After performing a DynaNail–based minimally invasive procedure in a high-risk elderly patient, foot and ankle surgeon Dr. Canon Cornelius gave a detailed interview to discuss patient selection, MIS joint preparation, and early mobilization.

How did you choose to combine DynaNail® with an MIS approach for this patient?

This patient is around 80 years old, obese, and had no help at home. She had some extremity weakness on the non-injured side from a childhood disease, so this was her good leg. The on-call surgeon asked if I could mobilize her faster to reduce the risk of prolonged bedbound status.

Based on my training and experience treating fragility fractures in elderly patients—where early weight bearing is critical—I felt a minimally invasive approach using DynaNail would be a good option. We discussed the implications of ankle fusion and the potential benefits of earlier weight bearing, like gaining strength back in her good leg earlier.

Given her significant peripheral vascular disease, I was also concerned about skin integrity and wound-healing risk with a more extensile open approach. Using a minimally invasive technique with an intramedullary device allowed me to achieve constant compression while minimizing soft-tissue disruption.

The goal was to enable earlier protected weight bearing and faster functional mobilization—potentially allowing her to transfer sooner and regain some independence—compared with prolonged non–weight-bearing or delaying fixation in favor of a traditional open reduction and internal fixation for a trimalleolar ankle fracture.

What other factors helped guide your decision and reinforce this as the best option?

Because of her difficulty mobilizing and comorbidities I felt a minimally invasive approach made the most sense.

Combining DynaNail with MIS is becoming more widely accepted, it’s a match that makes a lot of sense.

One advantage of DynaNail is that the implant itself is inherently minimally invasive. The challenge, however, is achieving proper ankle reduction and alignment—critical for shoe wear and a functional gait—while also adequately preparing the joints. These steps are often assumed to require an open approach.

By combining DynaNail with minimally invasive techniques, including burr-based joint preparation and percutaneous cartilage removal and bone grafting, it was possible to address those challenges through small incisions. This approach offered a way to minimize soft-tissue risk while still supporting earlier weight bearing and functional mobilization.

DynaNail is a powerful tool for advanced reconstruction. How did you plan the procedure to integrate it with minimally invasive techniques?

Combining DynaNail with MIS is becoming more widely accepted, it’s a match that makes a lot of sense. In hindfoot reconstructions, we’re concerned about skin healing, particularly with comorbidities like diabetes and obesity.

Implanting the DynaNail remains minimally invasive, with a small plantar heel incision and percutaneous interlock placement. If reduction and joint preparation can also be performed using minimally invasive techniques, the entire procedure can remain MIS.

One advantage in fracture cases is that the fracture itself can be used as a point of access to the ankle joint, further facilitating a minimally invasive approach.

The ankle joint is naturally curved, and when the malleoli are intact, preparing the joint often requires an anterior approach or osteotomies. With a bimalleolar fracture at the joint level, those fracture planes can be used as access portals, making it easier to prepare the curvature of the tibiotalar joint.

Another consideration is the dynamic position of the talus during preparation. When the foot is held in plantarflexion, it can be misleading in terms of where preparation is focused. As the case progresses, dorsiflexing the foot—or continuing preparation toward the talar neck—helps ensure the joint is prepared appropriately for final nail placement and fusion, which typically occurs in a more dorsiflexed position.

One challenge with minimally invasive joint preparation is managing debris. I prefer to use a small Shannon burr to remove the cartilage, followed by thorough irrigation to flush debris from the joint. This can be done through multiple portals using saline, helping clear cartilage.

After cartilage removal, I use a larger wedge burr to generate local bone graft within the ankle joint. I avoid irrigating at that stage. Because this involves extended burring time, continuous irrigation—typically managed by an assistant—is important. In traumatic cases, using the fracture planes as accessory portals can make joint preparation easier than when working around intact malleoli.

For subtalar joint preparation, there are several minimally invasive options. With the patient supine, I chose a sinus tarsi approach, which also allowed me to use the same incision for superior calcaneal interlock placement. Alternatively, the case can be performed prone—or with the patient rolled laterally—using a posterolateral portal, which can be more ergonomic. Regardless of approach, my primary focus with minimally invasive techniques is adequate preparation of the posterior facet.

Another consideration is graft delivery. Whether using autograft or a viable cellular allograft, delivering the graft through small MIS portals can be more challenging—and often more frustrating—than the joint preparation itself. The burrs are typically only 2–3 mm, which limits access.

I prefer using a wider forceps to deliver the graft directly into the joint, even if that means slightly extending the incision. In my experience, ensuring adequate graft placement in the ankle or subtalar joint is worthwhile, particularly in patients with significant comorbidities, where the added biology can be beneficial.