So, next up is Andy Velkovic, who also has to rush off for a flight, and she is going to tell us, Andy's one of my colleagues in Vancouver, and so she's going to tell us about percutaneous calcaneal osteotomies, arthroscopic calcaneal osteotomies, Pinit here has been big in this too. So, anyway, Andy. Actually, thank you for everybody for having me here, I really appreciate it. Today I'm talking a little bit about minimally invasive calcaneal osteotomy and percutaneous calcaneal osteotomy, and I really think this is the wave of the future and possibly the one way you should be doing this. I have no disclosures pertaining to this talk. I mean, the question really is, why should we do minimally invasive calcaneal osteotomy? And my answer actually is, why not? It's a very minimal incision, it has many benefits that you will see later on at the end of this talk. When it comes to percutaneous endoscopic calcaneal osteotomy, you can see here, that's what the open incision would look like, large incision with transsection of those lateral calcaneal branches. And then you can do something much less with these two little mini incisions that can help shield these injuries to these nerves. And what I found is that the more I did this technique, the less chance I had of that pain on that lateral wall. And I think that pain from that lateral wall is due to an open incision and those nerve branches stick to that incision. So in general, you know, we have these advantages of everything that we do in indications. So to me, the indication is the same as open, and in fact, it's lower threshold, so you can do smaller shifts and do it in more people. Advantages that it accommodates previous surgical scars and concomitant procedures with adjacent incisions. And there's also minimal soft tissue disruption. And you also can do massively large displacements and also rotate and slide at the same time, either medial, lateral, or dwire. In terms of your positioning and approach, it's a simple positioning and approach. I just like them to be supine with a bump under the hip. And we just need to think a little bit about the anatomy and the potential nerves that can be injured. And Taliesin describes that with the safe zones, as you can see described here. And what we know is by these safe zones is that as long as you're anterior to the insertion of the, an origin of the plantar fascia and insertion of the Achilles, and just back in that one area, that's a nice safe zone. In terms of the neurovascular risks that can happen, we have the sural nerve, which is in the Taliesin safe zone. We also have a chance for the medial and lateral plantar nerves. There's MRI cadaver study suggesting decreased tarsal tunnel volumes. And this is more specific in the cases where we're doing a lateralizing shift. And this is something that DiGiovanni and Alstra actually talked about. So that's important to think maybe you need to do a tarsal tunnel release for those patients. You also have a chance for injuries to the medial and lateral coccaneal branches. And these are more vulnerable, actually, in my viewpoint, with an open technique, which is actually accommodating for the saw. And so when we looked at this, me and Pennant, a long time ago, we actually looked at, you know, what are the neurovascular risks? Because whenever you're doing a technique like this, and Pennant's been doing this for many, many years, you have to think yourself, what can you injure, and you need to study and follow it. And so we actually looked at that, and we found that, you know, the biggest things that were closest to us were the lateral coccaneal branches. And these are the ones, I think, that are always injured when you make an open technique, as well as potentially the sural nerve or some of the sural nerve branches. The other thing, too, is when you're doing this and passing the saw on the inferior aspect, you're very close to Baxter's nerve in the tibial artery. So those are things to sort of think about that are quite close. So then we actually compared an open technique as if it was going to be open, and one that was doing the minimally invasive technique. And what we actually found is that there are significantly less lateral coccaneal nerve injuries in the percutaneous technique versus the potential open technique. So when it comes to osteotomy positioning, the more you go anterior, the more of a shift you can do. But the more you go anterior, the more chance it is that you can get a nerve risk, whereas the more you go posterior in the talus and zone, there's actually a less chance of a nerve risk, but less shift. You want to be somewhere in between, and you want to think about how big is the deformity that you have to treat. The bigger the deformity, the more anterior you want to go. In terms of this minimally invasive coccaneal technique that's becoming more popular, it's actually quite simple. You can mark this on the skin with your fluoroscope, have a look, and then mark that transecting line, make an incision, and do a snap down to bone. And it's fairly simple, and you just want to protect. Here then, you can insert your burr, so you would insert your burr, and you want to make sure that you're using quite a bit of irrigation. Those are the skin levels. So even though it's actually sending irrigation as you're doing the burring, you also want somebody to be irrigating for you as you're doing it, right? So that's very, very important. So basically, you perforate, the burr goes through, you do the supralateral portion, then you go and you do your supramedial portion, doing a nice, sweeping, simple motion in one plane. And then you go and do your infralateral portion and your inframedial portion, which is actually quite nice. Then, through that same incision, you can actually just put a nice laminar spreader, turn off that calcaneal osteotomy, and then shift the calcaneal osteotomy as required. You can use tools to do this in order to get that view that you need. I like having a large C-arm, because for me, a large C-arm, I can see the axis of the limb. But sometimes, if you're doing this in a small procedure room or an outpatient center, a mini C-arm is adequate enough. And this is actually the PICO technique. This is what I mainly do. I think that Pinit's doing this without the scope now, but it's very simple. It's a supralateral portal, infralateral portal, and this takes me under seven minutes to do the entire technique. So, basically, you make this, you put your snap in, you dissect down directly on bone. Same way you do this on the infralateral portion, directly on bone, and this is, again, under seven minutes. This goes across. And then, again, you're dissecting on top, just to make sure that everything is safe from supralateral to supramedial. You allow this to exit out on the medial aspect, and then, on the medial aspect, all you're doing here is you're passing a snap down, so you'll see how you come through. This comes through the skin very simply, and, again, this is just a nice rhythmic dance as you're doing it. You're listening to good music. And then you go from supramedial down with your clamp, and you aim this infralateral. So right away, you're now set around the bone, always staying on bone, always respecting the bony anatomy, and you're not at risk of the neurovascular structures. So, basically, you leave your clamp in here, and then, on the other side, you can just palpate for the tip of this, so you know the direction you need to go. It's fairly simple. One hand's around, one's palpating. And then you basically insert, from the bottom aspect here, a trocar. You don't even need a trocar. If you have a large clamp, you can take the clamp right out of the skin and grab the suture directly, or you put the scope in with a number two fiber wire suture at the tip, or whatever suture you like. I prefer having a tiger tail versus a blue one, because I can see it a lot better. And so as this goes in, on the inferior aspect, this is really what it sort of looks like. You can see this come in on the bottom, and then you see where this comes through, and you grab that clamp, obviously. And then that's what that clamp looks like when you're looking at it from the scope. More specifically, looking at the scope, it looks actually quite simple. You come in, and that's what it looks like. So you safely grab that suture, and now you've shuttled that suture out super medially. And you'll see how slick this is. So if you've been in the OR with me, you'll have seen this and been like, wow, this is pretty nice and simple. It's also very cheap, so if you're in a place where you don't want to spend a lot of money on expensive burrs, a jiggly saw is exceptionally cheap, and also exceptionally fast. So now this comes out super medial. I'll bring this out to the side here for you, so you can actually see it. And now you bring this out super lateral. So that's all it is. So you basically grab that suture, here it goes, goes around to the outside, and now you have your suture around the calcaneus safely on bone. Now what you want to do is you want to shuttle that suture around, and now exchange that with a jiggly saw. This is the best part of this whole thing, is that you can actually direct the jiggly saw into whatever cut you want, right? So if your calcaneus is like this, and you want to lengthen it medially, you just bring your hands up. If you want to shorten it in a cavus foot, you just bring your hands down. If you want to create a dome, you basically start, and then you move your hand up. And that can do anything you want, which is actually lovely. In addition to the fact that a cavus foot, you can slide it up and down if you need. Obviously up for cavus, down for planus. And then that simply just cuts things for you. You complete your cut with a little osteotome. That's what the heel looks like. You slide your heel over. And the mobility you have here is phenomenal. So that's your mobility, right? Because you're no longer having to worry about things like getting rid of that medial periosteum. The medial periosteum has been done for you. And then you pin it in whatever way you want, right? So then you get a nice reduction, hold it in place, okay? So really in the end, you ask yourself, why bother with this, right? So here's some very real-life cases. Forty-year-old male, recurrent ankle sprains. In the old days, you would be using big, large incisions. Dr. Glazebrook will tell you why that's not a good idea, why you should look at minimally invasive incisions, specifically when you're doing lateral ligaments. And here you can do an arthroscopic brostrom versus the big, large incision you see on your left. You now get these very small, tiny incisions that you're using. In addition to this, you can just use your calcaneal osteotomy to dial in that hindfoot alignment. And it's a small, minimally invasive technique. The patient's doing well. They're mobilizing faster. There's less swelling, less wound complications. This is an example of one of my cases, significant valgus hindfoot. You can see it here. And basically for her, a small, little incision. She's done tiny little cotton through a small, little incision, endoscopic gastroc recession, and you've nicely aligned her hindfoot compared to where she was. And then you can keep going further into bigger and bigger and bigger deformities. You can do the same thing with these various deformities. We can take something as bad as this and get that nice and straight to where it's nice and straight with these small, minimally invasive incisions compared to where the patient was before. Finally, you can be even more extreme, something like this, where you have someone with these large, large deformities. And you can start to do these cases again with minimally invasive techniques as much as you can. And this is him walking at six weeks, so he's walking. In the case of severe OA, something like this where you want to do a total ankle replacement, you might not want to have big, large incisions next to that total ankle with a chance of infection. So here, you can nicely dial in that calcaneal correction based on your ankle replacement. And you're mitigating your risk, less chance of having infection and wound problems with these ankle replacements. Here's another example of an ankle here, bad, bad varus here. A total ankle is put in. This is done sort of in staged fashion. And then the calcaneal osteotomy is dialed in. He's actually quite happy. He had a small aminomalleal osteotomy to hold him in case. So when you look at the post-op care for these patients, basically, they're non-wapering for four weeks. So this is an isolated calcaneal osteotomy. And then you get the mobilizing. If you're doing a foot technique, you're looking at about six weeks of non-wapering with progressive mobility. We look at the studies that are out there. There's comparative studies where there's looking at complications of minimally invasive calcaneal osteotomy versus open osteotomy. And this really becomes relevant to you when you look at these cases. You can see here that the wound complication in MIS was about 6.5%, whereas open, it approached to 28%. Infection was significantly lesser in MIS, 3% versus 20% in open, and less seronal nerve injuries. Seventy-three patients were looked at when they looked at MIS invasive calcaneal osteotomies. And most of these patients went delayed, had very minimal complications, no malunion, no nonunion, and seven delayed wound healings. Finally, a larger study that was out there looking at 122 patients comparing open and percutaneous. And what they actually found is there was no difference in their outcome scores. However, there were significantly lower wound healing problems and shorter hospitalization. For PICO, same thing, really no complications resulted. They had good reduction of their alignment and they had good functional outcomes, and they actually had lesser wound complications. So technical perils with MICO and PICO really is stay within the safe zone. Don't be scared. Start with the smaller cases and work your way up, obviously. I always say start with Plano-Valgas first because it's easier to slide. And then as you get more and more and more used to doing it, then you can get into those cave of various cases that are a little bit more sticky. Use it with irrigation when you're doing MICO. Make sure you don't load the brewer too short. Use a laminar spreader. And you can get people weight-bearing within a month. So thank you very much, guys. Thank you, Andy.

minimally invasive calcaneal osteotomy

foot surgery

benefits

nerve injuries

comparative studies