Review Article

Minimally Invasive Foot and Ankle Surgery: A Primer

for Orthopaedic Surgeons

Gregory E. Lausé, MD, MS

Christopher P. Miller, MD, MHS
Jeremy T. Smith, MD
ABSTRACT
There is rapidly growing interest in minimally invasive surgery (MIS) of
the foot and ankle. Technological advances, specifically with the
advent of low-speed high-torque burrs, have enabled the expansion of
MIS techniques. Accordingly, there is growing literature reporting
excellent outcomes of MIS surgery to address many different
pathologies of the foot and ankle. MIS techniques are particularly
useful for conducting percutaneous osteotomies and bony
débridement. These can be used to address bunion deformity,
hammertoes, metatarsalgia, bunionette deformity, bone spurs, and
hindfoot deformity. A detailed understanding of the technology,
equipment, and techniques is crucial to safely conduct MIS of the foot
and ankle. When done safely, MIS provides favorable outcomes with
an expedited recovery and limited complications.

M
inimally invasive surgery (MIS) of the foot and ankle refers to per-
cutaneous procedures that use small incisions for deformity cor-
rection, osteotomies, and débridement of the foot and ankle. These
From the Department of Orthopaedic Surgery,
Brigham and Women’s Hospital, Boston, MA techniques have gained attention because of reported faster recovery time,
(Lausé and Smith) and the Department of early weight bearing, improved cosmesis, and reduced postoperative opioid
Orthopaedic Surgery, Beth Israel Deaconess
Medical Center, Boston, MA (Miller).
use.1–3 Although MIS can include many minimal incision techniques,
including arthroscopic surgery, for the purposes of this review, we will
Miller or an immediate family member serves as a
paid consultant to Arthrex Inc; is a member of a discuss MIS techniques that use a specialized low-speed high-torque burr.
speakers’ bureau or has made paid MIS of the foot and ankle initially gained popularity in the United States in
presentations on behalf of Arthrex Inc; and serves
as a board member, owner, officer, or committee the 1980s for treatment of forefoot deformities. However, early procedures
member of AOFAS. Smith or an immediate family were largely abandoned because of poorly reproducible outcomes, soft-tissue
member serves as a board member, owner,
officer, or committee member of the American complications, and high rates of recurrence and revision surgery.4 The initial
Orthopaedic Foot and Ankle Society; editorial or MIS efforts were technically demanding and required challenging postop-
governing board: Foot and Ankle International
and JAAOS. Neither Dr. Lausé nor any
erative protocols, which were difficult to follow. Subsequent MIS procedures
immediate family member has received anything added provisional fixation using Kirschner wires, but these also had issues
of value from or has stock or stock options held
with stability and osteotomy positioning.5,6 For these reasons, early MIS
in a commercial company or institution related
directly or indirectly to the subject of this article. efforts failed to take hold in North America.
J Am Acad Orthop Surg 2023;31:122-131 By contrast, MIS interest in Europe remained strong, and with this interest,
DOI: 10.5435/JAAOS-D-22-00608 came additional research into MIS techniques and the development of the first
Copyright 2022 by the American Academy of
international MIS foot study group: Groupe de Recherche et Etude en Chir-
Orthopaedic Surgeons. urgie Mini-Invasive du Pied in 2002. International surgeons developed new

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 Gregory E. Lausé, MD, MS, et al

Review Article
techniques that were reproducible, safe, and effective. plications of MIS, which are soft-tissue injuries and
The cornerstone of the new-generation techniques was heat generation due to the lack of a traditional open
the use of a specialized burr hand piece that allows for surgical field. Many surgeons, including the authors,
low speed (,10,000 rpm) and high torque to decrease advocate using the burr off tourniquet to allow bleeding
heat and soft-tissue complications, which permits bone to help cool the burr further. Finally, it is often advis-
cuts and débridement using a percutaneous approach. able to pause and withdraw the burr to permit cooling
Systems with integrated fluid irrigation have been (Table 1). A recent study evaluated heat generation
developed to further improve heat dissipation. Surgeons during bunion correction with the MIS burr and noted
now advocate rigid internal fixation with cannulated that if the burr is used for less than 20 seconds at a time,
screws and reliance on intraoperative fluoroscopy. Re- the heat is minimized.11
sults of procedures using this burr have been favorable, There are two types of MIS burrs: the Shannon burr
and acceptance of MIS in the United States has been and the wedge burr. The Shannon burrs are narrow and
increasing rapidly in recent years.7 used for osteotomies, whereas the wedge burrs are
Surgeons now continue to identify new procedures that thicker and used for bone débridement. These burrs
can be converted to MIS using these newer techniques. come in various lengths and diameters, which are used
Although the indications for MIS procedures are the same for different procedures (Figure 2). Additional MIS
as those for open surgical methods, the use of less invasive surgical instrumentation includes elevators, rasps, and
techniques changes the expected risk profile after sur- reduction tools that allow manipulation of soft tissue
gery.8,9 MIS is currently being used for a wide variety of and bone through small incisions.
procedures including bunion surgery, cheilectomy,
hammertoe correction, lesser metatarsal osteotomies,
calcaneal osteotomy, exostectomy for Charcot foot cor-
rection, fusions, and hindfoot and ankle deformity sur- Forefoot
gery.10 With the potential for so many applications, it is The most common site of MIS surgery has been the
critical to understand the fundamentals of these techni- forefoot, and with proper training, many forefoot pro-
ques. The focus of this review was to highlight new cedures can be converted to MIS techniques. Maffulli
instrumentation, relevant anatomy, and results of some et al12 reported in their 2011 review that MIS forefoot
of the common MIS procedures.
techniques had promising results. More recent studies
point toward improved clinical outcomes and lower
rates of symptomatic recurrence with forefoot MIS
Instrumentation procedures.7,13
The burr and hand piece are the foundation of foot
Hallux Valgus
and ankle MIS techniques (Figure 1). As opposed to a
The minimally invasive chevron akin (MICA) technique
standard bone resection burr which may run at 40,000
involves a percutaneous distal first metatarsal osteotomy
revolutions per minute (RPM) and relies on the speed of
with lateral shift of the first metatarsal head. The MICA
the burr to resect bone with little torque, the MIS
osteotomy can be conducted either as a chevron cut or
burr spins at a much slower speed, typically 3,000 to
as a straight transverse cut; both techniques have equiv-
6,000 RPM, but with a higher torque to allow cutting
alent immediate biomechanical stability.14 Fixation is
of the bone. This high-torque and low-velocity com-
bination decreases heat necrosis and decreases the typically provided with screws placed from the first
likelihood of wrapping up soft tissues, such as tendons, metatarsal shaft into the metatarsal head. The first
vessels, and nerves. In addition, MIS burrs are shaped metatarsal osteotomy is then typically complemented
differently. They are elongated and have in cutting by a percutaneous akin osteotomy, conducted with a
flutes, which prevent grasping of surrounding tissue as closing wedge obtained using the burr at the medial
easily as high-speed cutting burrs. However, heat proximal phalanx (Figure 3). One of the most important
generation is a concern because the burr is used inside considerations in MIS is to conduct a skin-only incision
the bone. This is mitigated by decreased heat due to and then bluntly dissect straight to the bone. This helps
slower speed and continuous irrigation at the surgical avoid nerve injuries, which is particularly important
site. All these advancements in the instrumentation around the hallux because of the proximity of the
have been developed to help avoid the common com- dorsomedial cutaneous nerve.

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Minimally Invasive Foot and Ankle Surgery

Table 1. Pearls for Burr Use in MIS

Pearls for Burr Use in MIS
Preoperative
Participation in a cadaveric training laboratory and/or practice with sawbones/models to aid in the development of muscle
memory for proper cutting techniques
Intraoperative
Fluoroscopy and patient positioning to facilitate a planned procedure
Perform off tourniquet
Irrigation available to prevent potential soft-tissue thermal injury
Minimize consecutive burr use to ,20 sec to decrease potential thermal injury
Remove bone debris to prevent exostoses
Postoperative
Elevation and standard postoperative recommendations for swelling
Immediate partial and full weight bearing in a postoperative shoe or boot
Toe strapping/dressings may help hold lesser toe corrections in the immediate postoperative period

From a patient perspective, the benefits of a MICA They noted the early benefit of MIS on visual analogue
technique include immediate weight bearing, improved scale (VAS) pain scores, but otherwise no notable
cosmesis, a notable decrease in immediate postoperative differences in clinical outcomes or radiographic
pain, and possibly less stiffness compared with open measures at 6 months and 2 years.17 Finally, a pro-
procedures.9 A study by Mikhail et al15 demonstrated spective single-surgeon case series of 333 feet that had
91.6% patient satisfaction and a mean postoperative undergone MICA bunion correction between 2014 and
oxycodone pill consumption of 2.2 pills. In 2017, Lee 2018 with a minimum 2-year follow-up was reported
et al conducted a randomized controlled trial of 50 by Lewis et al.7 The authors reported notable
patients undergoing bunion correction with either scarf improvement in both HVA and IMA from 32.9° to 8.7°
osteotomy or MICA osteotomy. The MIS group had and 15.3° to 5.7°, respectively. Only 3 feet were
markedly less pain in the first 6 weeks and comparable
outcomes at 6 months as well as similar corrections
Figure 2
in the hallux valgus and intermetatarsal angles
(hallux valgus angle [HVA] and intermetatarsal angle
[IMA]).16 More recently, Tay et al reported on 60
patients treated with MICA versus open scarf in a
matched cohort study with 30 patients in each group.

Figure 1

Photographs showing minimally invasive surgery (MIS) burrs

available in variable sizes and shapes, which can be used to
Photograph showing a minimally invasive burr base with a achieve different bone resections and osteotomies. (adapted
hand piece and foot pedal. with permission from Christopher P. Miller MD, MHS © 2022.)

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 Gregory E. Lausé, MD, MS, et al

Review Article
reported to have radiologic recurrence (0.9%). No fluoroscopic guidance, the burr is used to undermine the
cases of osteonecrosis of the metatarsal head or dorsal osteophyte and resect the dorsal aspect of the
symptomatic sagittal plane malunion were found. The joint (Figure 4).
overall rate of serious complications requiring return to Outcomes after MIS cheilectomy have been reported in
the OR was 7.8%, including six episodes of osteotomy multiple studies. In 2020, Hickey et al13 reported on 36
displacement, four delayed unions, eight prominent patients with a 4.5-year follow-up with no conversion to
screws, four cases of prominent bone, four infections fusion and notable improvement in pain and function.
requiring I&D, and an all-cause screw removal rate of Teoh et al21 noted a mean improvement in VAS from
6.3% (21 cases). These results and others indicate that eight to three at a mean follow-up of more than 4 years in
there is a learning curve, which has been quoted to be 98 feet. The Manchester-Oxford Foot Questionnaire
as high as 20 to 50 cases.18,19 The advent of new (MOxFQ) improved from 58.6 to 30.5. However, there
aiming arms and jigs have hoped to flatten that were two infections, two cases of delayed wound healing,
learning curve (Figure 3). two transient nerve paresthesias, and two patients with
permanent numbness. Twelve patients underwent revi-
Hallux Rigidus sion surgery including seven first metatarsophalangeal
Cheilectomy for hallux rigidus is another common pro- joint (MTP) fusions, four revision cheilectomies, and one
cedure that can be conducted with MIS techniques.20 The removal of residual loose body. The authors noted that
goals and indications are the same as those with an open their relatively high revision rate was because of the
cheilectomy, namely to remove impinging dorsal os- learning curve and incomplete bone resection early in the
teophytes and loose bodies. MIS cheilectomy is con- series. Others have commented that nerve complications
ducted using a 2.9-mm wedge burr. A medial incision is may be lessened with technique modifications, including
made at the neck of the first metatarsal, and under blunt dissection to bone and ensuring proper burr size.22

Figure 3

Preoperative (above) and postoperative (below) clinical and radiographic images after MIS bunion correction using the MICA technique.
The intraoperative fluoroscopic image shows the use of an external targeting arm to aid in the shift of the metatarsal head and screw
placement. MIS = minimally invasive surgery, MICA = minimally invasive chevron akin. (Adapted with permission from Christopher P.
Miller MD, MHS © 2022.)

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Minimally Invasive Foot and Ankle Surgery

Figure 4

Preoperative (above) and postoperative (below) clinical and radiographic images after minimally invasive surgery (MIS) cheilectomy.
(Adapted with permission from Christopher P. Miller MD, MHS © 2022.)

In 2020, Stevens et al20 published a retrospective series of Calcaneus Osteotomy

MIS and open cheilectomies at a 3-year follow-up and Percutaneous techniques for a medializing or lateralizing
noted a 12.8% revision surgery rate and 11.3% com- calcaneal osteotomy are advantageous, in that
plication rate in the MIS group compared with 2.6% for they minimize wound healing complications and reduce
both in the open osteotomy group. postoperative pain and swelling. The avoidance of skin
As seen in the series of Stevens and Teoh,20,21 compli- bridges created with combined open approaches is a par-
cations can occur with MIS cheilectomy. To minimize ticular advantage of MIS techniques (Figure 6). Talusan
complications, Glenn et al23 advocated for MIS cheilec-
et al25 described a safe zone for calcaneal osteotomy that
tomy plus first MTP arthroscopy to address intra-articular
extends 11 mm distal to a line drawn from the postero-
pathology, including residual bone debris and synovitis.
superior aspect of the calcaneal tuberosity to the plantar
These authors reported VAS pain score improvements
fascia origin (Figure 7). With careful adherence to this safe
from an average of 7 preoperatively to 0.75 postopera-
tively with no nerve injury or infection. Overall, MIS zone, these authors demonstrated that the risk of injury to
cheilectomy shows promise, but careful adherence to the medial neurovascular structures was 10% lower in the
technique and avoidance of soft-tissue injury is critical. percutaneous group as compared with open osteotomy. A
The same principles can be applied to achieve a first MTP lower risk of wound healing problems and less frequent
arthrodesis for end-stage arthritis, with the use of the MIS injury to the sural nerve were also noted.
burr to prepare the joint surface and then percutaneous Being well-vascularized and having abundant cancel-
screw placement (Figure 5).24 lous bone, the calcaneus has excellent healing potential,
and MIS osteotomies seem to heal as well as open techni-
ques. Gutteck et al compared the results of 58 patients
treated with open osteotomy and 64 patients with MIS
Midfoot and Hindfoot osteotomy. No notable differences in VAS improvement or
MIS of the midfoot has been used principally for the radiologic parameters between groups and no pseud-
removal of bone spurs and less commonly for joint arthrosis in either group were observed, yet a markedly
preparation for midfoot fusion. In the hindfoot, MIS has lower risk of wound healing problems in the MIS group
been used for osteotomy of the calcaneus, hindfoot (0% vs 15.5%) was noted at 6 weeks and one year.26
arthrodesis, and treatment of Haglund lesion. As with Kendal et al, in a group of 81 patients with either MIS or
other MIS procedures, a thorough understanding of the open osteotomy, found markedly fewer wound complica-
anatomy and tools is critical to conduct these proce- tions in the MIS group (6.5% vs 28%). They reported a
dures safely. nonunion in one MIS patient versus none in the open

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 Gregory E. Lausé, MD, MS, et al

Review Article
Figure 5

Preoperative (above) and postoperative (below) clinical and radiographic images of minimally invasive surgery (MIS) first MTP fusion and
second hammertoe correction with percutaneous screw fixation. (Adapted with permission from Christopher P. Miller MD, MHS © 2022.)

group.27 Coleman et al28 specifically assessed risk factors of 189 osteotomies and found that healing complications
of complications associated with MIS medial displacement were present in 7% of cases. Heat osteonecrosis was
calcaneal osteotomy in a consecutive single-surgeon series suspected to be the cause of these healing problems. The

Figure 6

Lateral and axial fluoroscopic images demonstrating calcaneal osteotomy using an minimally invasive surgery (MIS) technique at the
time of total ankle arthroplasty. (Adapted with permission from Christopher P. Miller MD, MHS © 2022.)

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Minimally Invasive Foot and Ankle Surgery

Figure 7 Figure 8

Radiograph showing the calcaneal safe zone marked in the Radiograph showing a minimally invasive surgery (MIS) burr
shaded area. (Adapted with permission from Christopher P. within the talonavicular joint. (Adapted with permission from
Miller MD, MHS © 2022.) Christopher P. Miller MD, MHS © 2022.)

in cases of severe deformity and notable bone loss

authors additionally noted healing complications in pa- requiring structural or large amounts of grafting.
tients with American Society of Anesthesiologists three MIS fusion of the first tarsometatarsal joint (TMT) joint
classification, current tobacco use, and higher body mass has been described for hallux valgus deformity, first TMT
index. These results stress the importance of attention to joint instability, acquired adult flatfoot deformity, and
technique to avoid thermal injury. midfoot arthritis. In 70 feet treated with a percutaneous
Lapidus procedure with crossed screws, Vernois et al34
Midfoot and Hindfoot Fusions reported 95% good or excellent result, no infections, and
Percutaneous midfoot and hindfoot fusions, when com-
nonunion in four patients (6%).
pared with open arthrodesis, offer the potential for com-
parable outcomes with decreased postoperative pain and Insertional Achilles Tendinopathy and
risk of wound healing problems or infection.29 Cadaveric Haglund Deformity
studies have demonstrated a similar percentage of joint Insertional Achilles tendinopathy is often associated
surface area preparation.30 Although outcomes data are with a prominent posterior-superior calcaneal tuberosity
limited, one series of 77 MIS subtalar fusions reported a
(Haglund lesion) and insertional Achilles tendon spur.
92% fusion rate with no infections, delayed wound
Minimally invasive surgical techniques to address these
healing, or neurovascular injury.31 When conducting an
conditions include percutaneous Haglund excision. A
MIS fusion, the burr is used under fluoroscopic guidance
percutaneous incision is made adjacent to the Achilles
to first remove the cartilage. After the chondral debris is
tendon, and the burr is then used to remove the Haglund
irrigated out of the joint, the subchondral bone is further
lesion.35 As with other MIS techniques, it is important to
prepared with the burr and drills through the access
portals, and then, fixation is placed. mobilize soft tissue from the Haglund lesion before using
Certain joints pose particular technical challenges. For the burr. Fluoroscopic guidance can aid in the level of
example, the bone in the calcaneocuboid joint can be soft, bony resection (Figure 9). Bone debris is then extruded
so care must be taken to avoid excessive bone resection, through the incision. A hindfoot endoscopy can be done
which would shorten the lateral column. The curved in conjunction to ensure all of the bone is removed and to
nature of the talonavicular joint also poses a challenge for débride the anterior margin of the Achilles tendon.
MIS fusion because the flat surface of the burr makes Newer techniques are exploring the use of the MIS burr
joint preparation challenging (Figure 8). Despite this, to débride insertional spurs with percutaneous double-
there is evidence that the talar head may be easier to row Achilles repair augmentation, although long-term
prepare with MIS techniques and clinical results have outcomes have not been published for this technique.35
been positive.29 Tejero et al found an 89.5% union rate An alternative treatment of insertional Achilles tendin-
in 67 cases with a mean follow-up of 6.6 years, which is opathy is the Zadek osteotomy, which is a dorsally based
comparable with previously reported union rates after closing wedge osteotomy of the calcaneal tuberosity.36,37
open fusion.32,33 MIS midfoot fusion is also challenging Initially described in 1939, it reduces interference between

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 Gregory E. Lausé, MD, MS, et al

Review Article
Figure 9

Preoperative and intraoperative images demonstrating Haglund deformity before and after resection using a minimally invasive surgery
(MIS) technique.

the calcaneal tuberosity and the Achilles tendon by shifting ankle. In addition to more commonly conducted proce-
the insertion anteriorly and elevating the tuberosity. This dures such as the MICA bunion correction, cheilectomy,
also functionally increases ankle dorsiflexion and relieves and calcaneal osteotomy, MIS foot fusion and treatment
tension on the Achilles.38 When done with an MIS tech- of insertional Achilles tendinopathy is increasing. Another
nique, an 8- to 10-mm dorsal bone wedge is removed while area of MIS interest is the treatment of lesser toe pathol-
maintaining the plantar cortex as a hinge. The tuberosity is ogy. MIS techniques can be used to obtain toe deformity
then shifted anteriorly and fixed with one or two screws correction with flexor or extensor tenotomies, joint re-
(Figure 10). A recent study by Nordio et al demonstrated leases, and bone corrections such as intra-articular fusion
overall excellent results and showed a notable improve- or condylectomy or extra-articular osteotomies such as
ment in the Foot Function Index (from 65 6 9 to 8 6 12) the distal minimally invasive metatarsal osteotomy.
and VAS (from 9 6 1 to 1 6 2) with 92% satisfaction. In As a starting point, the authors recommend surgeons
26 cases, they reported two postoperative complications take a course with hands-on cadaveric training to gain
(8%), with one case of symptomatic nonunion and one exposure to these techniques before using the burr in a
patient with implant pain.39 clinical setting. Some of the techniques not only require a
thorough understanding of topographic anatomy but also
require the ability to mentally convert a two-dimensional
Future of Minimally Invasive Surgery fluoroscopy view into a three-dimensional procedure
In recent years, there has been exponential growth in the while relying on subtle tactile feedback and hand control.
interest and expanse of MIS procedures for the foot and As surgeons become more facile with the basic techniques,
Figure 10

Lateral fluoroscopic images demonstrating the Zadek osteotomy. A preoperative fluoroscopic image, intraoperative minimally invasive
surgery (MIS) osteotomy, and fixation with a single screw are shown. (Adapted with permission from Christopher P. Miller MD, MHS © 2022.)

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Minimally Invasive Foot and Ankle Surgery

development of newer techniques and instrumentation and radiological outcomes as scarf-akin osteotomy at 2 Years: A matched
cohort study. Foot Ankle Int 2022;43:321-330.
will continue to expand the application of MIS, flatten the
18. Palmanovich E, Ohana N, Atzmon R, et al: MICA: A learning curve. J
learning curve, and optimize the safety and efficacy of Foot Ankle Surg 2020;59:781-783.
these procedures. 19. Bedi H, Hickey B: Learning curve for minimally invasive surgery and
how to minimize it. Foot Ankle Clin 2020;25:361-371.
20. Stevens R, Bursnall M, Chadwick C, et al: Comparison of complication
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 Gregory E. Lausé, MD, MS, et al

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