Foot and Ankle Surgery’s Big Moment

Minimally invasive techniques, technological advances and regional anesthesia are bringing more cases to ASCs.

Before Christopher Miller, MD, an orthopedic foot and ankle surgeon at Beth Israel Deaconess Medical Center and New England Baptist Hospital in Boston, began performing minimally invasive surgery (MIS), he estimates he did maybe 10 bunion procedures in his entire practice. Within a year of converting to MIS, bunionectomies became his most commonly performed surgery. “I began doing between 50 to 100 of them per year,” says Dr. Miller, who is also a Harvard Medical School faculty member.

This is but one example of the powerful role MIS plays in transforming the outpatient foot and ankle space for patients and providers alike. However, Dr. Miller is quick to point out that “minimally invasive” is a broad term that also includes advanced arthroscopic techniques. “When I think of minimally invasive surgery, I also include arthroscopy techniques — and some of the advances in our anatomic understanding of the ligament anatomy of the foot that have allowed us to advance arthroscopy skills,” he says.

Coming to a facility near you

From an outpatient standpoint, bunionectomies are the most talked about procedure in the world of same-day foot and ankle surgery — but their time in the limelight has only just begun. “It’s only been in the last five to 10 years that it’s taken off in the United States,” says Dr. Miller. “Everyone talks about minimally invasive bunion procedures because you can convert almost all your patients from a traditional bunion surgery to an MIS case,” adding that the explosion in popularity is clear when you consider the difference between an MIS and an open procedure, a surgery countless patients have complained about in the past. In addition to less painful procedures without the major incisions and subsequent scarring, MIS affords patients a host of benefits. “There’s still a recovery, but 50 percent of my patients don’t take any opioid medications,” says Dr. Miller. “And instead of being non-weight bearing for six weeks, we can let them put weight down and at least get around their home after surgery.”

If you do offer MIS bunionectomies, a procedure with strong potential for profitability and growth, you likely won’t even need to worry about spreading the word about your offerings — patients’ word-of-mouth will take care of it for you. For instance, Dr. Miller’s patients specifically seek him out based on what they’ve heard from friends and colleagues. “Increasingly, there’s a word-of-mouth effect where a patient will have the procedure and next thing you know their entire wine club will follow suit,” he says.

Though popular and inherently marketable, bunion-only cases are far from the only MIS foot surgeries Dr. Miller performs. A common procedure he performs may involve a bunion plus hammertoes and an Achilles lengthening. “At many places, if you are combining a second, third and fourth hammertoe procedure with a metatarsal shortening osteotomy, it’s a complex foot reconstruction that may take two hours of surgery,” he says. “I can do that same case in 50 minutes to an hour and get at least as good an outcome from my patients — and I would argue an even better outcome in the short term because there’s less risk of infection and wound healing problems.” Plus, for the surgical center, the time savings provides a significant benefit because the surgeon can perform four or five cases in the amount of time it would take to do two or three via a traditional open method.

Another promising area of surgical innovation involves ankle replacement for the treatment of ankle arthritis, a procedure that has grown exponentially over the past decade, according to Constantine A. Demetracopoulos, MD, a foot and ankle surgeon at Hospital for Special Surgery in New York, N.Y. “Ankle replacement is an option to alleviate pain from arthritis but preserve motion at the ankle, making activities like walking on the beach, hiking, playing golf, tennis and pickleball, not only possible, but also enjoyable,” he says. “Recent advancements in perioperative care and anesthesia now allow us to perform ankle replacements as an outpatient procedure, both in the hospital setting and freestanding ASCs,” adding that multiple studies have demonstrated that this is not only safe but also cost-effective.

Historically, says Dr. Demetracopoulos, patients with ankle arthritis were treated with an ankle arthrodesis — a procedure to fuse the tibia to the talus. “While that alleviated pain, it reduced motion at the ankle and foot, making it more difficult for patients to walk, exercise and return to the activities they enjoyed doing,” he says. In addition to total ankle replacements, Dr. Demetracopoulos says minimally invasive surgeries for both the correction of forefoot deformities (bunions, hammertoes, bunionettes) and hindfoot deformities have become more prevalent and accepted among surgeons and patients in the outpatient community.

Revolutionized planning, correction capabilities

Technological advancements have also played a vital role in the emergence of many same-day foot and ankle surgeries. One prime example cited by Dr. Demetracopoulos is weight-bearing computed tomography or weight-bearing CT scans, which are performed either with a specialized machine with the patient standing or with a device the patient can press against while in a seated position.

“This type of technology has revolutionized our ability to understand deformity of the foot and ankle,” he says. “It informs us how to best choose procedures to balance the correction of foot deformity, and how to titrate the amount of correction we perform at the time of surgery to achieve the results we are looking for. Simply put, this technology allows us to better plan our surgeries.” Specifically, it makes patient-specific instrumentation and custom 3D-printing of patient-specific implants possible, and gives providers more options to address complex and challenging problems.

Advancements in anesthesia

Regional anesthesia is another core component of the migration of many foot and ankle surgeries to ASCs and HOPDs, according to Dr. Demetracopoulos, who explains that the anesthetic medicine that is placed behind the patient’s knee will numb the leg, ankle and foot for anywhere from 12-36 hours after surgery. “Regional anesthesia has allowed us to perform big surgeries in the ambulatory setting,” he says. “Patients can leave comfortably and travel home without pain.”

From there, patients have plenty of time to situate themselves, get the foot elevated and begin a post-op regimen of non-narcotic medications — a key component of a speedy, efficient recovery. “Once the numbing medication wears off, patients require little narcotics,” says Dr. Demetracopoulos. “This has been an important advancement not only to address risks associated with narcotic use, but also to improve the recovery of patients after surgery,” adding that on the rehab front, patients are now able to utilize newer technologies to make the recovery process easier.

Problem-solving periop staff

BEYOND BUNIONS Minimally invasive bunion surgeries are among the most popular and marketable procedures being done in ASCs, but foot and ankle surgeons can do so much more.

Regardless of the tools and technologies available, a same-day foot and ankle program can’t succeed without the right staff. This starts with the surgeon — a profession that Dr. Demetracopoulos says requires a tireless dedication to seeking the best option for their patients. “This means pushing innovation and new techniques in a responsible way,” he says. “It means always being curious about how something can be made better and asking the right questions through research to assess outcomes and identify limitations and pitfalls.” Same-day minimally invasive surgery checks all these best-option boxes.

Dr. Miller agrees that having the right surgeons is paramount to the success of a foot-and-ankle program, but reminds leaders that the individuals performing the procedures are only part of the equation. “The surgeon is only going to be as good as the people he has helping him,” he says. “When you have a staff who’s excited about what we’re doing, who knows the instruments and understands exactly what’s happening from an educational standpoint, it makes the surgeries go so much smoother.” An eagerness to jump in, be flexible and problem-solve is an essential quality of OR staff when you consider the nature of foot and ankle cases where, unlike consistently similar orthopedic procedures such as total knees and total hips, there’s an extreme variability from case to case.

“I do 400 different surgeries, so every time I go into the OR things are going to be a little bit different,” says Dr. Miller. “What I look for are circulators and scrub techs who are actively engaged in the surgery and trying to problem-solve. When I turn to them, they have an instrument they’re handing to me.” Ninety percent of the time when staff does this for Dr. Miller, they have the right instrument at the ready. The other ten percent of the time? “If it’s the wrong instrument, I’ll just say, ‘Oh no, I need that other one over there,’ and then they’re going to learn something. I’d much rather have somebody who is trying to figure out what the problems are without me needing to go through it all,” he says. “There is no substitute for having staff in the OR who are actively trying to problem-solve with you.”

Behind no more

When it comes to advances in foot and ankle surgery, Dr. Miller sees the present moment as a distinctly exciting time for outpatient facilities, one in which providers in the space are finally catching up to where those in the hip, knee and even shoulder procedures have been for years. “Until recently in this country, foot and ankle surgeons have been left behind,” he says. “What’s exciting, however, is that with recent advancements, this is our time to shine and modernize, to bring foot and ankle surgery into line with the philosophy of minimal incisions, fewer wounds and less postoperative pain. Now we have the technology and skills to do just that.” OSM