Power Tools Help Small Bone MIS Continue to Grow

Better equipment makes the prospect of foot surgery more palatable to patients.

Orthopedic patients are often surprised that their bones are repaired with screws, drill bits, saws and other tools that look very much like what they have at home. Indeed, there are many similarities to what’s on the surgeon’s back table to what is in a patient’s woodworking shop at home.

There are many differences, of course. The batteries must be able to withstand the rigors of regular sterilization, for example. One stark difference is that facilities absolutely cannot wait until a surgical power tool wears out to replace it.

Tools of the trade

“There’s a lot of truth to the saying, ‘A good surgeon never blames his tools,’” says Christopher Miller, MD, who practices at Beth Israel Deaconess Medical Center and New England Baptist Hospital in Boston and is a Harvard Medical School faculty member. “However, if the tool breaks, it doesn’t matter how good they are. They could be really up a creek.”

A nightmare example would be performing an intramedullary nail and the drill jams, explains Dr. Miller. The reamer would be stuck in the middle of the bone with no way to get it out because the drill has failed you.

“Replacing aging equipment is not a discretionary expense and not something facilities should ever wait to do,” he says, adding that the power tool fleet must feel good for surgeons to hold in addition to having the requisite features to get the job done. “Equipment that’s dependable and comfortable in your hands could not be more critical from a surgical standpoint.”

Other features to look for in your power tool fleet are weight and balance, as many surgeons prefer lightweight, ergonomically sound models that don’t tire them out and make it difficult for them to apply the right amount of force needed to get the job done. Noise is also a consideration for many physicians who are distracted by models with higher decibel levels. Polling your surgeons to see if they prefer electric- or battery-powered models is a good idea. Each power tool should also be versatile and have the appropriate amount of speed and torque — dual functions that are critical for successful outcomes.

MIS revolution

Ongoing improvements in minimally invasive surgeries (MIS) have changed the game for procedures such as bunion surgery. “Historically, this requires a three- or four-inch incision along the foot, which is very painful, leaves a large scar and can be accompanied with stiffness,” says Dr. Miller. “Now we can do them with approximately four narrow incisions that are only three or four millimeters in length, which benefits the patient by providing much less postoperative pain, a faster recovery and a much lower risk of problems surrounding wound healing.”

Replacing aging equipment is not a discretionary expense.
Christopher Miller, MD

A particularly important development is that of high-speed percutaneous burrs to replace micro sagittal saws for bunionectomies, cheilectomies, hammer toe and flatfoot surgeries, as well as fusion procedures. “It’s one of those things that, as a surgeon gets more comfortable and familiar with it, they start using it more and more in their practice as they convert more and more surgeries from traditional open procedures to a minimally invasive technique,” says Dr. Miller.

Placed on a handle that looks more like an electric pencil than a traditional drill, the burrs spin and oscillate so fast they can be used like a drill to pierce the bone, then used like a saw to cut through the bone when the surgeon sweeps his hand back and forth. “You’d have to open up pretty big to do that with a saw, and now you’re able to do it through that small MIS incision just by rotating your hand,” says Dr. Miller. “Surgeons were able to change from that to this very small instrument, and by using this new technology, avoid complications and improve the care of the patient.”

Almost all bunionectomies Dr. Miller performs involve using the burrs, and he says that and other MIS advances have revolutionized his practice — and outcomes for his patients. Use of the burrs is more common in Europe than here, but those who are willing to learn are doing so via special training and instruction from the device manufacturers and taking courses from national and international professional societies.

While patients generally select a physician because of their reputation and the outcomes they deliver, Dr. Miller says his transition to almost exclusively minimally invasive approaches has expanded his practice. “People started coming to me because they were interested in this approach specifically, so it can increase your volume of patients and your practice’s bottom line,” he says. “From a business standpoint, it’s a little more attractive for a patient to make the decision to get a minimally invasive bunion surgery that will be less painful and have a faster recovery than the traditional open surgery. Those still work very well, but why deal with that when you don’t have to?”

The next phase

Continued progress in foot and ankle surgery goes well beyond the use of power tools, notes Dr. Miller. Some soft-tissue foot and ankle procedures are being revolutionized by small-joint arthroscopy. This is following the same path of knee and shoulder procedures (and to a lesser extent spinal surgeries), for which open surgery was the norm and has been almost completely replaced by arthroscopic procedures. “Most of our residents today will never see an open rotator cuff repair and we do only arthroscopic ACLs today,” he says.

Now, ankle ligament repairs can be done through three tiny arthroscopic portals, analogous to modern ACL repairs, instead of a large incision on the side of the ankle. There are even more office-based procedures now than ever, and some surgeons are performing wide-awake surgeries in office environments.

“The history of orthopedics is a drive toward minimally invasive procedures to get the same outcomes,” says Dr Miller. “We’re using all our knowledge and arthroscopy skills and anatomy skills to do the same repair with the same durability and strength as ever.” OSM

Note: This three-part article series is supported by ConMed.