Podiatric surgery is constantly evolving, and so are the methods and tools used by podiatric surgeons. Advancements aim to reduce surgical complications, post-operative pain, and recovery time, leading to better patient experiences. Innovative advancements in medical technology and surgical methodologies have ushered in improvements in patient results and abbreviated recovery periods.

There has been growing interest in minimally invasive surgery (MIS) to correct foot and ankle deformities. Although minimally invasive surgery for the foot and ankle has been around for many years, improvements in tools, implants, and surgical training have inspired the renewed popularity of these surgeries. A wide array of new shifters, guides, jigs, screws, and other devices have helped to improve foot and ankle MIS.  External jigs may aid in osteotomies and facilitate accurate placement of internal fixation.  Advancements in burr technology are another reason MIS of foot and ankle surgery has become more effective in recent years. Low-speed, high-torque burrs allow a surgeon to make an osteotomy without disrupting the soft tissue. Small incisions are cosmetically pleasing to the patient, avoid dissection and soft tissue stripping, which can result in postoperative swelling, and preserve blood flow to the surgical site, which allows for improved bone and tissue healing and faster recovery.  Another benefit from any MIS foot and ankle surgeries includes early weight bearing on the patient’s postoperative foot. There is a steep learning curve associated with foot and ankle MIS, and some factors may help to lower the learning curve.  These include attending saw bone and cadaver labs to practice techniques and spending time with well-versed MIS surgeons. To date, many MIS techniques have been developed to treat deformities such as hallux valgus, hammertoes, and bunionettes.  However, even more complex conditions such as Charcot are being addressed increasingly through a MIS approach. Percutaneous, minimally invasive techniques are being used to repair Achilles tendon ruptures. Historically, open techniques have been used to repair an Achilles tendon rupture, but they can be complicated by wound-healing issues and infection. This minimally invasive technique is ideal for middle-aged patients, where there may be a heightened concern for wound-healing issues.

Regenerative medicine, including platelet rich plasma (PRP), is becoming more commonly used in podiatry. Regenerative medicine therapies, sometimes called orthobiologics, use biologic tissues, such as blood or bone marrow, to improve symptoms of certain conditions and have the potential to enhance healing in musculoskeletal tissues. Platelets release growth factors play a critical role in tissue healing. PRP is produced by obtaining a small sample of a person’s own blood. The blood is centrifuged (spun down) to isolate and concentrate platelets that assist in natural tissue healing processes. PRP, which is depleted of red blood cells and granulocytes, including neutrophils, which are associated with inflammation, is then injected back into the site of the injury or surgical site. The injection contains proteins that can potentially decrease inflammation, reduce pain and improve tissue healing. PRP can be used to aid in healing tendon repairs, augment arthrodesis sites, and hydrate various bone grafts, such as demineralized cortical and cancellous grafts.

Autologous chondrocyte implantation is being used to repair full thickness cartilage defects of the ankle joint. Arthroscopic, single stage cartilage restoration is now available for foot and ankle surgeons. Autologous chondrocytes are harvested arthroscopically with a shaver and then mixed with PRP to make a cartilage-scaffold paste and an autologous fibrin glue to fix the chips in the cartilage defect. BioCartilage® extracellular matrix (ECM), from Arthrex, contains the ECM that is native to articular cartilage, including components such as type II collagen and additional cartilaginous growth factors. After processing, the dehydrated allograft cartilage has a particle size of 100 µm-300 µm. The small particle size improves its injectable nature after it is mixed with an autologous blood solution, allowing easier delivery to the defect site. PRP is productive when it comes together with cartilage. It has proliferative properties, can control inflammation at the joint repair site, and is pro coagulation which means less bleeding and quicker rehabilitation.

3D printing, also known as additive manufacturing, has revolutionized the treatment of challenging foot and ankle pathology. Treatment options for patients with large structural defects of the foot and ankle have typically included bulk allografts, autografts, and bone transport.  These options may be susceptible to donor site morbidity, nonunion, infection, and can require several surgeries to complete.  Bone allografts can also collapse over time.  Avascular necrosis of the talus is a disease process occurring when the blood supply to the talus is damaged either by trauma or systemic condition.  With advanced stages of AVN, removal of all avascular bone followed by arthrodesis was routinely the only surgical option.  Failed ankle arthroplasty is also difficult to manage.  If the native talar components erode and collapse, tibiotalocalcaneal arthrodesis and a bulk allograft can be performed, but the graft can collapse over time. A potential solution to improve management of large defects is the use of custom, 3-D printed porous titanium implants. 3-D printing technology has allowed for the development of custom metal implants that provide superior mechanical stability while also conforming to the patient’s anatomy.  Titanium alloy implants are designed with an interconnected porous architecture to encourage bony ingrowth. The implants can be made in a variety of sizes and footprints to reconstruct deformity and fractures across several anatomic indications. While 3D printing technology offers immense potential in orthopedics, there are several challenges. Cost-effectiveness and accessibility are key concerns, as implementing 3D printing infrastructure and materials can be expensive. Healthcare costs are a tremendous burden on hospitals and patients, and the use of expensive implants may be denied in favor of more traditional implants. Additionally, the long-term durability and biocompatibility of 3D printed materials need further investigation.

Numerous companies dedicated to foot and ankle surgery have emerged over the past several years.  The foot and ankle market are one of the fastest growing segments in the orthopedic industry. We are in the initial stages of harnessing the full therapeutic potential of biologics, and there are plenty of opportunities to advance the standard of care in foot and ankle surgery.