Outpatient Foot and Ankle Make Huge Strides

An ever-expanding list of MIS procedures has made same-day lower extremity cases a surging market with a bright and lucrative future.

Fans of the only-a-quarterback-away New York Jets were rightly full of hope when future Hall of Fame signal-caller Aaron Rodgers took the field at MetLife Stadium for the season opener on Sept. 11. Their emotions turned to dread four plays into the game, however, when Rodgers tore his Achilles tendon.

Most fans assumed his season was certainly over. While that might still wind up being the case, Rodgers has said he plans to play this year, and he stunned people when he began throwing passes before games only weeks after his surgery.

While many joked that such an unlikely return could only be chalked up to Rodgers’ affinity for days-long darkness retreats or taking the plant-based psychedelic ayahuasca, the truth is that advancements in minimally invasive foot and ankle surgery are making his return this season — while still unlikely — a possibility.

Gains on multiple fronts

New MIS techniques, premium power tools and improved pain management are making for faster recoveries. Physician practices and surgery centers that can offer these procedures could wind up very busy by taking advantage of a largely untapped market that could be lucrative for providers, while providing patient care that leads to fewer wound complications, less postoperative pain and high levels of satisfaction.

The change isn’t a matter of migrating cases from inpatient to outpatient settings, as a large percentage of open foot and ankle surgeries have been performed with same-day discharges for years. While some MIS procedures have been performed for 10 to 15 years, many of the latest advances began to emerge about five years ago, says Christopher Miller, MD, MHS, FAAOS, a foot and ankle surgeon at Beth Israel Deaconess Medical Center and New England Baptist Hospital in Boston.

“A facility that uses the latest minimal-incision techniques quickly gains the reputation for excellence and will become a destination place for patients to get very high quality care,” says Dr. Miller. “Caseloads will explode because more people will be willing to undergo these outpatient procedures, when they would have otherwise opted to not to have them done after learning it meant a three-inch incision and significant immediate post-op discomfort from an open surgery.”

High-profile case

GET WELL SOONER Endoscopic Achilles repairs are among the minimally invasive techniques surgeons are employing on foot and ankle patients that significantly speed up their recovery times.

Rodgers underwent a “SpeedBridge” procedure performed by Neal ElAttrache, MD, of the Cedars-Sinai Kerlan-Jobe Institute in Los Angeles. The innovative procedure is part of the reason that such a rapid return to the field for Rodgers is even a possibility, says Kenneth Jung, MD, a colleague of Dr. ElAttrache’s at Kerlan-Jobe. Dr. Jung is a foot and ankle consultant to the Los Angeles Rams, Los Angeles Kings and Anaheim Ducks.

The SpeedBridge procedure employs an extremely strong polyethylene suture over the distal end of the tendon in an hourglass pattern that is anchored into bone with four screws, allowing a knotless repair and large area of compression that lets patients put weight on their foot with a significant range of motion almost immediately after surgery.

“The SpeedBridge technique is an element of a surgeon’s armamentarium that they can utilize,” says Dr. Jung. “In this case, when you’re taking care of an elite athlete, it’s a stronger repair that allows him to push the rehab envelope and see where he can get to as far as a quick return.”

The SpeedBridge procedure isn’t something that’s only selected for pro athletes. Its use is fairly common and increasing all the time. It’s only one of the reasons that outpatient foot and ankle procedures are advancing, however. Dr. Jung credits the ever-expanding use of regional anesthesia as perhaps the most important development. Pain control issues were the biggest reason for keeping someone for observation overnight. Now, not only are most of his cases performed at surgery centers, but even most of his patients who undergo their surgeries in the hospital are allowed to go home the same day. “Here in Los Angeles, for example, anyone who has to wait until the general anesthesia has worn off and gets discharged after 3 p.m. has a two- to three-hour drive home,” explains Dr. Jung. “Regional anesthesia allows their pain to be controlled so they can get home sooner and get situated. The blocks are good for 12 to 24 hours, so we can explain to the patients that there’s no difference between being in the hospital or at home if your pain is controlled.” While recovery times are faster for patients who underwent a SpeedBridge procedure compared to a more traditional Achilles repair, patients such as Rodgers still have advantages most patients do not.

The outcomes of open and MIS procedures might be the same in two years, but MIS provides significantly more benefit in the first three months.
Christopher Miller, MD, MHS, FAAOS

“Professional athletes are getting paid to get back as quickly as possible, so the rehab is part of their job,” says Dr. Jung. “The rest of us go to rehab and physical therapy a few times a week, but elite athletes have the time and incentive to do much more. They can take more risks while pushing the envelope, because the windows for them to play are very short.”

Expanding procedure list

Other innovative surgeries that have been around for more than a decade — and have gained popularity in the last five years and thanks to the publicity when a pro athlete undergoes them — include the TightRope and InternalBrace procedures.

Each involves improved sutures and anchoring techniques that are far better than sewing a tendon back together. and enable patients to engage in early weightbearing that speeds up recoveries. In addition to Achilles repairs, surgeons can now perform minimally invasive ankle fusion, ankle arthroscopy and ligament repair, ankle fracture repair, hindfoot and midfoot fusion, midfoot osteotomy, flat foot reconstruction, Jones fracture repair, hammertoes, first MTP fusion and other procedures. “When you say ‘minimally invasive surgery,’ even people who know about this field automatically think, ‘Oh, that’s for bunions,’” says Dr. Miller, who is also on the Harvard Medical School faculty. “Not only is MIS used for more than that, but it’s actually a philosophy of care that uses advanced arthroscopy techniques to achieve the same or better clinical results through smaller incisions that will therefore decrease the risk of wounds and postoperative complications.”

MIS foot and ankle procedures are growing to the point that more patients are now asking if practices do them, says Dr. Miller. Many practices in most major cities are trying to hire MIS specialists or training their surgeons to become proficient in MIS techniques. “Right now this is cutting edge, but in 10 years it will be the standard and those who don’t get on board now will soon be behind the times,” he says, adding that a centimeters-long incision is much better for the patient in the short-term postoperative phase than a multi-inch cut from an open procedure. “Two years out, the outcome might be the same. But the MIS way is significantly more beneficial in the first three months.”

Rodgers returned to practice Nov. 29. The Jets have until Dec. 26 to activate him. Even if he doesn’t hit that target date, Dr. Miller says earlier returns to action like Rodgers’ will one day become the norm. “The combination of a tiny incision, improved materials and surgical technique were a significant benefit to him because his Achilles was repaired in a way that allowed him to rehab faster,” he says. “All rotator cuffs are now done arthroscopically, and ankle ligament repairs are increasingly following the same path. This soon will be true with Achilles repairs.” OSM