Small Cuts, Big Impact: Achieving Complex Forefoot Reconstruction With Minimally Invasive Surgery
What is minimally invasive forefoot reconstruction surgery? Forefoot reconstruction encompasses a range of surgeries aimed at correcting bunions, tailor’s bunions, hammertoes, and any associated metatarsal deformities. In essence, these procedures can involve the surgical correction of the entire forefoot, with techniques surgeons perform through percutaneous or open incisions and fixation, or utilizing minimally invasive approaches.
Within the past few years, there has been a notable increase in both patient demand and surgeon interest in minimally invasive surgery (MIS) for foot and ankle conditions. Both proponents and critics have called for more robust studies to assess the long-term outcomes of MIS techniques. Currently, we have access to fourth-generation MIS burrs for osteotomies, joint preparation for arthrodesis, and wedge burrs for osteophyte removal and bony prominence excision. The evolution of internal fixation devices has significantly advanced, with innovations far surpassing the use of stainless steel Kirschner wires. To ensure reproducibility in outcomes, targeting guides and jigs for MIS bunion surgery are now available from various manufacturers. There is also a reproducible guide for MIS hammertoe fixation.1-6
These advancements have led to an increase in publications, book chapters, and conference presentations detailing the execution of MIS techniques and the diverse methods of fixation. Additionally, a new journal, the Journal of Minimally Invasive Bunion Surgery, has emerged, dedicated to minimally invasive bunion surgery for a global audience. We are learning more about unique complications regarding MIS foot surgery and how to manage and prevent them.7-11 We will further explore this later in the article.
Many medical device companies have developed comprehensive MIS systems for foot surgery, offering a variety of internal fixation options for bunion, hammertoe, and tailor’s bunion correction. However, a standardized system or implant for distal lesser metatarsal osteotomies remains elusive, which may explain why distal metaphyseal metatarsal osteotomy (DMMO) via MIS techniques are underutilized and often overlooked. While many surgeons successfully perform MIS for bunion, hammertoe, and tailor’s bunion corrections, they often revert to more traditional open approaches, such as the intra-articular Weil osteotomy, for distal metatarsal correction. Distal metatarsal osteotomies are extra-articular and do not lead to complications of a floating toe and restriction range of motion as studies have shown to happen with Weil osteotomies, which are intra-articular, open distal metatarsal osteotomies.1,8,11-13 This article aims to emphasize the potential for complete forefoot reconstruction using exclusively MIS techniques.
Case Presentations in MIS
Patient 1. The first patient is a male in his 40s with no comorbidities and no history of tobacco or nicotine usage. He has had pain his whole life and works in a physically demanding job. Preoperatively, he had sagittal contractures of the second, third, fourth, and fifth toes; prominent and painful respective metatarsal heads (metatarsalgia); and a painful bunion deformity. He had a gastrocnemius and soleus equinus contractures, sagittal contractures of all of the metatarsophalangeal joints, mild-to-moderate metatarsus adductus, and hammertoe deformities. Figure 1 shows the clinical preoperative appearance. Figure 2 shows a clinical appearance one week postoperatively.
The patient underwent forefoot reconstruction through minimally invasive surgery techniques. An intramuscular gastrocnemius and soleus lengthening addressed his equinus. The forefoot reconstruction included a MIS double osteotomy bunionectomy, hammertoe arthrodesis with screw fixation of the second, third, and fourth toes, flexor tenotomy of the fifth toe, distal metaphyseal metatarsal osteotomies (DMMO) of the second, third, and fourth metatarsals, and a medializing osteotomy of the fifth metatarsal.
I utilized a 2 x 20 mm cutting burr with attached sterile normal saline attachment for the distal first metatarsal osteotomy. The diameter of the burr is 2 mm and the cutting length is 20 mm. I utilized a 2 x 8 mm cartilage burr for preparation of the distal and proximal interphalangeal joints for the MIS hammertoe corrections. This specific burr has a less aggressive flute design to remove cartilage and provinces tactile feedback of “bouncing” off the subchondral cortical bone if there is normal bone density present. There is built-in irrigation. One tip is to detach that irrigation tip and irrigate the bone paste from the arthrodesis site since it is a small stab incision. Another option is to have an 18-gauge angiocatheter attached to a syringe size of your choice and irrigate that way. I have done both. To reduce unwanted inflammation and edema postoperatively, make sure to squeeze and irrigate all of the bone paste.
For the proximal phalanx osteotomy, or Akin osteotomy, I used a 2 x 12 mm cutting burr with irrigation. I used the same size burr for the MIS DMMO and tailor’s bunionectomy. I opted for no fixation of the fifth metatarsal osteotomy as I have found this osteotomy is stable and heals well. I have utilized intramedullary fixation in the past but have also had to remove hardware due to pain. Percutaneous screws and K-wire fixation are options, but inserting the somewhat flimsy K-wire for percutaneous screw fixation is a technically difficult “throw” to get in one try every time. My patients seem to not do as well with K-wires and they are less likely to be weight-bearing sooner, which I feel is a major determining factor for choosing a MIS approach.
The patient was in a tall controlled ankle motion (CAM) boot for 6 weeks. He returned to work at 12 weeks. X-rays at 12 weeks showed complete healing of the hammertoe arthrodesis, proximal phalangeal osteotomy of the hallux, and the second, third, and fourth metatarsal osteotomies. The first and fifth metatarsal osteotomies showed progressive bone healing but it was not 100% radiographically complete at that time. He remained asymptomatic. He was supposed to present for follow-up 1–2 months after returning to work and with repeat X-rays, but he returned at 6 months postop. X-rays then showed complete healing of the first and fifth metatarsal osteotomies. In this case, I could not appreciate the precise timeline in which those 2 osteotomy sites healed since he did not follow up appropriately.
Figure 3 shows a weight-bearing preoperative dorsoplantar X-ray. Figure 4 shows the postoperative weight-bearing dorsoplantar X-ray with bone healing at 6 months. Figure 5 shows a preoperative weight-bearing lateral X-ray and Figure 6 shows a postoperative weight-bearing lateral X-ray at 6 months. The patient’s postoperative hallux angle was 17.6 degrees compared to 40.4 degrees preoperatively. The postoperative first intermetatarsal (IM) angle was 1.9 degrees with a tibial sesamoid position of 2 compared to preoperative values of 10.1 degrees and 5, respectively. The postoperative fourth–fifth IM angle was 4.2 degrees compared to 9.1 preoperatively.
The patient had no complications with healing or ambulation. He did have a proximal first metatarsal screw that became irritated with certain types of shoe gear. He returned to work without pain as well as performing pushups, weightlifting, and running—all previously painful activities. He wants to address his other foot after a year of being back at work.
Patient 2. The next patient is a 71-year-old female who had a painful large bunion, tailor’s bunion, and semi-rigid hammertoes. She was very independent and lived alone. She did not see results with nonsurgical treatment. She also had an adult acquired flatfoot deformity and opted for a custom ankle-foot orthotic (AFO) brace for that, but she needed to be able to wear that AFO in supportive shoe gear, which was painful with her existing forefoot deformities. Her medical history included hypertension, hypercholesterolemia, and hyperthyroidism. She had decreased bone density on X-rays but her 25-hydroxyvitamin D levels were within normal limits. I determined that she was a great candidate for forefoot reconstruction through a MIS approach to allow for smaller incisions for her thin skin, earlier protected ambulation due to living independently. Figure 7 and 8 show the clinical preoperative and immediate postoperative appearance, respectively.
The patient underwent MIS double osteotomy bunionectomy; distal interphalangeal joint (DIPJ) and proximal interphalangeal joint (PIPJ) arthrodesis of the second, third, and fourth toes; flexor tenotomy of the fifth toe; DMMOs of the second, third, and fourth metatarsals; and osteotomy of the fifth metatarsal. I utilized the same technique and burr sizes for the MIS bunion, tailor’s bunion and DMMO procedures as described in the first case. I utilized a different MIS technique for the hammertoe arthrodeses of the second through fifth toes. This particular hammertoe targeting guide (OptimalHT, Forma Medical) is the first of its kind, engineered to assist in the reproducible insertion of the K-wire and cannulated headless screws if that is the preferred method of fixation. This device helps eliminate multiple throws of the K-wire since there is no way to retrograde the K-wire in a MIS approach. I fixated the hammertoe arthrodeses with 2.5 mm headless cannulated screws. This particular device company also has 2.0 mm and 1.9 mm cannulated headless screws available for smaller toes.
The patient was allowed to fully bear weight in a tall CAM boot for 6 weeks and then transitioned into a supportive sneaker. She had no postoperative complications or issues with returning to activities of daily living. She only took opioid pain medication the first couple of days. She is looking forward to having her other foot corrected in the same fashion. Figures 7 and 8 show the preoperative and immediate postoperative clinical presentation, respectively.
Figure 9 shows a preoperative weight-bearing dorsoplantar X-ray. Figure 10 shows a 6-month postoperative weight-bearing dorsoplantar X-ray. Figure 11 shows a preoperative weight-bearing lateral X-ray. Figure 12 shows a 6-month postoperative weight-bearing lateral X-ray reflecting healing. The patient’s hallux angle was 13 degrees compared to 35.4 degrees preoperatively. The first IMA was 2.2 degrees with a tibial sesamoid position of 3 compared to preop values of 16.3 degrees and 6, respectively. The fourth–fifth IMA was 2.3 degrees compared to 8.3 preoperatively.
MIS for Complex Forefoot Reconstruction
Baskin has thoroughly articulated other considerations for complex forefoot reconstruction through MIS approaches in his recently published article.12 He describes a stepwise approach when metatarsus adductus is present with hammertoe and bunion deformities due to retrograde deforming forces these deformities have on the metatarsus adductus angle (MAA). Surgeons should perform DMMO after hammertoe correction to determine if the procedure is warranted and which type: distal intracapsular, DMMO, or distal oblique (DOMMO).13 Baskin also discusses that provisional MIS fixation may need to be removed if the first metatarsal head cannot be shifted more lateral due to the second metatarsal.12 He recommends performing the second, and if warranted, third and fourth metatarsal osteotomies before final lateral translation and fixation of the bunion.
Redfern and colleagues also provide a stepwise approach and even go on to describe how a right-handed versus left-handed surgeon may approach a DMMO.1 Surgeon experience and skills dictate the decision to perform complex forefoot reconstruction through a MIS approach. Baskin and Redfern recommend thorough didactic and cadaveric training. Beginners might need to tackle complex forefoot deformities using a hybrid approach, blending MIS with open techniques when necessary.1,12
Common Complications With MIS Forefoot Surgery
What complications can occur with MIS bunionectomies? Minimally invasive surgery of the foot is not without risks of complications as with any surgical procedure. A lot of studies correlate complication rates with individual surgeon experience, meaning that there are higher complication rates with the inexperienced surgeon. What are some notable complications now that MIS is more prevalent in the US than ever before? For MIS bunion surgery, Blitz and colleagues have coined the term “metatarsal explosion” as one potential complication to consider. They classify the different types of metatarsal explosions and the recommended treatment protocols. There is even novel discourse and research on how to prevent this type of complication, the perfect placement for screw fixation, and the types of bone healing or regeneration that can be classified with MIS bunion surgery.7-10 A majority of the literature on MIS bunion surgery shows a very low recurrence rate of up to 2% when compared to open techniques, and the percentage of revision for these recurrences was less than 1%.1,2,4-10, 12
What complications can occur with MIS hammertoe surgeries? Nonunion, delayed union, wound dehiscence, superficial infection, and undercorrection are complications that can occur with MIS digital procedures.3,7,14 This depends on the MIS approach used: arthrodesis of PIPJ and/or DIPJ or phalangeal osteotomy. The most common question asked about MIS hammertoe, especially if performing the incision and burr insertion from the medial or lateral aspect of the joint, is if there is iatrogenic injury to the digital blood vessels. There is still a paucity of literature on this procedure, but there has been no published neurovascular compromise with MIS hammertoe surgery.1,3,7,14
What complications can occur with MIS lesser distal metatarsal osteotomies? Surgeons can perform a lesser metatarsal osteotomy at various regions of the distal metatarsal for metatarsalgia, metatarsus adductus, or sagittal contracture of the metatarsophalangeal joint with concomitant hammertoe deformities. This MIS procedure is historically and presently not fixed with an implant. This procedure relies heavily on Wolff’s law of the mechanical stress on a bone with weight bearing and bone growth and regeneration, and special postoperative bandaging for a duration specific to the surgeon.1,12,13
The Future of MIS
Current advancements in MIS foot surgery leave room for further innovation and improvement. Despite significant advancements in MIS, there remains ample opportunity for further innovation. Currently, no standardized osteotomy guide or internal fixation system exists for distal metatarsal osteotomies of the second, third, fourth, and fifth metatarsals. While intramedullary plating is available for the fifth metatarsal, it has yet to be developed for the other lesser metatarsals. Some surgeons can skillfully place a percutaneous cannulated screw in the fifth metatarsal, but an increasing number of experienced MIS surgeons are opting to leave it “floating,” relying on Wolff’s Law, which suggests that mechanical stress during weight bearing promotes bone healing.
Since I began performing MIS forefoot reconstructions in 2019, the most common complication I have encountered has been nonunion in lesser metatarsal osteotomies. This is unsurprising given the lack of a standardized system for ensuring reproducible osteotomies and fixation techniques. In my experience, all cases of nonunion in lesser metatarsal osteotomies have successfully healed with an external bone stimulator—except for one. This particular patient underwent MIS distal metatarsal osteotomies of the second, third, fourth, and fifth metatarsals. While the bone stimulator successfully healed all but the fourth metatarsal, the patient is now scheduled for open reduction and internal fixation (ORIF) with autograft and continued bone stimulator use.
In contrast, I have encountered only one symptomatic nonunion following MIS bunionectomy in my patient population. That case resulted from a traumatic injury to the osteotomy site during the postoperative period. However, the patient ultimately healed without recurring pain or a bunion deformity, aided by an external bone stimulator.
In Conclusion
Minimally invasive foot surgery remains a safe, reliable, and effective treatment for foot deformities. However, some MIS procedures present a steep learning curve, particularly those that do not involve internal fixation or when dealing with revisions or complex deformities. Surgeons at novice or intermediate levels may still find it necessary to use a hybrid approach for complex forefoot deformities. That said, complete forefoot reconstruction can be successfully achieved using only MIS techniques, often with outcomes that are comparable to, or in some cases, better than traditional open surgery. With the introduction of advanced MIS guides and internal fixation, there is still potential for further innovation, particularly in procedures like lesser distal metatarsal osteotomies. As more research, case studies, and discussions on complications emerge, surgeons will be better equipped to understand, manage, and prevent issues associated with specific MIS procedures.
Dr. Saysoukha is the CEO & Founder of Premier Foot & Ankle Centers of Tennessee. She is a Fellow of the American Society of Podiatric Surgeons (ASPS), Fellow of the American College of Podiatric Medicine (ACPM), Diplomate of the American Board of Podiatric Medicine (DABPM), board-qualified in Foot Surgery and Reconstructive Rearfoot & Ankle Surgery with the American Board of Foot & Ankle Surgery (ABFAS). She serves as Education Chair for ASPS and has given several lectures nationally on MIS foot and ankle surgery.
Disclosures: Dr. Saysoukha is a consultant and/or shareholder for the following entities: Forma Medical, Inc., MiRus LLC., Smith+Nephew Bio Tissue, Suturegard Medical, Inc.
References
1. Redfern D, Vernois J, Legré BP. Percutaneous surgery of the forefoot. Clin Podiatr Med Surg. 2015;32(3):291-332.
2. Siddiqui NA, LaPorta G, Walsh AL, Abraham JS, Beauregard S, Gdalevitch M. Radiographic outcomes of a percutaneous, reproducible distal metatarsal osteotomy for mild and moderate bunions: a multicenter study. J Foot Ankle Surg. 2019;58(6):1215-1222.
3. Mateen S, Raja S, Casciato DJ, Siddiqui NA. Minimally invasive versus open hammertoe correction: a retrospective comparative study. J Foot Ankle Surg. 2024;63(2):156-160.
4. Gonzalez T, Encinas R, Johns W, Benjamin Jackson J 3rd. Minimally invasive surgery using a Shannon burr for the treatment of hallux valgus deformity: a systematic review. Foot Ankle Orthop. 2023;8(1):24730114221151069. Published 2023 Jan 29.
5. Ji L, Wang K, Ding S, Sun C, Sun S, Zhang M. Minimally invasive vs. open surgery for hallux valgus: a meta-analysis. Front Surg. 2022;9:843410. Published 2022 Mar 21.
6. Kim J, Oh M, Kyeong TH, Choi MN, Lee SY. Radiographic comparison of open and minimally invasive distal chevron metatarsal osteotomy in patients with hallux valgus. J Foot Ankle Surg. 2024;63(3):386-391.
7. Di Nucci KA. The unfamiliar complications of minimally invasive foot surgery. Clin Podiatr Med Surg. 2025;42(1):117-138.
8. Blitz NM, Wong DT, Grecea B, Baskin ES. Characterization of first metatarsal regeneration after new modern minimally invasive bunion surgery. A retrospective radiographic review of 172 cases. J Min Invasive Bunion Surg. 2024:1.
9. Blitz NM, Grecea B, Wong DT, Baskin ES. Defining the cortical purchase zone in new minimally invasive bunion surgery. A retrospective study of 638 cases. J Min Invasive Bunion Surg. 2024;1:92777.
10. Blitz NM, Wong DT, Baskin ES. Patterns of metatarsal explosion after new modern minimally invasive bunion surgery. A retrospective review and case series of 16 feet. J Min Invasive Bunion Surg. 2024;1:92774.
11. Yeo NE, Loh B, Chen JY, Yew AK, Ng SY. Comparison of early outcome of Weil osteotomy and distal metatarsal mini-invasive osteotomy for lesser toe metatarsalgia. J Orthop Surg (Hong Kong). 2016 Dec;24(3):350-353.
12. Baskin ES. Complex forefoot reconstruction with percutaneous techniques. Clin Podiatr Med Surg. 2025;42(1):47-60.
13. Rowe P, Koller A, Sharma S. Physiology, Bone Remodeling. [Updated 2023 Mar 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499863/.
14. Gilheany M, Baarini O, Samaras D. Minimally invasive surgery for pedal digital deformity: an audit of complications using national benchmark indicators. J Foot Ankle Res. 2015;8:17. Published 2015 Apr 21.
