A Quarter Century of Surgical Hardware Advances

Q: What do you feel are some of the most notable innovations in podiatric surgical hardware that have emerged since the year 2000?  

A: Jason Miller, DPM, FACFAS, FAPWCA, said 3D printing bones and hardware specific to a patient’s needs is a “game changer for both foot and ankle surgeons and patients alike.”

“We no longer are constrained in what we can offer a patient who has sustained a horrific trauma to their foot or ankle or sustained bone loss due to an infectious or neoplastic process,” said Dr. Miller.

H. John Visser, DPM, FACFAS, cited an advance in total ankle arthroplasty in the form of the Prophecy Infinity (Stryker), whose design allows the creation of navigation guides. He noted proper orientation for insertion of the implant allowed a marked reduction in tourniquet times. With decreased operative times and proper anatomic placement, Dr. Visser said outcomes were much improved.

One of the most notable innovations in the foot and ankle in the last 25 years is the concept of biplanar plating in the foot, specifically for bunion surgery, said Mindi Dayton, DPM, FACFAS, noting in her observation, that the technique offers several distinct advantages in terms of stability, precision, and postsurgical outcomes. She said that she finds the biplanar plating technique enhances stability during the fusion healing process. Biplanar plating involves the use of two plates positioned at different angles, usually 90 degrees to each other, to provide multidirectional support to the fusion site, noted Dr. Dayton.

“This technique addresses the challenges posed by fusions in the foot where forces on the joints are complex and multidirectional,” said Dr. Dayton.

Dr. Dayton noted the primary biomechanical benefit of biplanar plating is its ability to provide multiplanar stability to the fused joint. By applying plates in 2 planes and specifically for a first tarsometatarsal (TMT) joint arthrodesis, typically one on the dorsal lateral side of the joint and one on the medial aspect of the joint—approximating 90–90 to each other—she said surgeons can create a construct that provides resistance to angular movement in multiple planes as well as resistance to torsion. She called this critical in promoting bone healing and minimizing the risk of nonunion.

“This approach to fixation significantly increases the mechanical stability of the fusion site compared to traditional single-plane techniques,” said Dr. Dayton.

“This stability is particularly important in areas subjected to rotational forces and dynamic loading, such as the first TMT joint and the first metatarsophalangeal joint, which greatly benefit from multidirectional fixation.”

Dr. Miller also cited the broader acceptance and application of suture-based fixation for soft tissue traumatic injuries, saying this facilitates more minimally invasive procedures and less need for joint destructive procedures in the future. An advantage, he said, is that suture-based products rarely necessitate removal.

Dr. Visser noted the advent of a circular external fixator allowed management of midfoot Charcot breakdown. This technology, he said, provides stability during strut movements, and surgeons could use it to correct deformity in all 3 planes and create a plantigrade foot.

Osseous replacement with bioengineered titanium struts has “revolutionized” the replacement of vital bone loss in the foot, said Dr. Visser, saying the technology can virtually replace any bone in the foot.

Q: How have these innovations impacted surgical technique?

A: With a biplanar plating technique, Dr. Dayton noted surgeons can often perform procedures with a more minimally invasive approach, reducing soft tissue dissection and preserving vital structures. She called this “essential” in the foot and ankle, saying extensive soft tissue involvement can lead to complications such as wound infection or delayed healing. Because the two plates are in perpendicular planes, Dr. Dayton noted the plates can be smaller and thinner without compromising stability, permitting a less invasive approach.

Dr. Dayton noted with monoplanar plating the plate and screws must be larger, wider, and thicker to provide adequate stability requiring more exposure and dissection as well as taking up a bigger footprint on the bone surfaces. As she noted, that can also lead to less hardware irritation and less need for removal due to the thinner profiles.

Q: How have these innovations impacted patient outcomes and patient care?

A: With the improved multiplane stability of biplanar plating, Dr. Dayton noted patients may be able to begin weight-bearing activities sooner due to the enhanced stability provided by the position of the plates. With biplanar plating, specifically in reference to the first TMT, surgeons can get patients safely weight-bearing in a boot almost immediately (her patients bear weight in 4 days) and they are typically in tennis shoes between 4–6 weeks. There is no need for casting or complete non-weight-bearing, and Dr. Dayton said patients can safely do early active rehabilitation, such as ankle joint range of motion almost immediately. She said that she sees this allowing patients to feel better faster, resume their activities, and get back quicker to a great quality of life.

“I feel strongly that early mobilization is imperative for patients to have a good short-, mid-, and long-term outcomes,” she said.

Dr. Miller noted that total ankle replacement (TAR) cut guides specific to a patient’s unique deformity and anatomy have made the process of ankle implantation very reproducible and predictable. He noted this technology will greatly reduce the learning curve of more difficult TARs and shorten operative time, saying this potentially lowers cost and can benefit patient recovery.

Q: What do you feel may be on the horizon in the next 25 years?  

A: Dr. Miller said there is much potential with AI and 3D printing that he feels will evolve how and when surgeons operate. Those technologies are in their infancy in the foot and ankle realm, and he said they will continue to progress into systems that allow both the surgeon and patient to see their outcomes before the surgery actually occurs. He noted that will enhance patient’s understanding of how a procedure will correct deformities in a visual manner that reduces the need for a surgeon to spend excessive amounts of time explaining the nuances of a procedure.

In addition, Dr. Miller said AI will assist the surgeon in reducing time spent with the patient under anesthesia as the surgeon will be able to “see” the end result before it happens in real time. Although the technology is already being applied to surgery, Dr. Miller said it is only in its beginning stages, and he looks forward to what this will provide to him and my patients as it evolves.

For Dr. Visser, future innovations include instrumentation that allows better removal of soft tissue about the tarsal and ankle joints, which he said could allow better mobilization and visualization of hard-to-mobilize joints.

Dr. Dayton foresees more patient-specific instrumentation in the foot in the next 25 years, similar to what exists for the ankle. She said that while some refer to hallux valgus as “just a bunion,” these are “truly complex foot deformities,” especially when compounded by additional deformities, such as metatarsus adductus. Dr. Dayton said in the future, she thinks patient-specific instrumentation for precise bone cuts will be the norm and permit the surgeon to achieve true anatomic correction. She also noted the utility of patient-specific hardware to fit the foot and achieve correct deformity correction.

“I am very excited about innovation such as this, as it will hopefully allow all patients to get a precise correction, and we will no longer have so many have incomplete corrections or recurrence of deformities to due lack of full correction,” said Dr. Dayton. “Patient-specific instrumentation will also help surgeons that may not typically address all components of the deformity in an anatomic manner at this time to feel more comfortable and confident doing so, which is what every patient deserves from us as their surgeon.”

Editor’s Note: PodiatryToday.com houses a multitude of information and education on surgical hardware innovations. For more on such advancements, see any of the following pieces of content:

• “Understanding Surgical Innovations Within Foot and Ankle Surgery” in the November 2024 issue of Podiatry Today;
• Dr. Visser’s podcast series on options when there is no talus in Podiatry Today Podcasts;
• Dr. Millonig’s podcast episode, “Deformity Planning in Total Ankle Replacement;”
• Dr. Fallat’s interview, “Exploring Applications of 3D Implants in Foot and Ankle Surgery” in our Videos section;
• the Podiatric Surgery or Trauma options under the Specialty Channels section; or
• archives of coverage from meetings across the country under Conference Coverage.