Minimally Invasive Surgery in the Foot & Ankle
What is minimally invasive surgery? [1,2,3]
There are different terms associated with Minimally Invasive Surgery (MIS).
1. Percutaneous surgery: Surgery performed within the smallest possible working incision in a closed procedure, i.e. underneath intact skin
2. Minimal incision surgery: Surgery performed through the smallest incision necessary to perform the procedure properly
3. Minimally invasive surgery: Surgery performed with minimum injury to the surrounding structures
No matter what name we are using, the advantages of MIS:
• Minimum injury to adjacent tissue
• Reduced post-operative morbidity
• Enhanced rehabilitation progress
History and development of MIS in the Foot & Ankle 
In 1945, Podiatrist Dr Morton M Polokoff first described subdermal surgery using fine instruments. In the 1970s the concept of MIS was spread among North American Podiatrists. In the 1980s US surgeon Dr Stephen Isham developed forefoot procedures using MIS techniques. In the 1990s Dr Mariano de Prado broadened the indications and developed the procedures in Spain.
Organisation of MIS Foot & Ankle Surgery 
In the USA there is the Academy of Ambulatory Foot and Ankle Surgery. In Europe, GRECMIP (Group of Research and Study in Mini-Invasive Surgery of the Foot and Ankle) was formed in Bordeaux in 2002. Both organisations have developed percutaneous surgery, ankle related arthroscopy and computer assisted surgery. Hong Kong has close ties with GRECMIP.
Clinical application in Hong Kong
Hallux valgus [1,2,3,4] (Bunion)
There are over 100 surgical treatment methods for symptomatic bunion.
One recently developed MIS method 4,10 is Percutaneous Distal Chevron Osteotomy of the 1st metatarsal bone, with internal fixation, to treat mild to moderate severity bunions. Using this method, there are only a few tiny wounds over the dorsum of the foot. This method has decreased post-operation complications such as wound infection, wound pain and is cosmetically more acceptable because of the smaller scars.
For severe bunions, we may use multiple percutaneous osteotomies to correct the deformity.
Hallux Rigidus [1,2,3]
The term means ‘stiffness of the great toe’, but is usually caused by osteoarthritis. The motion of the 1st Metatarsophalangeal joint is decreased which affects walking and can be very uncomfortable. We can use a tiny wound to decompress the joint, to remove the osteophytes (Percutaneous Cheilectomy) [1,2] and improve the motion of the toe.
Metatarsalgia is a general term which describes pain over the metatarsal heads or metatarsophalangeal joints. Usually the cause is too much load on the metatarsal heads, and in severe cases there are painful plantar callosities over the metatarsal heads which affect walking. We can perform distal metatarsal minimally invasive osteotomy (DMMO) [1,2,5] to realign the metatarsals to relieve the pain.
Plantar Fasciitis [3,6]
Plantar Fasciitis is a common problem in the general population. Classical symptom is heel pain on weight bearing or initiation of first few steps of walking. Most of the patients recover with medication, orthoses, plantar fascia stretching exercises and weight reduction. For resistant cases, we can offer endoscopic plantar fascia release  to release the symptomatic part of plantar fascia to relieve the pain.
Arthroscopic and endoscopic applications in the foot and ankle region [3,7,8,9,10,11]
Arthroscopic techniques [8,10,11] provide a far superior view to open techniques, and have become the standard of care for many procedures:
• Anterior and posterior ankle impingement
• Osteochondral lesion or loose body inside ankle, subtalar , Metatarsophalangeal joints 
• Synovitis of foot and ankle joints
• Ankle, subtalar, midfoot and forefoot degenerative disease
Tendoscopy application for tendinopathy in the foot and ankle region [3,10,11,12,13,14]
The tendons of the foot & ankle have a hard life, and can be injured or degenerate. A new technique of tendoscopy allows an excellent view without the conventional long incisions, and allows treatment of some conditions.
• Achilles tendon 
• Tibialis posterior tendon 
• Flexor hallucis longus 
• Peroneal tendons 
1. Cazeau Cyrille CHIRURGIE MINI-INVASIVE ET PERCUTANÉE DU PIED
2. Mariano de Prado, Pedro Luis Ripoll, Pau Golano Minimally Invasive Foot Surgery.
3. Michael J Coughlin, Roger A Mann Surgery of the Foot and Ankle, 8th edition
4. SW Kong, YH Chow Minimally Invasive Surgery (MIS) in treating Hallux Valgus: Hong Kong Experience and Short Term Results, oral presentation of 31st HKOA Annual Congress
5. Kelvin KW Tam, SW Kong, YY Chow, Distal Metatarsal Minimally Invasive Osteotomy in treatment of Primary Metatarsalgia: Case Report oral presentation of 31st HKOA Annual Congress
6. Stephen L Barrett, Chapter 17 Endoscopic Plantar Fasciotomy, Foot and Ankle Arthroscopy 3rd edition
7. C. Niek van Dijk, M.D., Kirsten M. Veenstra, M.D., and Barbara C. Nuesch, M.D Arthroscopic Surgery of the Metatarsophalangeal First Joint. Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 14, No 8 (November-December), 1998: pp 851–855
8. C. Niek van Dijk, M.D., Ph.D et al Arthroscopy of the Ankle Joint Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 13, No 1 (February), 1997: pp 90-96
9. Lijkele Beimers, MD etal, C, Niek Van Dijk MD, PhD Arthroscopy of the Posterior Subtalar Joint. Foot Ankle Clinic N Am 11 (2006) 369-390
10. Tun Hing Lui Current Concepts Arthroscopy and Endoscopy of the Foot and Ankle: Indications for New Techniques Arthroscopy:The Journal of Arthroscopic and Related Surgery, Vol 23, No 8 (August), 2007: pp 889-902
11. T. H. Lui Flexor hallucis longus tendoscopy: a technical note Knee Surg Sports Traumatol Arthrosc (2009) 17:107–110
12. C. Niek van Dijk, M.D, Ph.D., and Nanne Kort M.D Tendoscopy of the Peroneal Tendons, Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 14, No 5 (July-August), 1998: pp 471–478
13. Ferry Steenstra, MD, C. Niek Van Dijk, MD, PhD Achilles Tendoscopy. Foot Ankle clinic N Am 11 (2006) 429-438
14. Gythe H. Bulstra MD, C. Niek Van Dijk, MD, PhD Tendoscopy of the Posterior Tibial Tendon. Foot Ankle Clinic N Am 11 (2006) 421-427
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