The minimally-invasive revolution in foot and ankle surgery

Foot and ankle surgery has undergone and is still undergoing significant leaps forward in the surgical techniques used. Mr David Redfern, a leading orthopaedic surgeon, is playing a key part in the advancement of minimally-invasive foot and ankle surgical techniques. Here he delves into the transformation he has witnessed and been part of, explaining how foot and ankle procedures are becoming less reliant on the need for open surgery.

What did foot and ankle surgery look like 10 years ago?

Ten years ago foot and ankle surgery in the UK was beginning to become well-established as a sub-specialty within orthopaedic surgery, but still not attracting the same attention from industry as more established sub-specialties such as knee and hip surgery. Just over 10 years ago I began working with a French surgeon who had begun to take an interest in some minimally-invasive surgical techniques being used in southern Spain. These techniques originated in the USA some years earlier but hadn’t been refined.

Together, my French colleague and I began developing new minimally-invasive techniques to treat bunions (hallux valgus) and forefoot problems. These were much more reliable and safe due to advances in technology and strict training protocols that we introduced. We presented our results at national and international meetings and rapidly began to attract the attention of the orthopaedic community and industry which has since heavily invested in these technologies.

We were the first to introduce these techniques here in the UK and in Australia and have since developed numerous minimally-invasive techniques covering both the forefoot and hindfoot. We train surgeons from all over the world in these techniques and are internationally recognised for our expertise and contributions in this field. Together we have trained over 1000 surgeons all over the world and are currently introducing the techniques in the USA. We designed / invented the MICA technique for bunion correction (known as “ProStep” in the USA) and any surgeon offering our MICA technique in the UK will have been personally trained by either myself or my French co-inventor (Dr Joel Vernois).

David Redfern lecturing at a European Foot and Ankle Society Meeting. The meeting was held in Geneva this year and Mr Redfern lectured on minimally-invasive techniques in the hindfoot and chaired a session on minimally-invasive surgery.

A photograph taken at a minimally-invasive training course held by Mr Redfern in Germany earlier this year. The delegates had literally travelled from all over Europe and further afield (Germany, France, Switzerland, Austria, Czech Republic and Singapore).

What difference has the introduction of minimally-invasive techniques made?

Minimally-invasive techniques have revolutionised many aspects of forefoot and hindfoot surgery. There’s no going back! Some corrections I am able offer in the forefoot simply aren’t possible with traditional open surgery. Using tiny drills called burs, we can now undertake 3-dimensional corrections of deformities through tiny keyholes (these are just a few millimetres in length) that are simply not possible with open surgery without causing much more scarring (inside as well as on the surface).

My mission for the last ten years has been to encourage surgeons worldwide to gain experience in using these techniques which I believe can greatly improve the surgical treatment available to patients. I also aim to encourage surgeons to think in each case whether the option of keyhole surgery can add to the quality of their surgery and patient outcome. In some cases, such as the MICA keyhole bunion surgery, medical studies performed by surgeons I have trained internationally have concluded that these techniques produce significantly less pain post-operatively than conventional techniques such as the open Scarf Akin technique. These techniques and technology continue to evolve and I firmly believe that the next ten years will bring even more change in this direction with far more surgery untaken using minimally-invasive techniques. Exciting times indeed.

Bunions before:

Same feet after MICA keyhole bunion surgery:

This patient was treated as a day-case and was able to get back into their own shoes with just a few days.

How widely practised are these new techniques in the UK?

Any surgeon offering the MICA type of bunion correction in the UK will have been through at least one of my training courses. A large number of surgeons have been through these courses. As with any technique, it will work better in some hands than others and surgery remains a craft although this is sometimes not always well understood by patients. Thus, surgeons will opt to use the techniques that work best in their hands.

Minimally-invasive surgical techniques require training and are no doubt demanding for the surgeon who needs to possess very good 3-dimensional awareness and the ability to work using intra-operative imaging for guidance in some circumstances. As the technology advances and computer-assisted guidance becomes more advanced, these techniques are likely to become more widespread. There are now quite a large number of UK surgeons who offer at least some minimally-invasive surgery techniques and this is likely to continue to gradually grow with time and further technological advances.

Are there areas in foot and ankle surgery where open surgery is still performed?

For the moment, patient access to minimally-invasive foot and ankle surgery still remains fairly limited within both the NHS and the private sector. Other than myself, there are however quite a large number of surgeons in the UK who have become proficient in these techniques. Traditional open surgery still remains most widespread due to the demands placed on surgeons in needing to undergo specific training and hence go through a learning curve.

What upcoming techniques or technology do you expect will overcome these limitations?

There is now massive industry investment in this technology, especially within the USA, and I spend quite a lot of time travelling back and forth to assist in this research and development as well as training US surgeons. There is no doubt that it will continue to evolve and replace more and more traditional open techniques. The technologies available to assist in training surgeons are also rapidly evolving and I suspect further advances including virtual reality will likely play an increasingly important role.

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