On June 11 to 13, the Academy of Minimally Invasive Foot & Ankle Surgery held its 40th anniversary international scientific meeting on minimally invasive foot surgery at the Louisiana State University Medical School in New Orleans. More than 60 podiatrists and orthopedic surgeons, from North America, Latin America and Europe attended. The course included a cadaver lab and informative lectures on minimally invasive surgery techniques of the forefoot, rear foot and ankle. In addition, the Academy honored Al Brown, DPM, one of the founders of the AAFAS.
Some of the lectures and lecturers that attendees were treated to included:
- "Transitioning From Traditional Surgery to MIS Foot Surgery" and "Treating Lesser Metatarsalgia with Minimally Invasive Surgery" by Don Peacock, DPM
- "Minimally Invasive Hammertoe Surgery Procedures" and "Minimally Invasive First Metatarsal Base Wedge Osteotomy for the Treatment of Severe Hallux Valgus Deformities" by Carmen Naranjo Ruiz from Spain
- "Fox Arthrodesis for Hammertoe Correction" and "Minimally Invasive Forefoot Reconstruction Surgery" by Jeffrey Adler, DPM
- "Minimally Invasive Hind Foot Stabilization" and "Peripheral Neuropathy" by Michael Graham, DPM
- "Incorporating Biomechanics Principles into Minimally Invasive Foot Surgery" by Dennis Shavelson, DPM
- "Soft Tissue Procedures for Foot Pain, Wounds and Deformities by James Laborde, MD
- "Minimally Invasive Foot Surgery Around the World" and "Treatment of Complications in Minimally Invasive Surgery of the Foot and Ankle" by Fernando Sancho Barroso, MD of Mexico City
- "Miniamlly Invasive Surgical Treatment of Tarsal Tunnel Syndrome " and "The Reverdin-Isham Minimally Invasive Bunionectomy Procedure" by Steven Isham, DPM, MD
- "Use of Stem Cells in First Metatarsal Phalangeal Joint Surgery" by Darlene Kulhan, DPM and Jeffrey Adler, DPM
- "Hypocure Implant and Effects on the 1st Metarsal Phalangeal Joint" by Alex Tievsky, DPM and Michael Graham, DPM
- "Minimally Invasive Surgical Correction for Hallux Varus" and "The Wilson Bunionectomy Procedure " by Sheldon Nadal, DPM
- "Minimally Invasive Osteotomy with Cheilectomy for the Treatment of Arthritic 1st Metatarsal Phalangeal Joints" by Victor Horsley, DPM
- An external bandaging and splinting workshop was put on by Dr. Jeffrey Adler and Dr. Borys Markewych and a biomechanics workshop was presented by Dennis Shavelson, DPM
The next minimally invasive surgical seminar will be presented by the Academy of Minimally Invasive Foot & Ankle Surgery along with the Temple University School of Podiatric Medicine Alumni Association on Saturday September 19 and Sunday September 20 at the Temple University School of Podiatric Medicine, 148 North 8th Street, Philadelphia, Pennsylvania, 19107. For more information, please contact Denise Krenski (215-625-5249) or Joe Leso (215-625-5410).
COME BACK TO AAFAS IN NEW ORLEANS!
Ten Reasons To Come Back To Our Conference JAN 12-14, 2017
- Attend the advanced track which is only available to practitioners who have been to at least one previous AAFAS meeting.
- Dr Ed Behmer will present a new minimally invasive bunion surgery procedure! This will be presented in the advanced track.
- We are now staying at the famous Hotel Monteleone in the French Quarter. We will no longer have to walk to the Quarter. We will be in it.
- The hotel is home to the famous Carrousel Bar with live jazz entertainment.
- Dr Richard Jacoby, past president of the Association of Extremity Nerve Surgeons, is returning to AAFAS to lecture on the science and use of stem cells in the treatment of lower extremity pathology.
If you heard him lecture last January, you will not want to miss him this January.
If you missed him last January, you are getting one more chance.
- If one past president of AENS is good, two is even better!
AAFAS is pleased to present Dr Robert Parker who will lecture on "Minimally invasive juxtamalleolar aspiration lipectomy, an aesthetic procedure" as well as"The surgical treatment of recurrent neuromas".
- Our state of the art cadaver lab at the LSU medical school.
- Dr Brad Bakotic, The only podiatrist in the nation to hold specialty board certification in dermatopathology, will present case studies illustrating the differences between benign and malignant skin lesions of the lower extremity.
- Even if you think you are an expert on minimally invasive foot surgery, you only have to learn one new pearl to make your trip worthwhile. Some of the worlds best minimally invasive foot surgeons will be on hand to share their pearls with you.
- It is New Orleans! Have you been to every great restaurant in that great city?
Register today as attendance is limited to 65 practitioners in the cadaver lab. We have applied for 25 continuing education credit hours.
We hope to see you there.
Sheldon Nadal DPM
For more information:
Hotel Reservations at group rate:
Virtual tour of Hotel Monteleone:
The Academy of Ambulatory Foot & Ankle Surgery
3707 S Grand Blvd, Suite A
Spokane, WA 99203
Peacock Modified Reverdin-Isham-Bosch (PRIB)
Distal first metatarsal osteotomies are widely accepted for treating mild to moderate HAV deformities.(1) These osteotomies lend themselves well to MIS techniques. (2) Drawbacks may arise due to shortening observed when performing through and through osteotomies(3). The rationale behind modifying the Reverdin-Isham, Bosch is aimed at bringing about a MIS osteotomy which can directly address PASA, IM angle, and achieve plantar flexion and/or lengthening of the first ray when needed. The author calls this the PRIB procedure and is the acronym for Peacock, Reverdin, Isham, Bosch procedure.(4,5)
A percutaneous punch incision is performed with a 64 blade and is made over the plantar medial border of the first ray where the metatarsal head fans out in the distal diaphyseal area. The incision is continued down in a single cut until reaching the periosteum. From this position the 64 blade is used to underscore the capsule at the first metatarsal phalangeal joint employing a sweeping motion. Under fluoroscopy a 3.1 wedge burr is inserted and the medial prominence is resected from the first metatarsal head. Pressure is applied to the first metatarsal phalangeal joint area and the medial eminence is eliminated as bone paste.
The first step of the osteotomy involves a wedge osteotomy in the distal diaphyseal area of the first metatarsal leaving the lateral portion of the cortex intact. This is accomplished using a straight Isham burr. The osteotomy is angled at a 35°-45 from dorsal distal to plantar proximal and is angled distally to help maintain length of the first metatarsal in patients with a relatively short 1st ray. It can be made parallel to the 2nd metatarsal or proximal if desired. The final cut of the osteotomy involves completing the lateral cortex cut with a J stroke movement leaving a lateral plantar shelf. This maneuver will allow for further 1st ray lengthening and added stability for patients requiring plantar flexion of the 1st ray.
The osteotomy is then shifted by inserting a Locke elevator through the incision site into the medullary canal of the 1st ray and using this as a fulcrum to transpose the osteotomy. Prior to laterally shifting the osteotomy a percutaneous lateral release is done. Thumb pressure can transpose the osteotomy in some patients. With the lengthening style cut the Locke elevator maneuver is easier. Subsequent to displacing the osteotomy fixation is accomplished via percutaneous K wire. This fixation technique permits torqueing to further close the PASA correction. The osteotomy can be plantar flexed by distracting the distal fragment and pressing the medullary portion of the fragment on to the plantar lateral shelf created by the osteotomy.
Advantages of PRIB:
The advantage of this osteotomy is that it allows for correction of large IM angles over 16 and can directly address PASA while limiting shortening realized with through and through osteotomies. Also, by creating the plantar lateral shelf, added stability is gained with patients demanding plantar flexion of the first ray.
Disadvantages of PRIB:
The most obvious disadvantage of this osteotomy is its more proximal placement than standard distal osteotomies, such as the Austin etc. This characteristic will result in a less stable osteotomy requiring fixation.
The PRIB technique borrows from already established osteotomies including the Reverdin- Isham and Bosch techniques. The procedure can be performed under local anesthetic in the office setting and the technique can be performed in 15 minutes. The PRIB is usually done in conjunction with an Akin osteotomy. Other than the fluoroscopy no special equipment is needed and the cost of the K-wire is not prohibitive to office based procedures. Figure 1 and 2 are Preops. Figure 3 and 4 are 3 week post ops. Figure 5 and 6 are 2 month post ops.
Note very little shortening and plantarflexion achieved via this osteotomy technique. In the presented case the hallux osteotomy was intentionally performed to allow for dorsiflexion of the proximal phalanx to address mild functional hallux limitus issues. The author feels a surgeon should be judicious when dorsiflexing the proximal phalanx since this can result in a hammered great toe and/or toe purchase issues especially when not plantar-flexing the 1st met at the diaphyseal area . Under most bunion correction circumstances the surgeon should endeavor not to dorsiflex the proximal phalanx.
Don Peacock, DPM (professor AAFAS), ACFAS
Fig 1: Preop Weight Bearing AP
Fig 2: Preop Weight Bearing Lateral
Fig 3: Post op 2 weeks Weight Bearing
Fig 4: post op 2 weeks Weight Bearing
Figure 5 and 6---- 2 month Post op
1. Austin DW, Leventen EO. A new osteotomy for hallux valgus: a horizontally V displacement osteotomy etc. Clini Ortho 1981;157:25-30
2. Schilero J:Minimal incision podiatric surgery. Principals and applications. J Am podiatry Med Assoc 75(11): 586-574, 1985
3. Zlotoff H: Shortening of the first metatarsal following osteotomy and its clinical significance. J AM Podiatr Assoc 67(6): 412-426, 1977
4. Isham S. The Reverdin-Isham procedure for HAV: Clin Pod Med Surg 1991;8: 81-94.
5. Bosch P, HAV correction method Bosch: 7-10 year follow up. Foot Ankle Clin 2000; 5:458-98.
Minimally invasive foot surgery lends itself well to the treatment of diabetic ulcers and of infected bone tissue. MIS techniques allow for osteotomies away from infected bone and can be combined with tendon re-balancing to achieve stellar results in eliminating diabetic foot ulcers.
The Academy will have Dr. Monroe LaBorde MD, teaching techniques of tendon re-balancing that reduce pressure areas in the foot allowing ulcers to heal. These methods have proven effective as outlined in multiple published research articles.
For those attending the Academy seminar this June 2016, they can expect to be exposed to both lectures and hands-on cadaver teaching allowing for implementation of these techniques into their practice.
Here is a case where the author used both tendon re-balancing techniques learned from Dr LaBorde with the use of minimally invasive surgery to reduce a bony prominence in a Charcot patient. This intervention allowed for complete resolve of the chronic ulcer.
The patient underwent gastrocnemius recession and MIS debridement of Charcot exostosis by minimally invasive surgical techniques.
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