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Melanie Cole, MS: Welcome to GW Doc Pod, a peer to peer podcast for medical professionals with The George Washington University Hospital. I'm Melanie Cole. And joining me is Dr. Marc Chodos. He's an orthopedic surgeon, a foot and ankle specialist, and an Assistant Professor of Orthopedic Surgery at The George Washington University School of Medicine & Health Sciences, and he's affiliated with The George Washington University Hospital. He's here to highlight minimally-invasive foot and ankle surgery.

Dr. Chodos, it's a pleasure to have you join us today. How does minimally invasive foot and ankle surgery differ? As we get into this really great topic, how does it differ from traditional foot and ankle surgery? Tell us a little bit about the evolution and some of the recent improvements that have been made to make this procedure possible and indeed preferable?

Dr. Marc Chodos: So I like to look at it as another tool in the tool chest. So we have all sorts of different things that we can pull from. And it's a very useful tool to have from our tool chest. So minimally invasive surgery, especially in foot and ankle, has been started years and years ago. Definitely by the 1990s, people were trying to do stuff mostly in Europe. Most of the early stuff was met with pretty miserable failures and problems. And I'd say we're probably on our fourth iteration at this point. And with a lot of the changes that have transpired over time, we have better ways of doing things, better ways of fixing things to hold them in place. And the current generation of options for minimally invasive surgery in the foot and ankle has been much more successful than what we see before.

In some ways, a lot of the studies are still in their relative infancy, I guess, is the best way of putting it. So there's not the same level of data to support stuff that's been going on for 20 or 30 years, but it looks like the results are pretty equivalent to the traditional ways of doing things. But oftentimes there can be lower risks. So one of the problems in foot and ankle oftentimes is wound healing problems, this can be a really big deal. And with the minimally invasive options, a lot of times we can do things that have a much lower risk of wound problems. I find it particularly useful in people that are higher risk for surgical problems. This may open up options that were not good options beforehand.

In the acute after-surgery phase, people tend to have less pain, a lot of the nerves and things that cause pain after surgery are actually in the skin layer. And if you're able to minimally get in there and not have to make as big an incision, this usually leads to much, much less pain, much less swelling after surgery. It's still surgery and it still has a discrete healing process. And it's not in some ways different than the traditional open surgeries in that sense, but it may heal up a bit faster. There's less stripping of the soft tissues off the bones for a lot of these procedures and that leads to better blood supply, which can speed up the healing process as well. There's also less heat generated by the equipment pieces. So for instance, a lot of times we're realigning bones and you have to actually cut the bone. With the minimally invasive options, there tends to be lower generation of heat with the low-speed, high-torque, cutting burrs that we use. This leads to less damage to the bone, which also helps with the healing process. So we've really come a long ways in our options in the last 30 or 40 years.

Melanie Cole, MS: Well, thank you for that comprehensive answer. So as we're discussing this, tell us what foot and ankle conditions that you would treat with minimally invasive surgery.

Dr. Marc Chodos: So for me, I find it extremely useful for problems when people have what I would term lumps and bumps. So for instance, an area that that has been very useful is insertional Achilles problems. A lot of patients present with essentially irritation of the back of the heel bone rubbing on the Achilles tendon. Over years, this can start to lead to wear and tear of the Achilles itself. We get a lot of people that come in with chronic degeneration of the tendon attachment, calcific changes at the attachment site earlier on in the process where the tendon itself is less irritated and it's more of like a retrocalcaneal bursitis. This is really amenable to minimally invasive options where you can, through small poke holes, basically burr off the bump on the back of the heel bone that's rubbing on the Achilles. I actually think this probably changes the natural course of the condition. Once you get rid of the thing that's inciting the irritation, these people don't tend to go on in my opinion to develop these more severe damaged tendons over many years. We see these people later on where the traditional approach has been to make a bigger incision along the back. And you actually have to release the entire Achilles tendon off of the attachment site, clean out the worn diseased tendon tissue, take out the bony bump that's rubbing, reattach everything. It can lead to a very long recovery process when you have to muck around with the tendon itself. In some cases, these things are amenable to actually using a special burr to take out a wedge from the heel bone and rotate the heel bone in, so you're actually rotating it away from tendon itself.

There's situations where you can actually avoid having to mess around with the Achilles. So that type of a situation I think works really well. Certain neuropathic or diabetic situations where people have an ulcer from a bony prominence, especially if the foot itself is a stable foot, you don't have instability, things have healed in, say a Charcot foot, where you have a bump, you can actually go in and bur off the bump, sometimes even in the setting of osteomyelitis infection in the bone, you can bur all that out through very small incisions, which leads to much quicker recovery process than if you're having to make a large incision to get there.

So for me, the lumps and bumps, I think are really important. Situations where we're realigning the heel bone, this is a relatively straightforward thing that can be done minimally invasive. So the traditional way of realigning the heel bone involves making a several inch incision along the outside of the heel. We then take a saw and cut the heel bone and then shift it over to where it needs to be, and then anchor it in with screws. Well, that approach, the sural nerve is running along that area. So you can directly injure the sural nerve if you're too far anterior. There's also multiple branches that come off of the sural nerve that give sensation along the back outside of the heel and the outside of the heel pad. Those branches often get disrupted with that approach. And sometimes this can lead to problems of small neuromas or numbness in that distribution.

With a minimally invasive burr. You can do all this through a poke hole. So you really run very low risk of problems to these nerve branches. It can be really useful if you're doing other stuff along the outside of the heel where the traditional way to get there would involve having to extend an incision already. So for instance, the peroneal tendon on the outside of the ankle, traditionally, if you have to realign the heel bone in someone with a very high arch, you have to really extend the incision or make a separate incision that's very close to the first one. You have to get around the other side of the sural nerve, and then you're realigning the heel bone in that area. There's a much higher risk of wound healing problems. And all it takes is someone to have a major issue there. And it really makes you rethink how to do things.

Now, with the minimally invasive burrs, we can make a small poke hole, sometimes through the same incision, sometimes a little bit further back, cut the heel bone without risking all these other structures without risking wound healing issues and then shift it and fix it with screws like we traditionally would really, but without the same kind of risk for wound problems. I find this extremely useful in situations where people are on a blood thinner. If people have other risk factors that would make them at a higher risk for major complications. The healing process is much faster. I just saw someone the other day back in the office that we did a bunch of tendon work and ligament work and then realigned the heel. And he's probably 25% ahead of schedule already at two months out. it just looks like a completely different foot than you would normally see at that point out from surgery.

Melanie Cole, MS: Dr. Chodos, when you speak about that specialized burr that allows for that lower speed and higher torque, and it can then decrease those complications you were mentioning, are there certain patients for whom this is not an option? Are there any conditions or circumstances that would prevent someone from having this type of surgery? Speak about patient selection for us.

Dr. Marc Chodos: So I think with all of medicine, especially surgery, especially when you're talking elective surgeries, a lot of the stuff that we do is not necessarily someone coming in where it's an emergency and there's not another good option. And I think patient selection is incredibly important. So a lot of these same rules apply with this as with any other surgery. Though the risks are lower, if someone is a smoker, if someone has uncontrolled diabetes, if someone doesn't have a good blood supply, you still run into the same problems no matter how you do it. It may decrease some of these risks, but you still have maybe a higher risk of major problems, infection, wound healing issues, things like that. If you don't have a blood supply to heal something, it doesn't matter what you do. You still don't have that blood supply. So you still need to do your due diligence as a surgeon and make sure that you're dealing with someone that's as healthy as they can be for that procedure so they can recover properly.

There are certain types of deformities that can be very difficult to correct or stabilize and perhaps the minimally invasive option is not the best option in that situation. And this ranges from bunion surgery all the way through major hindfoot deformity problems. So, some things work well with one set of tools and some things work well with another. And if you have a hammer, not everything looks like a nail. And I think it's important to have all the options available to you when you're addressing these problems.

Melanie Cole, MS: What great points you've made. Now, the procedure itself, is there a difficult learning curve for other providers? Are there technical considerations? You are highly experienced at this? Are there some considerations you'd like to share with other providers to help achieve better outcomes?

Dr. Marc Chodos: The minimally invasive burr that we use for a lot of these procedures, it's a very different tactile field than if you're using a drill bit or a saw, a lot of the stuff that we're traditionally familiar with. It's not the same kind of feel once you hit the cortical solid bone that you get with these more commonly used instrumentation. And a lot of it is almost like a sound, change in pitch. And there's a very discrete learning curve with these things. We spend a lot of time in the early learning process working with donated body parts, I guess, is the best way of putting it, cadeveric things in the lab to try to perfect some of these skills before you're trying them on patients.

Melanie Cole, MS: That's so important. What's involved, and you spoke a little bit, but I'd like you to expand before we wrap up, involved in the days and weeks after minimally invasive foot and ankle surgery?

Dr. Marc Chodos: In some ways, a lot of the recovery process is similar to any type of other surgery. I find a lot of these things that's really dependent on what was done in terms of when you can start walking on it, things like that. The initial week or two for almost anything, I like to immobilize people depending on what the surgery is, but something that is going to allow the soft tissue to heal up, something that's going to minimize the amount of swelling.

With our better fixation options, so for instance, minimally invasive bunion surgery, which we haven't really talked about too much, there are much, much better, much more sturdy ways of fixing things. We have basically like rods or nails that can be used just like with a tibia fracture or a femur fracture to fixate fusions in the midfoot. We have much more sturdy ways of fixing things with cannulated screws now. And that does allow us to push the recovery process where we maybe couldn't in the past with a minimally invasive Lapidus procedure, which is a great way to fix a moderate or severe bunion. After something like that, the traditional open approach, usually you're looking at about six weeks of strictly non-weight bearing afterwards. I find with the minimally invasive option, we can get people starting to put weight on it much, much earlier now. The soft tissue has much less stripping, it heals faster. Our fixation is very solid. People have less swelling and recover much quicker. I actually find sometimes that I almost have to slow people down in the recovery process to make sure they're not doing too much too soon. So it does speed up the entire process. Yeah.

Melanie Cole, MS: And Dr. Chodos, you wanted to talk about bunions a bit. What would you like to tell other providers?

Dr. Marc Chodos: So we have some just amazing advances in the last few years with minimally invasive forefoot surgery for bunions and hammertoes. There's wonderful ways now to fix with plates and screws or rods, osteotomies where we're realigning things or fusions where we're fusing things to correct bunions, hammer toes that we just did not have in the past. So procedures that I think work extremely well that I do, so we do minimally invasive midfoot fusions for bunions called a minimally invasive Lapidus. We do osteotomies to realign the big toe called minimally invasive Chevron or Akin osteotomies. A lot of these things can be done through poke holes or maybe where the biggest incision is maybe a half an inch in size, which is just phenomenal.

We also have these great ways of fixing more flexible hammertoes through little poke holes. There's something called a TenoTac, which works extremely well for straightening out more flexible toes. It just leads to much quicker recoveries now. Much, I think, better results overall. It's been a really fun time to be in foot and ankle.

Melanie Cole, MS: What an exciting time to be in your field, Dr. Chodos, as we wrap up, please speak about the unique areas that set you apart. Why it's important to refer to the specialists at the George Washington University Hospital. And if someone wants to refer a patient in for minimally invasive foot ankle surgery, when is the best time to do that?

Dr. Marc Chodos: I think with anything, someone that is highly trained doing it, that does a lot of this stuff is probably going to do better than someone that has never tried it before, or does it once a year? The nice thing, here we have specialists in different areas that have done a lot of subspecialized training after their residency training in orthopedics. I think one of the nice things with an orthopedic surgeon for these kinds of things is that our tool chest, I guess, is, almost a bigger tool chest. So we can go to other parts of the body if we need to do bone grafting, things like that. We're not confined to just the foot or the ankle. We have a broader perspective in terms of our training in that sense.

When is the right time? So I am happy to see people at any point along in the process. Sometimes it's nice to have people come in earlier, even if it's something that maybe won't need surgery. We have great ways of getting people better without surgery. And it's nice to get to know people and follow them along through the process. So if they do need surgery, you're able to take care of someone that you already have a good connection with, that feels comfortable and trusts you to get them better.

I would much rather take care of something early on that maybe doesn't need anything major done than to have something come in that really needed something major done a year ago or six months ago, but the person was trying to handle something, that maybe they were a little in over their head or was a little more complicated that they weren't as comfortable with, and our doors are always open.

Melanie Cole, MS: Thank you so much, Dr. Chodos. What a fascinating interview this was. To refer your patient, please call 1-888-4GW-DOCS. Or if you have a question for one of our specialists, please email physicianrelations@gwu-hospital.com. That concludes this episode of GW Doc Pod, a peer to peer podcast for medical professionals with The George Washington University Hospital. I'm Melanie Cole. Thanks so much for tuning in today.

Disclaimer: Physicians are independent practitioners who are not employees or agents of the George Washington University Hospital. The hospital shall not be liable for actions or treatments provided by physicians.

Individual results may vary. There are risks associated with any surgical procedure. Speak with your physician about these risks to find out if minimally invasive surgery is right for you.