bunion just seems like a painful endeavor for me at this point, it's become so routine. And it's like anything in surgery and there's plenty of literature support this, especially in arthroplasty, but the more you do one technique, the better you are at it, right? In terms of complications. And so you do it, I mean, so many hundreds, thousand times, right? Then it just, it becomes very repeatable, reproducible, staff know what you're doing, but for me, it's 100%. And I think what differentiates is this from prior MIS approaches that have come and gone are really twofold. One is the correction, right? This is really an IM correction as opposed to small translation with a medial invocation. And then the fixation really is the key, it allows for early weight-bearing, very stable construct. And that's as opposed to the older techniques, which were just kind of K-wire fixation, one screw fixation, one small screw, I should say. And then finally, just that, with these four and one reducers on our new burrs, right? Really reducing heat generation, you're just not seeing the same level of nonunion, asvascular necrosis that we kind of saw with older techniques.
Dr. Gonzalez: And Dr. Loder, I mean, you alluded to this, but what do you feel is your biggest driving force that has kept you evolving MIS techniques, continuing to develop new techniques and not come back to more open procedures that historically still worked?
Dr. Loder: It's definitely the patient outcomes. It's satisfaction rates, it is the low complication rate, low joint stiffness, low nerve issues, low risk of infection. And most importantly, I mean, you see so many patients coming back for the contralateral side, which you just don't see very often on an open bunion surgery. And they're coming back rather quickly. I mean, they'll do it within three to four months or five months, have the other side done. That is almost unheard of through an open bunion surgery. They usually have too much pain and don't want to proceed. I mean, as Oliver said, the narcotic use is hugely different. I mean, patients take one or two day one and never go back to them, go to Tylenol and Motrin. So overall, patients one, are asking for it, but number two, their outcomes and satisfaction rates are so high. I just can't go back away from that just because of the satisfaction rate alone.
Key points on MIS for hallux valgus
Dr. Gonzalez: Two points I liked, or three, that you said I think are key for our audience. So number one is bilaterally. I think all of us have done these and people did it bilaterally, but often long waits. I think these MIS bunion patients ask for it. They're ready to go there because the recovery is easy because they weren't in pain which speaks for the surgery themselves because if you're willing to go through it all again, it must have been not that bad. So I think that's really important. We're not making this up—the patients are saying it.
The second thing you said is the stiffness. I think minimally invasive surgery, it's about the tissue. Tissue’s the issue. And we don't strip tissue. We don't this capsule or invocation, and so their joint, their MTP joint is way less rigid. And I think that allows for less pain, faster mobility. And I think that's another real benefit of this procedure.
And lastly is narcotic use. So, I mean, we've published two papers now. We don't even give narcotics for this procedure. We do multimodal Tylenol, Meloxicam, Lyrica, Tordal, and we don't even give narcotics anymore. Most patients are still on Tylenol by day two. And so I think with the opioid epidemic, this is a doing minimally invasive surgery, especially MIS bunions has really dropped that. I mean, there's literature out there recently published that says narcotic use for bunion surgery can be 14 to 20 tabs. That's a ton when we're giving one to zero. That's a 20X difference, right? For narcotics. So I think that is a big factor that, that when you're considering this, think of these outcomes to your patients.
Dr. Schipper: I'll say real quick, just to one point you made, because I think it's important, but I think Tyler was discussing how these patients tend to have less stiffness. I mean, I would agree with them probably 50% of people, you know, they come in, you've got pretty much near full range of motion 'cause we're not violating the joint. We're very rarely doing lateral release, which, you know, in my opinion is probably necessary, maybe less than 5% of the time, if that. And then number three though, the only thing, the only caveat to that is just when you're doing this technique, and this is a little technique pearl, real quick. If you angle too distal with the burr, you're going to lengthen the first ray, but the soft tissue can only go so far. I'm just cautioning people just don't overangle the burr too distal because that would create stiffness in this technique, which otherwise people tend to have minimal stiffness, just so everyone's aware.
