Good morning, everyone. Ken Ellington, co-chair of the meeting with John Kwan, and we look forward to an exciting day. Good to see some faces out there I hadn't seen in two years. Thank you for attending and fighting some of the weather this morning. Typically, Charlotte at this time of year is beautiful, and it's supposed to be a good tomorrow here. So I want to say a special thanks to Carol Jones and Bruce Cohen for the opportunity to do this. It's been an amazing experience. I have a newfound respect for people who have put on these meetings in the past, and these gentlemen here have definitely done it in the past. So thank you for everything you've done. It's more work than I expected, but a huge honor. Please, the AFS wanted me to give a couple bullet points to be sure to visit the exhibit hall and support the companies and appreciate them during the scheduled breaks. Take advantage of the industry satellite sessions. If you have questions during the sessions, you can walk up to the microphone in the aisle and speak clearly, and to the presenters, we answer the questions. The program is very full to our speakers, and they've, as you know, tried to want me and Mike to keep us on time so we can get through all these wonderful talks. Complete the session evaluation CME claim form, and the Wi-Fi password is AOFAS2021. Without further ado, the great, majestic Dr. Coughlin is going to be the moderator of this session, and we have a fantastic thing. If you look at the agenda, we're going to have a great roundtable session with some of the greats of our society, and it's going to be exciting to listen to that later, too. And he has a, his daughter's got a 40th birthday party, so he came in special for this. Thanks, Kent. Yeah, my Uber is actually warmed up and ready to go, and it hasn't even slowed down. I'm just going to dive in at the end of this conference and head back to San Francisco. But I'm totally pleased to be here with all of you and to this august panel of just very erudite people who will give us some, their thoughts on different aspects of forefoot surgery. In a society where things have really evolved to a lot of hind foot and ankle and other big time stuff, the forefoot still comprises a great deal of our practice, and so there are some real interesting thoughts, interesting progress that's been made in different topics. And we'll start out with Bob Samstrock from Morgantown, West Virginia, who's going to talk about TMT fusion, things he's learned, things he really believes in, and I look forward to this. Bob? Good morning, everybody. Thanks for having me, Mike. I appreciate everybody showing up in person. It's been a while. So I've got 10 minutes to tell you everything that I've been learning for the last seven and a half years, everything that's consumed my professional thoughts in the last seven and a half years. I've got 10 minutes to tell you kind of the breakdown of my thesis on why I believe that the triplanar TMT arthrodesis has become the new way of going about correcting bunions. And so my thesis has about 10 bullet points, and I'll try to race through these, and I'm sorry that it's going to be a little fast, but we'll take questions at the end of the whole session. Really my belief is that hallux valgus is midfoot instability. It's midfoot instability at the TMT joint, mostly rotational instability, as opposed to just a bunion. I believe a bunion deformity is really secondary to the midfoot instability. The uterus bind hallux valgus and intrusalotes sort of took us down the path of metatarsus promisferus, but everything after that has really been based on severity. We've been really looking at how things are deformed at the MTP and really not looked at much of what is really the true pathology, although it's been there sporadically in the literature. Basically our algorithm has become severity and not anatomical based. The disease of the hallux valgus is really this midfoot instability, and with this video you can see just release of the TMT joint, relaxation of the ligamentous structures, the hallux valgus deformity can appear, and it's really all just through a rotational movement here. I don't think rotation is the only thing going on, but it's certainly a major effect and a compounding effect. How does this happen is really I believe there's evidence in the literature to support that the TMT joint is pathologic in hallux valgus, and this has been seen sporadically throughout the literature. Even Lapidus wrote about this in his 1960s summary about how the primate foot, when the primates were living in the trees, they needed opposable thumbs on all four limbs, but once they became upright and walking on the lower limbs, the hallux became more rigid and had different facets, and the facets are noted to be less continuous or more divided up into the tri-facet and the normal foot, but in a hallux valgus foot there is a continuous or unifacet or sometimes a bifacet as seen by a couple of our panelists up here who described some of the facet morphology differences as well. In our study we're presenting as opposed to this meeting, we'll see that there is a significant propensity towards this continuous or unifacet, bifacet nature in symptomatic hallux valgus is presented to about 82% of those patients. One of the things that always bothered me about bunions is that the cora was always still present after I did distal surgery, and I never really could understand why I looked at x-rays and saw this deformity at the midfoot while I was treating it separately distal to this, and it just blew my mind that we ignored what always seemed to be a constant as the propensity of what I was trained 20 years ago. Rotation is the key here, so rotation is the multiplier of that deformity. If you leave the rotation behind, the sesamoids will not be aligned, and we know from ACUDA that there is a 10 to 12x times of recurrence when those sesamoids are not returned to all three planes of normal position, and I didn't discover rotation as a contributor. It's been in our literature since 1956 in multiple places by people we know has described it, but it really was the advent of weight-bearing CT in the recent years, and Kim's study, she showed that there was an 87% propensity of how it's valgus rotation, and there's an average of 22 degrees of rotational deformity, and so by leaving this behind, treating it in a uniplanar fashion is difficult to see that you can have a successful result. It is important to note that with the rotation there, the recurrence is very high. Traditional surgery fails too often, and this is something that also bothered me. I teach at a teaching institution, and I tell my residents that in general, the vast majority of our patients would not receive surgical options unless they had a 90% success rate, yet the radiographic success rate of traditional one-dimensional or two-dimensional bunion correction fails at 30 to 70% of the time by a survey of multiple different types of procedures, and this seems to be an unacceptable rate compared to what we normally offer in orthopedic surgery. If you go through the TMT joint that is pathologic that I'm describing, then you do not necessitate creating a new deformity. One of the golden rules of treating deformity correction is you have to account for the next deformity, and if you do not, you often create or compound the problems, so in my hands, I like to look at a pathoanatomical treatment where I'm going at the TMT joint, what I believe is pathologic, and anatomically realigning the foot to the best biomechanical advantage. There's no downside that I can find in the literature for TMT fusion. We have a lot of suspected things that we think, but I'd spent exhaustively one summer trying to look up the downside of TMT joint fusion, and I couldn't find it. As a matter of fact, if you look at anything, the survey of our society shows that the majority of us will offer TMT arthrodesis to even athletes and return them to sport, and the concerns regarding adjacent joint arthritis, increased risk for stress fractures, and such has not been proven out in the literature thus far. We'll certainly need to continue to survey this, but if you stabilize the unstable pathologic TMT joint, you will preserve the functional MTP joint, especially if you do it in a triplanar fashion. This is the same patient treated eight years, and follow up here, and you can see on the left, they were treated with a triplanar TMT arthrodesis, correcting the rotation, and the MTP joint looks well-preserved and functioning, but on the right side, which was a failure to do it in a triplanar fashion, just a uniplanar fashion, you can see that the MTP joint now, which is bound by the sesamoids, not tracking correctly, has become arthritic. If you address at the TMT joint, you often will be able to address intercaneiform instability, and you may wonder, was this a big deal or not? Well, it is something you would have to go separately if you didn't, and by the literature, we see that 73% plus is associated with intercaneiform instability, which makes sense if you adopt the philosophy of TMT joint instability. And TMT joint arthrodesis is compatible with early weight-bearing. With our studies, we've had a couple that we've been able to show that weight-bearing, near immediate fashion, with one week to two weeks at most, limited weight-bearing, and a six weeks follow-up and a boot, you can achieve a very high 95 plus percent fusion rate of MTP or TMT joint, and in our study of truly the triplanar TMT arthrodesis, with our most modern technique, we have in our first go, we had 97% maintained three-plane correction, and only 1.6% non-union rate. I'm often given the argument that shortening is a factor, and shortening is significant, but truthfully told, we haven't seen this to be a factor. There's probably a lot of forgiveness from the frontal plane rotation putting the sesamoids in the right place, but your actual shortening is only 2.4 to 3.1 millimeters on an osteotomy through the TMT joint or bone cuts, and through an osteotomy, it's actually 3.8 to 7.4 millimeters, and so not really much difference, if anything, just a little bit shorter. But if this were true that shortening is a factor, then there's no bunion surgery that would make, that would be able to do this. All bunion surgeries have some sort of shortening, and submetatarsal pain theorized to come from this is really not playing out with the triplanar correction, because the sesamoids are taking a better load, being more plantar than the lesser metatarsal heads as the normal foot appears. With our current ongoing longitudinal study, we're at 165 patients at two years follow-up, and we do not have any incidents of metatarsalgia thus far, and we're not doing routine lesser metatarsal osteotomies either. Those are excluded from that group. So what about foot width reduction? It's very easily achieved with a triplanar TMT arthrodesis. You're able to get the foot width reduced about a centimeter, which is a dramatic improvement for the patients. And what does that say about osteotomy, which is often that the foot actually gets wider as presented by some of our colleagues. So there's a high success rate with TMT arthrodesis, as opposed to what may be theorized about lapidus in the past. There is really a very high success rate as compared to Chevron osteotomy, which was in the last year's AOFAS, which showed the failure rate to be very high. But the success rate for this is in the 97%, as we showed you radiographically. And clinically, we have a favorable patient-reported outcomes, return to work, and return to sport at four months with this type of a procedure. Thirty thousand of these procedures performed in the last five years, and 19 peer-reviewed publications, I think we're on the way to a good analysis, and I think it needs to be continued. But in my opinion, it's not fiction anymore. It's fact, and I believe 3D anatomic first TMT arthrodesis is a patho-anatomic correction. Thank you. Thanks, Bob. Our next presentation is going to be on the painful implant. What now? By Scott Chawin from North Carolina. Scott? Thanks everyone for coming out so early. Just as disclosures, I don't have any disclosures that are relevant to this talk. So, hallux rigidus, second most common condition affecting the hallux NP joint. I think Dr. Santrock already gave us an introduction to the most common affectation to the hallux NP joint, termed late in the 1800s after a description by Davies and Colley. When I look at this as far as arthroplasty, I didn't mean to steal this off your thing. I just didn't look, Jesse, on what the title of your talk was. But I thought this is looking for the holy grail, and just wanted to highlight some of my mentors. I included Bob in here, even though he's not one of my current partners. But, you know, we really are searching here, and I think we'll continue searching for what works best in the hallux NP joint. Hemiarthroplasty really encompasses two different applications. One is at the distal metatarsal head, and then the other is at the proximal phalanx. I find this one to be the more complicated implant to deal with, due to the bony kind of paucity of bone, I would say, in the proximal phalanx of the hallux. And when you remove the implant, we'll get into that a little bit more in a bit. Then there's the total toe arthroplasty, which essentially is just like a total joint for the hip or the knee, and it's bifocal as far as your treatment. There's been other arthroplasties, even something like gel foam, which we know is going to resorb over time. There's various applications of autograft tendon interposition. All of these usually have some sort of color arthroplasty to the proximal phalanx in order to provide some dorsiflexion, but different application of different tendons and different structures around the hallux NP joint, which have been interposed. Allograft tendon and graft interposition has also been utilized, something like a dermal allograft that wraps around the metatarsal head. Again, this also encompasses a portion of a keller arthroplasty to the proximal phalanx, or taking something like a semitendinosus allograft, and in some institutions, possibly even autograft that you ball up and then interpose in the hallux NP joint. Other applications that we've seen have been silicone interposition arthroplasties. I've found these to be probably the most osteolytic of any of the interposition arthroplasties, causing a fairly large amount of bone osteolysis. And then we talk about the search for the Holy Grail CARTIVA, or the synthetic cartilage implant, which is a polyvinyl alcohol hydrogel interposition that has become really a focus of attention over the last five years since the FDA approval in 2016. And some question whether or not this is the closest we've come to finding the Holy Grail, but I'm not going to really go too much more into this specific implant as it's beyond the scope of this presentation. So when you look at interposition arthroplasty in the hallux NP joint, there's all kinds of adverse events. It is not essentially selected towards CARTIVA solely, but any of these implants can have problems. So this is a study looking at the FDA administration data from 2010 through 2018, and there's a whole plethora of different implants that can have adverse events, meaning that return to surgery and either revision or other procedures are performed. So what do we do next, you know, after you have a painful implant? I think all of us have seen painful implants come in, whether they've been placed by us or by other surgeons. Do we perform an arthrodesis? If you're performing an arthrodesis, is it a distraction arthrodesis? Is it an interposition type of arthrodesis? Is it just a native arthrodesis? Are we revising the implants? Are we doing something else? Are we adding phalanx osteotomies or Moberg osteotomy? And in my experience, well, that depends. It depends on what you're presented with. So, you know, how do we decide what to do? I think that the biggest thing that affects our decision-making is, is there bone loss, and then where is the bone loss? Whether it be in the metatarsal, which you can see here in this picture, which combined in this picture also with the proximal phalanx, both, is it just overwhelming arthritis that we can deal with without having to do extreme measures? So this hemi or arthroplasty typically do have some bone loss in the application of the construct. There's arthritis and osteophytes, and most often, in my experience, requires some sort of interpositional arthrodesis. When you look at this one, again, there was not a lot of bone loss, so I was able to, you know, perform a primary arthrodesis and did not have to do any interposition. Other cases, though, you have some bone loss with this implant, and again, most phalanx hemi arthroplasties have extensive bone resection. This one was not terrible, but it was still present. The biggest problem that I see is that there's bone ingrowth on the stem, and so you have a very soft bone. The bone is really ingrown to around the stem, because this is not a smooth metal. Typically, it's treated either plasma spray or something else trying to promote bone growth, and many times I've had to make a window in the dorsal phalanx in order to get this implant out. Then if you've ever, you know, gone into the middle aspect of the proximal phalanx, there's no bone in there. And so then how do you fix this? And so that becomes problematic. And so this is an interposition. So, the other aspect is your metatarsal head arthroplasty, though some of these are a solid implant. grows into the bone. And so even if you have the right screwdriver to get it out, you may have to destroy bone in order to get it. So in this case, we just took off the hemicap, did a distraction arthroplasty, and we're able to get this to eventually heal. There are implants available that provide you Again, as I alluded to earlier, silicone interposition arthroplasty, in my experience, has the most extensive bone loss. Silicone is unpredictable in my mind as far as what it's going to promote the body to do. I think many times it does cause osteolysis or soft tissue reactions, and so in cases like this, And so, you know, this patient's already had a wild osteotomy shortening of that segmented tarsal but has a painful hallux NP joint at this point. And so this is a rather large allograft that we did use some physiologic adjuncts such as bone marrow aspirate concentrate and soaked that in that, took some autograft in addition for around the implant and were eventually able to get this to heal. It did have extensive bone loss. We packed the autograft both distally as well as proximally. So, what do you do in cases like this? You know, this has very severe shortening. You've got a lot of osteolysis from a silicone implant. And so, you know, how do you handle this? One of the things is your soft tissue envelope. You can't just go in here and put a 12 millimeter graft into that area and be able to get it closed. And so, in this case, a distraction with a external fixator for about a month, followed by, in a position, arthrodesis. And she did very well for about two years, but then started to break down. So, you know, now we come to the synthetic cartilage implant. So, you know, this all started, like I said, about five years ago. There was a prospective randomized multicenter trial looking at this, and essentially it was a non-inferiority type of study looking at the implant, which was the polyvinyl alcohol versus helix NP fusion, and it had equivalent pain relief and functional outcomes, and the article indicated that secondary surgical procedures ended up being similar between the groups, which was about 10 percent. Hardware removal for the helix NP fusions and revision to fusion with the synthetic cartilage implant. A more recent study that was done last year was looking at essentially MRI, but also looking at outcomes after placement of this synthetic cartilage implant, and so they demonstrated that all cases demonstrated an increase in arthritic change, and MRI showed that the implant was smaller than the surrounding bone. At this point, there was fluid, and And so about 38% of the patients in this study underwent revision surgery, fusion, revision of the implant, and then revision of the implant with Moberg, or just a lysis of adhesions. So this is a case that we performed. Hallux rigidus, a dorsal colectomy with a cartivagraft was placed. We didn't go into staging, but this would be probably a stage two. This is after the implant was placed. You can see a little bit of loss of joint space. The patient did initially fairly well for about 11 months. But at around 11 months, you can see complete collapse of the joint, recession of the implant, cavitation of the implant space within the metatarsal head, and this patient went on to fusion. And again, there are market available implants that could be placed into the defect, or you can use autograft bone. Here, we just used autograft bone from the calcaneus and filled in the space as well as the Hallux NP joint, and this patient went on to a successful fusion. Other options, you know, can you revise? Dr. Thudarson's group did demonstrate you can revise this, add on a Moberg osteotomy, which is a dorsiflexion osteotomy at the phalanx to try to take some of the pressure off of the Hallux NP joint. Again, you know, this depends on what the patient presents you with and also what their desires are. I didn't go into patient desires, but some patients do desire to continue to have Hallux NP range of motion, and in those cases, you have to essentially think outside the box. So, you know, in my experience, the Holy Grail is still out there. might happen specifically, bone loss, fractures of the bones as you're trying to fix them. I wouldn't hesitate to also pin the hallux NP joint from the tip of the toe just to provide some extra fixation for the first six weeks. I find that the phalanx hemis are the most difficult. They have very soft bone. They're well fixed into the bone, and so as you're removing the implant, you destroy some of the bone, and you have to think ahead on how you're going to fix that. Have your distraction graft available, whether it be an autograft versus allograft, and think about adjuvants. Anyway, thank you very much, and have a great meeting. Thanks, Scott. Our next speaker is Joe Park from Charlottesville and UVA, who will talk on complex salvage of the first ray. Joe. Thank you for having me here. It's a huge honor to be here. Thank you, Dr. Coughlin. So we're going to briefly talk about first ray salvage orthodesis. I'm going to focus on the first MTP. And Scott's talk actually is a perfect segue into my talk. I'll show you a different approach that I've used in my practice. Here's my disclosures, none that are really pertinent for this talk. Remember that fusion of the first MTP, there's many challenges and a lot of the challenges are related to poor alignment of the MTP, previous surgeries, incisions, etc. Loss of the medial longitudinal arch support, which can dramatically change the way these patients walk. And then, as Scott mentioned, resultant lesser ray overload related to that shortening and malalignment. So briefly, I'll talk about MTP revision, interposition orthodesis using a different technique. And also go through severe hallux valgus with first TNT instability. Remember that sometimes it comes with a flat foot deformity. And so you have to address that alignment issue as well. Not just rotation, which I do think is a huge component. There are a lot of treatments for arthroplasty, as Scott just went through beautifully, so I'm not going to go through all these options. But they all have varying degrees of success. And when these fail, these patients often present with pain, swelling. Sometimes the joint is subluxated or dislocated, as I'll show you in some of my cases. And often the implants are subsided and it has osteolysis shortening that can lead to metatarsalgia. So certainly there's a lot more research needed. But when these failures occur, regardless of who does them, they tend to end up in our clinic as orthopedic surgeons. And the basic surgical goal is to restore the length, alignment and stability to the first ray. Remember that if there is an infection suspected, you should work these up. So I would always get inflammatory labs at that visit. I like to get all the op reports just to know what implants are in place, assuming I didn't do it myself. And then try to figure out, do they have a history of wound healing problems, dehiscence? This can come back to bite you if you haven't thought about vascular disease, things like that. Look at vitamin D levels. Again, check your pulses. Look at your vascular status. And if you're concerned about infection, it's always good to try to send an intraoperative culture, ideally off of antibiotics. If it is infected, I would consider using an antibiotic spacer. This helps with your soft tissue. So remember that Hallux Valgus surgery is very challenging, but fusion, even after a failed Hallux Valgus, can be very tough. And this is a patient who had a bunion correction done 10 years before this calcaneus fracture that I fixed. And she healed in a little bit of varus, so I had to do an osteotomy. And long story short, her first MTP became more and more symptomatic, just because her gait was altered because of these surgeries. And in her case, I ended up fusing her with this dorsal plate. And just remember, if you're worried about the bone quality, always consider bone grafting. Use longer plates for longer working length or increased working length. Here's a patient, 50-year-old female, like the case Scott showed. But this is a failed synthetic cartilage implant. Both, she's a nurse at my hospital. You can see here's the cavity where that hydrogel implant sits. You can see on the lateral view, I see this frequently, but there's a lot of osteolysis. And that dorsal bone was so thin that I could literally put my forceps through the dorsal bone. So always be prepared for a longer plate fixation. So this woman, I took to the OR and ended up fusing both of hers. I used cellular allograft to fill those defects. And at six months, she had fully healed and had returned to full activity. And here's her right foot. I did the identical thing. But remember, I think one challenge that we don't talk about is that for a patient to have an arthroplasty, a surgeon has already convinced them that a fusion is not a great surgery. And so sometimes that discussion is tough. They don't always want a fusion if they failed a replacement or arthroplasty. So that can be a challenge. And I think some of that has to do with talking about positioning and the function. And there's a lot of great studies looking at what very excellent surgeons can do in their hands. But here's a case from Alhotra, published this, 25 cases using iliac crest bone graft, autograft. And 22 of 25... All of the cases required removal of the K-wires. There were only three cases, but large defects. But they had very good outcomes, 13 out of. So, at UVA, I started using these porous titanium wedges. You can use whichever bone graft you choose to pack in the middle and around these implants. And I would say that four out of ten ended up requiring removal of hardware. And so I took out the dorsal plate, and I always placed... And so for this this woman, I did that exact procedure. I put a porous titanium wedge I just saw her yesterday. She was one of my only happy patients in clinic So she's doing quite. Well. This is a 53 year old Runner whose status post how it's vagus correction hemiarthroplasty And so in her case, this is one of the earlier ones in my series. But for her, I did an interposition arthrodesis. I used that porous titanium wedge, packed it with bone marrow aspirate and demineralized bone matrix, shortened her second metatarsal. And interestingly, she did quite well. And a year and a half out, she came back and she said, I started jogging. I'd really like to know what you think about me returning to running. And I had never even thought how to answer that question. So for her, I got a CT scan. This is now a year and a half post-op. And you can see that she had good bridging bone through the wedge and good incorporation. And here she was at six years post-op. I saw her for an issue on her other foot. 60-year-old, another challenging case, 68-year-old, very healthy female. She had a lapidus procedure and a hallux MTP hemiorthroplasty. You can see, looking at these x-rays, she has many problems, but the two that are most notable, you know, she has a very dorsiflexed first t-cell. very active to having this surgery and now she flex through the first TMT using a cotton. We got good restoration of length and restoration of Miri's angle, and she also is doing very well. This x-ray was taken four years after that procedure. I was a little worried about maybe a stress riser between these two plates. Not my ideal construct, but she actually has done quite well. And then first TMT joint, I'll just briefly talk about that. I know rotation, as we all know, plays a major role in the Hallux-Valgus deformity. But sometimes, you know, you can get a pretty significant arch collapse, which can also then result in posterior tibial tendon dysfunction. So it's important to remember that it doesn't just exist. or the risk of recurrence is very high, even if you get the rotation correct. So here's a lady, 44-year-old, former professional ice skater, who presented with this x-ray, IM angle of 24, severe pes planobagus of 10 degrees, actually still had very good posterior tibia. And here she is a year post-op. Again, these deformities are very challenging to get to fix properly. Her other side sorry, and so this is another example 76 year old female severe pes planavagas with medial arch collapse And here she is a year post-op, and you can see just on that right picture how dramatically her medial arches has been improved. So in conclusion, failed HALX-MTP or arthroplasty procedures lead to significant gait disturbance and often transfer metatarsalgia. You should consider using these porous titanium wedges if you feel comfortable or custom implants to restore the length function to the HALX-MTP and even TMT joints. Instability and degenerative changes at the TMT joints can lead to profound arch collapse and remember to check the posterior tibial tendon function. Everyone has complications, myself especially, and every surgery is an opportunity to be humbled. So I would encourage you guys to learn from your failures, talk about it with your partners, and as a result, your patients, colleagues, residents, and fellows will all benefit from this. So this is our UVA Foot and Ankle Division, Dr. Cooper and Dr. Paramal, who are my partners, and thank you very much for your attention. Thank you, Joe. Thanks, man. So we're just cruising along at a wonderful rate here, and I think it's a chairman's prerogative to maybe disrupt the schedule a little bit, and in sort of the tradition of the AOFAS where in the early days there was lots of time for questions and opinions from people in the audience, and I'd like to just stop at this point because it's a natural division point between the first ray and the lesser rays as we move on to the second part of this program. So, I'd like to not have you wait for two hours to ask your questions for the first three presentations, but I'd also like our whole panel to weigh in on this as well. So, I'd love to recruit some questions, and you have to stand at the microphone because we're recording this, so please. Hi, good morning. Excellent talks, guys. Steve Neufeld. So, one thing I've learned from you guys over the years is the importance of a Lapidus first EMT fusion, rotational as we talked about. I have challenges getting it to fuse with early weight bearing, and I do a lot of first EMT fusions, and I have a lot of non-unions, so I'm curious, the panel, how many people walk them right away. Maybe that's my fixation standard, locking plate, two locking screws, rigid fixation. I'm curious, the panel, who walks them right away, and do you think adding bone grafts or biologics makes a difference? So, that's a very great question. Of course, the Achilles tendon of the Lapidus procedure for decades was that they really had crappy results because they had such a high non-union rate. A fellow from Dallas published a 50% non-union rate, and many of the early studies from Seattle had a 20% fibrous union rate. Maybe they were doing well, but they still didn't heal, so I think it's a very timely question, and so I think we can go right down the line here to those that are doing Lapiduses and maybe share your technique, your weight bearing pattern, and just how you have changed that paradigm from those days of the 80s to the present days when your results are obviously significantly improved. Don Bohe, how about you? Oh, thanks for the opportunity, Mike. Can you guys hear me? All right? Is this thing working? All right. Bob, I can't thank you enough for that talk, because we've been, Grand Rapids has been doing that three-dimensional rotational Lapidus for 20 years, and I think it's finally taken off. To answer your question specifically, Steve, we've changed our technique so that instead of two screws across the TMT, we evolved to a screw across the intercaneiform joint to address that instability, and there's an intermetatarsal screw, and then the trick might be a spot weld that happens between the first and second TMT and the intercaneiform joint. That whole area, we burr down, we take a local autograft, and we spot weld. We did do some work with a different device, similar to the lapidoplasty, but gives you great compression across the TMT joint, which I think is key. You need to have really good compression, and in those patients, we studied this, and I think the paper's in Evolution, where we looked at half of our standard fixation and half with a different kind of fixation, and we walked the new ones after two weeks. Now, when you say walk them, that's the trick, so we tell them that they can advance their weight-bearing as they're comfortable, and they often don't do that. They're afraid, or it hurts, and they really self-modulate their weight-bearing pattern. Our paper on that series of those two groups had about a 97% fusion rate. Our paper on just our standard technique was similar, so I think you can. I think you can't just say ... I don't think you can just put them in a hard-soled shoe like the Europeans do and just say, go ahead and have some fun and walk on it. I'm a little nervous about that, particularly in our environment, but I think we can. I'm not sure. Maybe we can talk offline what your technique is. Maybe there's something that might be missing a little bit, but I think, again, I can't thank Bob enough for at least bringing all this stuff to the forefront, because it's really what we've been doing for years. Other ones on the panel that might opine on this? Bob? Go ahead. You'll need the mic, though. Can you hear me? Can you hear me? Can you all hear me? Yeah. Okay, sorry. I think there's three major changes that I've been able to visualize. One is, as Don pointed out, there's an inter-kinetiform instability, and I think that inter-kinetiform screw really triangulates everything in and is vitally important, especially when you consider the rotational correction. The second is really the hardware. We have adapted what I call flexible hardware. This hyper-rigid construct, in my opinion, in a weight-bearing fashion, is difficult to get zero micromotion, no matter your construct. If you go for zero micromotion to get primary bone healing, you may be having a difficult time with that type of fixation, because you may not get zero micromotion, thus your non-union rate can go up. I went with secondary bone healing. I went with more callous formation by having the construct somewhat flexible, and that's what's helped me tremendously. What percentage of your cases do you see callous formation? My partners do lapidoplasty. I've done that as well. I've been doing this for 20 years. I do a lot of lapidus. I think my technique is good. I can't get these to heal 97% of the time. Are you taking down the inter-kinetiform joint? No, I do not take down the inter-kinetiform joint. You just put a screw across it? I just put a screw across it. It just triangulates and locks things in and prevents that external or that internal rotation or that reproduction or that pronation of the first ray that is there. You put them in a boot and let them walk right away? Put them in a boot. I put in a standard boot walker, not a low boot walker, and I don't use a shoe, so I don't have that experience. I just use a standard boot walker for six weeks, weight-bearing immediately. Now, I agree with Don. They don't do much for two weeks. I tell them to weight-bear immediately, but I doubt they do hardly anything for two weeks. You don't bone graft them? I don't routinely bone graft a single straightforward TMT. Some toxins. A single straightforward. All right. Don, you do? I remember this. We're not taking bone graft from the calcaneus and dumping it into the joint. We're just taking a bone graft from just our drillings from the joint, and we just put it into a spot weld in the corner. That was something that Hanson and Minoli talked about. It may just get the transverse osteon to just start healing, so it takes some of the pressure off the fusion mass. It probably is a flexible fixation technique to try to stimulate the fusion and not take the pressure off the heart. Maybe DC patients are different. I don't know. We have political issues. Well, so, Steve, I mean, you bring up a good point, and when we saw the level one study come out from basically from Canada on CARTIVA, and then no one else was able to duplicate that, and you go, what am I getting wrong with this picture here, you know? And then we have something come out that we now know is a 40% failure rate, and we'll talk about CARTIVA later, but I think that's a really good point, and the same thing with the Lapidus. The good results of the experts is going to be maybe in the high 90s, but in us common people out there, it may be decidedly lower, and that's why, still, we haven't had the perfect solution here that we continue to struggle, so your point is extremely well-taken. Brian? Yeah, Mike, I'm really interested in your perspective on this as well. The statement was made by Bob and I think by maybe some others that this is really, the bunion's really a mid-foot instability issue. And I know you've maybe challenged that in the past, and of course, you did a proximal osteotomy for your bigger bunion corrections for a lot of years, but you stick mainly with the distal osteotomies. I want people in the room to understand that this, all bunions don't need a Lapidus, because in our practice, we do mostly distal osteotomies, even for bigger deformities. We know it's not at the apex of deformity, but I just think there's a, you know, I think the balance is, I still do Lapiduses, I think they're a great procedure for, especially for instability, and that's demonstrable on examination, or there's evidence on x-ray and standing x-rays that there's some instability there. But I just want to maybe, you know, balance things a bit, maybe you, and see what you want to comment about the Lapidus as well, because I've had issues like Steve has with non-unions, it's 10% or greater, at least, and I think there's, I just had a patient come in, had this procedure done, with probably about a sonomy or a half shortening of the first metatarsal, so there was significant transverse metatarsal, or transfer metatarsal alger. Well, thanks Brian, I mean, I wasn't given an assignment on this topic, and I don't want to sort of steal everybody's thunder, because it is your chance to make a case for your individual procedures, however, having been asked, I would just tell you that having seen this pendulum swing from the Keller to MTP arthrodesis to scarves and so forth, there's no perfect solution here. The reason the Chevron does so darn well throughout the whole population, I'm not a big Chevron guy, because I think that it doesn't get, it doesn't have much octane in the repair, but it's very simple to do, and people know how to push it a little bit, and they get somewhat decent results, although they really rarely get sesamoid realignment. Having said that, I was a proximal osteotomy, not a distal osteotomy guy, and once we got the CORA figured out, Bob, which I appreciate what you were saying there, instead of reversing the osteotomy so that the action was at the MC joint, we started getting, really we're not creating a deformity, and we could dial that in very nicely. The question, of course, the thing comes down to is this so-called instability, and this erroneous notion by Morton and Lapidus that we have some ape-like trait that reverts back to simian years is the biggest bunch of hogwash I've ever seen. I mean, that doesn't happen. You know, Morton said ontogeny capitulates, phylogeny recapitulates ontogeny, and that was just a bogus deal about the embryo as it comes along. You look like an amphibian, and then you look like a gorilla, and then you look like a human being, and that was actually some fallacious work that was done, and so when we say, well, you have an atavistic trait, we need to get rid of that. That's just bogus jargon that we should not accept, and the next thing is about hypermobility of the first ray. Unfortunately, that's what Ted did. I love Ted, but if he'd just not used the word hypermobility, he would've gotten a lot more traction with all of us, but it's not a hypermobile joint in most cases. Sometimes it's unstable, and there certainly is mobility, and I will grant you that, Bob. There is, you know, more instability in that joint, and sometimes it's in a single plane, and sometimes it's in a double plane, but we showed, and unfortunately, the people in Seattle don't want to read those articles, but in fact, we prove with lead-off articles in JBJS that if you realign the first ray, the stability improves, and you can pick your way to realign this as you wish, and you can do a distal osteotomy if it realigns it or a proximal osteotomy, or you can do an MTP arthrodesis, and I'm not an anti-lapidus guy because I think that if you do a good job, and you get a high rate of fusion, that's hard to beat because you're going right where the action is, but you can also, if maybe you're not that good at it, you can do a proximal osteotomy of whatever you want to do, and you can often achieve a similar result. So there's lots of ways to skin a cat, and I don't think, what we'll see here with the lapidus and the tsunami that's occurred here, which is good because everybody's going to try that, and then the pendulum's going to swing back a little bit with complications, just like MIS surgery. Eyes down that road once before, we'll see complications from that, and we'll go, holy cow, that's really, that's going to be troublesome. So I think that there's more than one answer, and this is not the only answer, right? Yeah, I think, Mike, that's a great point. I think, you know, a well-done operation, I mean, Don, you've been doing this operation for 30 years, and you do a great job at it, you get good results. Distal osteotomies can, they actually can do a triplanar correction with a distal osteotomy. I can do that, Chris Coetzee, I can do that, we get that. So the notion that you have to go to the first TMT to get rotational alignment proper is really false, but the question is, you know, I just have fewer complications if I do a distal osteotomy in a patient, it's not as much pain for my patients, so. Thank you, Brian. I want to ask him, please, anybody else come up with a question, I want to ask just number-wise here, cost-wise, because, so, Scott, you were talking about painful implant, and the reason why total toes didn't get much traction was they cost like $5,000 or $6,000, and if you were competing with an HMO or with PPOs or whatever, they'd look at it and say, well, you're doing a chialectomy, which isn't perfect, or you're doing this, or you're doing this, or you can put that total toe in, which costs just the metal, and plastic was, what, $6,000 down, or some huge number, and it was just pretty hard to get traction on that. And so I assume that cost is not much different at this point, I mean, do you have any notion of that? I have no idea on what a total toe would cost, I think that, you know, for us, as far as my training, we never did any HEMIs or total toes, it was either a dorsal chialectomy, maybe adding a Moberg, and then, which I do almost all the time now with my dorsal chialectomies, or a Halx MP fusion, whether it be a medial or a dorsal approach. So, Don, on your lap, what do you think the cost of your implants are, you're mainly a screw man, right? So 15 times maybe $200 for the implants, and we don't use, and we use autographed, but, and you're right about the cost, and unfortunately that isn't a very important part of what the medical dollar does in 2021, it's not gonna get better or easier, so, these implants are either gonna have to get cheaper, or something else is gonna have to change, because you can't mitigate that just by volume at the surgery center, the hospitals are different, they've got contracting and things like that, but I think cost is important, and we've mitigated that by virtue of our cost. So Bob, what's the Treece package price, I mean, I'm sure there are lots of bargains that different people get, so throw me a number of, Don's at $200 for his screws, what's the Treece price? I would say it's competitive. Really? I think it's unfair for me to say, because there's such different contracts across the country, but I would say, don't forget to factor in, if you are getting a 10% non-unirater higher, or you're getting a 30, 40, 50% recurrence rate, that's a lot of cost to the system as well. Oh, there's no question of the complication, just like an MTP implant, so you're gonna, you're telling me that, anyway, it's in $400 or $500 for the whole bag, ball of wax, something like that. No. No. Okay, I guess I misunderstood you, I'm sorry. I don't consider two screws the same construct, though, I think that if you, you know, I have a, I'm directly testing the weight bearing, the non-unions, the propation report outcomes, getting on the podium at posters every six months with those results. So I don't set the price, but I do think that it's a different construct. I'm not even equating that to it, I just wanted a number, but would you rather not give me that number? I think it's inappropriate for me as a consultant to give that number. Okay. Okay. Well, pardon me? $4,000. Okay. Okay. All right. Well, it's better coming from one of you, because you guys are on the front lines having to then go to your people at the hospital and say, Bob's results are amazing, I want to use this, and then they go, well, we'll try to screw him down a little bit with price and so forth. Not Bob personally, but the company. So okay, that helps me a lot. Yes, sir. Well, the question is regarding the use of interposition bone, whether it be autograft or allograft or otherwise. Would the panel comment on their use of biologic augments, again, either auto or out of a box? So let's start with some of the people I haven't really touched yet and get your input, but I think that I would have that on my list was allo, auto, stem cell, aspirate, the wedges. So go ahead, Jason and Jesse. Let's talk about just a salvage type procedure where you're putting an interposition bone graft. What do you want to do? I try to talk the patients into the trichorticoliliac crest, because I think the healing's better, but the challenge is you got to talk to them about the pain from that surgery, and often that pain is almost worse. For me, I probably use their bone if I don't have to lengthen, and then if there's a lengthen, I'll just use an allograft like a distal fibula, plug that in, and then I'm a big believer in biology, and so I tend to use BMP and try to do it at the hospital, and we have some data from our spying partners at Emory who did a lot with BMP before that. It actually makes bone, and so that's where we push for that, but I don't use any of the BMAC or any of the others. One of our questions was augment. Anybody use an augment here? Is it mostly cost or what? Augment. Yeah, I'll use, I agree with everything Jason said, and I'll use augment sometimes rather than BMP. I'll use one or the other. I've found that at this point in my career, kind of like he alluded to, I'm less apt to go to the iliac crest. In fact, I try to avoid doing that, and I'll use a structural iliac allograft or a fibula allograft, but always soaking it in BMAC or even taking a little bit of calcaneus bone graft and putting it around the allograft dowel. So Jesse, I'm an equal opportunity annoying person, so I want to ask you just cost-wise for what's the augment, what's the BMAC? So augment, it's my understanding that augment now gets reimbursed, so it's less of an issue for the hospital, but it is super expensive. Like what? I'm going to guess it's, I think it's $2,800 or $3,000, I think BMP maybe $4,000 at our hospital. Okay, all right. I just want to add, like, let's come back to the titanium wedges a little bit. I think that bears talking with briefly, and they're not terribly expensive. Is that true? Yeah. You know, Mike, I think the prices have come down a lot since many companies make them. I think the future is going to probably be the 3D printed. You can make it of different metal. So for example, Wright Medical uses 3D cobalt chrome, which I didn't understand, but for their total angle, that's a 3D printed cobalt chrome. Right. Porous implant. So I think the costs are going to come down. I just, I think the question is, you know, you worry, I worry, you know, what happens after you've put that in for years and years, but so far it's worked okay in my case. So we saw one case out in San Francisco, which really was very frustrating. So it was a revision of some kind of, you know, they needed to do a space, a spacer and a plate, and so it was all one piece. It was 3D printed, and it healed, and then they got some IP joint arthritis, and they ended up having to cut off the end of the plate because they really couldn't take the whole thing out because it was attached to the plate itself, and that sounds like a really cool idea that actually is a disaster if you have to take it out. Has anybody had the experience of dealing, putting those in or trying to take them out? So, you know, I've used them fairly frequently for Evans, and they heal very, very well. Right. And you really have to saw them out, and so that becomes difficult, and then what do you do with the space afterward? Yeah. Okay. Yes, sir? Hi. Errol Bailey, Atlanta. Final laparoscopic question. I do a fair number of these, too, and my nonunion rate is a little higher than I would like, so I'm in support of what Steve is saying, but I found that I need to do an M1, M2 screw or a C1, C2 screw to add some stability, and I'm just wondering, I didn't see any of those on your x-rays on anyone who did laparoscopy today. How often are you using those screws for stability? So, Don, you actually spoke to that. Thank you for your question. So, our screw construct is across the TMT, and then one between the first and second metatarsal, and one across the intercuneiform joint, so it's a box, just like you described. And again, I take the intercuneiform joint down and do a formal arthrodesis of it. My partner, John Anderson, doesn't. We haven't seen any difference in those two techniques, but we really firmly believe in the intercuneiform joint instability as a function of the stability of the construct and potentially with recurrence. That's why we started doing it, because we had some recurrences, and they weren't through the TMT joint, because it was fused. Super. Okay. We're right on time, and we've done sort of the first ray part of our journey here, and now we're going to go to the lesser side of the foot, and it's my pleasure to introduce Don Bohe, a long-time friend from the heartland of America, and he and I are going to try to make some debate out of something. I'm not really sure if we really have a debate at all, but anyway, it's on metatarsal osteotomy and how you do it and how they do it. Don? Thanks, Mike. Yeah. Debate? I'm not sure about, but we'll play around with it somehow. We'll figure it out. These are my discussions. Okay. First, I want to give a special thank you to the program director, Ken, thank you very much for making me debate first metatarsal, or second metatarsal osteotomy with the world leader in metatarsalgia. It was very, very helpful. Thank you. Made my job easier. I kind of felt like this guy walking through a snowstorm trying to figure out how I'm going to do this. Second, there's something that some of you may not know about me. I'm born in Calgary, Alberta, so I'm a native Canadian, raised there until age of eight in Ontario, and then moved to Southern California. Grew up in a nice beach town, went to University of California for my undergraduate, and just to make my Canadian roots even deeper, I went to McGill University in Montreal for medical school. So I've got some Canadian roots, and you might ask, well, what is the purpose of this bohe ancient history? I don't get it. Besides distracting you from the fact that I've got to debate him on metatarsal shortenings, I still have this Canadian poise and the ability to be diplomatic and reasonable when it comes to debates. That's what I'm trying to show here. So the debate centers around while shortening osteotomies versus a mid-shaft, segmental metatarsal osteotomy. And the answer is yes. Thanks, Mike. No, I'm kidding. Debate over. Yeah, debate over. Yeah, consider a shortening osteotomy in the metatarsal if you have a clinical situation where lateral transfer metatarsalogy is your enemy. There's a lot of metatarsal osteotomies. It's not quite as simple as one or another, and they all come with their own set of problems and advantages. I'm just going to show you some papers. One of them shows an association of abnormal metatarsal parabola with second MPP joint pathology in the plantar plate. And they looked at 100 patients with plantar plate ruptures, 200 controls, and they concluded that a long second metatarsal was the only significant factor for plantar plate pathology alongside a metatarsal, plantar plate failure, and pain. And while osteotomy, can't debate it, is an essential component for open repair of the vulvar plate, I don't do that operation, but I don't think you can do it without doing a while osteotomy. And this paper had no comment really on the participation of the osteotomy as a mechanism to alter the parabola. So it was basically you need to do a while to get to the MTP joint to do the plantar plate repair. Even this technique with a very percutaneous osteotomy of the lesser metatarsals concluded that a shortening of the ray improved plantar foot pain. So metatarsal shortening, one way or another, is an improvement for the patient if done correctly in the right patient. We looked at 126 mid-shaft metatarsal shortenings, 99% union rate. We had one heart removal. That was done several years ago. I thought this was interesting. This is a large literature review, but it's 1,100 while osteotomies. This floating toe problem in 36% of the patients, and 15% had some recurrence. There was some transfer metatarsals and a non-union delay of 3%. And Mike's over here scribbling notes, so all the stuff that I just said probably in about seven minutes will be all nonsense, but yeah. Remember, Canadian, diplomatic, not. So which osteotomy you choose would depend on what you wish to accomplish and your comfort level with the procedure. If you're attempting to repair a volar plate rupture, well, a mid-shaft osteotomy is going to do you no help. On the other hand, if you're trying to reestablish the parabola, a mid-shaft osteotomy is reliable and it can be precise. You can predict exactly how much you want to shorten. This slide is supposed to be enough of the nice guy, and I'm supposed to go on to be mean and ugly, but I just don't have it in me, so I really can't do that, but yeah, sorry. Don't worry. He will do it. He has it in him. You can argue that the mid-shaft osteotomy requires separate incisions. That's one of the things that people argue against it. They say, well, if you have to do a mid-shaft osteotomy, you've got to make a separate incision to get to the second metatarsal. We combine a lot of our medial column stabilization procedures with the dorsal incision, and we can get to the second metatarsal very easily through that same incision. So we mitigate a second incision, at least on the second. How about the technique? It's mid-shaft, obviously. You make a mark for the resection based on just making a little saw score. You apply a pre-bent plate to the metatarsal. You drill the distal screw. You place and remove the next screw. You slide the plate over, exposing the osteotomy site. You make a small cut, depending on how long you wanted to make the metatarsal. Resect the segment. Place the plate back over. Put some compression on the plate, and put in your screws. You can use spot weld bone graft if you wish, as shown in the diagram here. This is reliable. It's not hard. If you find this operation hard, you might want to go back to orthopedic school, because it isn't hard to do. The devices that we have now allow some compression across the osteotomy. They're locking devices, available now for patients that have a bad bone. So with the correct technique, malunion, plantar flexion or dorsiflexion, nonunion are rare. So in closing, select the osteotomy that's appropriate for what you're trying to accomplish. If you want to shorten the metatarsal precisely, you want to take a millimeter and a half, you can do that precisely with the shortening osteotomy in the midshaft. If you need to do a plantar plate repair, you're going to have to use a while, and I think that's the only way you can do it. Use something stable to help along the way with their weight bearing and their fusion or their healing rate. But really, the most important element, and maybe we'll get to some of this in the discussion, but you have to understand why you're using a shortening osteotomy of the metatarsal in the first place. Why are you doing it? What are you trying to accomplish? And maybe we'll get to that in the discussion, but it's beyond the scope of this talk. Thanks. __________________________________________________________________________________________________________________________ So I'm going to go to talk number two. Talk number one was the aggressive, mean talk, and then this is the benevolent talk for my northern Canadian neighbor who actually grew up just north of where I live in Idaho. So thanks, Don, for not just pillaging me. I really appreciate that. So I'm giving you a perspective for a lot of my career. I used to be one of the really young guys here, and now I'm not. And so I've seen a lot happen, and I've seen a lot that didn't work and I didn't want to do and some things that actually work pretty well. I have a few disclosures, none of which are really significant here. So why do we do a lesser metatarsal osteotomy? And it's just like what Dr. Bowie was talking about. Well, we want to shorten it usually. We may want to relocate a joint that's not located. We may relieve plantar pressure or correct malalignment. And the considerations, I think, are the length and number of the incision, skin bridges, hardware issues with later removal, exposure issues, and bone healing. So I think you can do them in lots of places. You can go distal, which is where I often go but not always, midshaft where occasionally I go, and proximal, which we don't want to forget about as well. So if you're going to do something, you've got to do it right. And it seems like so easy when you think about the wild osteotomy, and everybody does a lot of these, but I don't know that they do them that well or think about them that much. It becomes just sort of secondhand to do that. And I want to talk about this because a fellow of mine and I spend a lot of time just sort of analyzing it. First of all, do you just distal it? You go, well, I'm just going to shorten that today. Well, I think you've got to think about it. You decide, are you going to do it 2 millimeters or 4 millimeters, 6 millimeters? There are ways to measure this both preoperatively and interoperatively as well. So you want to think about how much shortening. If you see the x-ray on the left, and this is the same patient many years ago where we shortened it back to the length of the third. You certainly don't want to shorten it too much, and you also have to think about what you're doing with the magnitude of the shortening that you do. So here's a person who had a wild osteotomy who came in to see me in San Francisco, and he has an MTP fusion. He's short on that side. He has excessive shortening, and he hurts. He actually hurts both at the second and at the third MTP joint. So let's talk about the angle of cut that Grimes and I worked on, and it was really interesting. Lowell described all this, and his wife was a mathematician, and she did all the math work on this, and she said it's a cosine or a tangent or something like that, which I forgot a long time ago because that really was extraneous knowledge that I couldn't retain in my brain. But Speak Grimes, who worked with me, said, Well, that's not right. It's some other cosine or cotangent, and she's got the numbers incorrect here. So we reworked the numbers. We looked at the osteotomy line and the angle, actually, of the osteotomy as well, and the average declination is about 25 degrees of the metatarsal. That does vary, but you've got to at least be thinking about that when you do your cut, and you want to be more parallel with the plantar aspect of the foot, certainly in that zone as opposed to being vertical with your cut. And if you have a contracture, I can just tell you it's harder to be parallel because that toe is dorsiflexed and it's forcing you into a downward cut. Likewise, the shortening is a thing that Hans-Georg Trinke talked about a long time ago, and as you shorten it more, you're going to get a plantar translation, even if there's just a slight inclination of your osteotomy cut. So in that case, you may need to have what we call a larger curve to take more bone away so that you don't translate it in a plantar direction and cause an iatrogenic IPK. So you can do thicker blades with the old striker power. You can stack the blades, which is a cheap way to go. This is a little out of focus, but the kerf is really the saw blade. So if you've got a chainsaw, you can have a wide cut or a narrow cut on your chain, and what you want is here you want a wider kerf so that you actually will elevate this a little bit as you translate it in a proximal direction. And also, as Mark Meyerson showed us, if you want to, if you're really doing a lot, you can do a little sliver of bone. If you're going up in the range of 4 to 5 millimeters, which I don't do very often, you can take a little sliver of bone, as we see in the lower right-hand corner, and that will keep you from translating it as well. I got striker to make a bunch of different blades, which give you a wider kerf here, and sometimes you need about a 2-millimeter kerf when you're doing it. So this is a 49-year-old male who came in to see me at UCSF, had an MTP arthrodesis, plantar plate repair within a while, and continued pain and swelling. So I just showed you this x-ray earlier, and as they presented, they have a short second metatarsal, so they have some pressure beneath the third, but the second is what really hurts. So it's all scarred down, which occasionally it can be, and we'll talk about that a little bit later. But following plantar plate repair, there was essentially no motion, pain on the plantar aspect of the MTP joint, and with a failure, there's a fullness on the plantar aspect of the metatarsal head, and this patient has a nonunion. So let's talk about why that happened. Well, they had a vertical cut, as you see on the left, not as you see on the right, and I've taken away that 25-degree plantar flexion sort of metatarsal inclination. But if you do a vertical cut like this, there's less contact area, there's probably less robust fixation, and you may get a lot more plantar displacement. They also got a nonunion and an IPK as well. So how about my fixation? Well, I initially used a single 2-0 synthese screw because it was cheap and it was just easy to do, but it never compressed it and it sometimes pushed apart, as you've probably seen when you try to be economical. Then I went to a 2-2-0 synthese construct, and the reason I like that, you could still use a K-wire and not worry about it breaking loose. So that was a pretty good change. And so with that more robust fixation, as you see here, that's what I did, and you can see on the right side I'm now using those spin screws as well. I rarely use a K-wire. I'd want to balance this toe, and Dr. Doty will talk about plantar plate repairs, but I don't use a K-wire because often when you take them out, some of your deformity recurs. So you want on the table to get the correction that you're after. But let's talk about screw length. When Dr. Grimes and I measured this, we measured a huge number of these metatarsals, and the average length height-wise of the second and third was 24 millimeters with a range of 19 to 25. So in the package that we sort of created for people to use, we thought that 12, 13, 14 is pretty good. It's pretty good unless you do a steep cut. Then you need a bigger screw, a longer screw, but you're really playing with fire because you may not get very good fixation. They also have many of these ratchets in most of the kits, and if you see right here where the arrow is, you can actually, when you clamp that down, you can see if you need a 13 or a 14. You don't want to put a 19 or a 20 in. I recommended on this fellow that they have a second soft tissue arthroplasty and a hardware removal for this very stiff joint. So when I got in, I used a McGlamory to free up the plantar aspect, and guess what? It stopped. I couldn't push it any farther forward. The reason why, and this is a mock-up here, but you can see here's the screw coming through, and it came out right at the bottom, and that's why this person got a frozen toe. If you're going to do a while, I mean, think about the fixation. Do the right cut, but also do the right fixation. This is just simple stuff. I mean, when you fly an airplane yourself, you check the gas before you get in. You say, well, it's probably okay. You want to really think about what we're doing for these people. So following the arthroplasty and the second MTB hardware removal, the screws were 20 and 18 that we took out, and we put shorter ones in. And this is a post-op routine that I've gone to aggressively now with all our plantar plate repairs. We start very early, really a week post-op, and we start plantar flexion exercises at three weeks, and dorsiflexion exercises really after that three-week point, and we're getting good motion and good relief. We're after trying to avoid stiffness, and you really need to, if you're doing a while osteotomy, which is an interarticular osteotomy, you're at risk for getting some stiffness. We do early motion-type things where we use any one of these removable splints that has a removable device you can take the toes out easily. We get them going on TheraBands on the big toe to trick the FHL and the FDL to work together. I want to address the floating toe because it was mentioned that 36% of these were floating toes, and after one year after a plantar plate repair, it might be stable, but this patient was not happy with the cosmetics. And Mark Meyerson brought a big point out about the floating toe and about changing the center of the rotational axis, and that's what was the cause of this. Well, Mark had a good point, but the other point was they never fixed the plantar plate. So if you're just doing a while osteotomy and you're going to go, well, gravity will bring that toe down, that's wrong. That won't work. If you do a while osteotomy, you ought to fix the plantar plate as well if you've got plantar plate pathology. So I think fixing the plantar plate can address the floating toe if you then implement a good postoperative regimen. The other thing you've got to talk to these patients about is their expectations. Most of these people, if you start having them use their toes, they lose function in all their lesser toe extrinsic flexors as this deformity progresses. So show it to them preoperatively on one side versus the other. Very quickly, I just want to show you that in the big review that we did on plantar plate repairs, they had good results, 80% good and excellent results, but this is what was not as good, and that was the poke contact and the paper pull-out test. They still had weakness and they still had some floaters, and that's when we changed our postoperative regimen, which is very aggressive at this point. We don't do this any longer. We actually tape them, and then we've gone to, as you see, the dynamic splint with the top shelf or a darco splint with these Velcro loops to get them really going. There's a top shelf splint as well. So while I like a distal osteotomy, it puts the decision where the action is. You can treat a dislocation of subluxation, you can shorten a long metatarsal, and you can elevate it as well, but you certainly have to do it correctly. But I want to give equal time to other things. This is a person who had a fifth metatarsal osteotomy, but you can see the pressure underneath the second, third, and fourth metatarsals. So you can certainly go proximal. I would just tell you that a little bit of proximal angulation goes a long ways. You don't have to do very much to elevate these lesser metatarsals. I also want to just talk about Lisfranc action as well. This is a 42-year-old female secretary, marked metatarsus adductus and painful hallux valgus deformity. You can do the whole ball of wax here. You usually don't have to do 4 and 5, just a 1, 2, and 3 TMT fusion. So I've done that as well, and this person has done one. You can see a little lucency at the first MC joint, but that went on to heal very nicely. You can also do mid-shaft osteotomies, and there's no question. Don and John have showed that they work, but at what price? That's always the question. It's not advancing here, so can you advance? AV, can you advance that for me? It's not moving. Don, why did you do this? I didn't do it. Yes you did. We're passive, but not that passive. Not that mean. I'm in a debate, by the way. Just a glitch. Just sit back, let the computer fail. I didn't even say anything mean yet. Oh, yeah, tell me. Oh, well, that's true. It is, but. Unless you can't get the computer working. The show may be over. Okay, so do you want to just be my wingman here for a minute? No, it stopped again. There it is. Yeah. Okay, so I'll tell you what let's do, let's stop this right now and let's just call up one of our visiting firemen here to, Jesse, I'm going to have you come up while I try to fix this, and Jesse Doty is a long time acquaintance of mine, a former fellow, and he's going to talk about lesser MTP joint instability, the holy grail, and if the computer doesn't register yet, Jesse will. Thank you Dr. Coughlin, and thank you for having me this morning, those were fascinating talks and I'm so glad I got to hear the, well I love it when Bob and Don and Mike are all in a room and we get to talk about hypermobility and non-hypermobility, it'll be interesting to see if we're still having the same discussions in 20 years. So lesser MTP instability, the holy grail, have we found it? These are my disclosures, none of which are relative to this talk. Primary disclosure, if there's any truth to my talk, in my hands this is really the only predictable operation for MTP instability. So if you look and you want to know if we found the holy grail, you really have to understand from where we came, and then you have a better understanding of where we're headed. And really most of what we know on lesser MTP instability was developed and integrated into the literature after 1985. This was a territory that was largely unsettled. This was the one article from JAMA in 1956 which queried seasoned surgeons, and really not a whole lot of data, but level 5 evidence discussing soft tissue releases and flexor tendon transfers. So enter into the forefoot frontier, and certainly this is not a comprehensive slide, but there were a lot of people who contributed to what we now know about lesser MTP instability. So you have to go way back, and again this is the story that I'm most familiar with. In 1978, Dr. Coughlin finished his residency at UCSF and then convinced Roger Mann, who was rounding there at the time, to allow Mike to become his first fellow, and so they spent six months together. From there, Dr. Coughlin went back to Boise, Idaho where he began doing hips and knee replacements, but really focused on forefoot deformities based on his fellowship. And he was astounded by the degree of MTP deformity that he saw in that large catchment area, and a lot of that was from rheumatoid feet, some of it was from failed kellers, and then overload of lesser MTP joints. And then to give you an idea of when that was, I was born in 1980. Actually on this day. Thank you. So the notion at the time was that perhaps this is a neuroma, and we felt like they were equally distributed in the second and third web space, and there were leaders in the field who felt that that notion wasn't exactly true. And Dr. Coughlin can go back to a case where he took out the so-called neuroma and evaluated that the lateral aspect of the MTP joint had an injury, and so as he watched the toe over the next six months, the toe began to drift, and that was his epiphany that, hey, this is not a neuroma, this may be some sort of capsular instability. And so he wasn't the only surgeon, but over the next 10 to 20 years it became a trial and error process, and so these surgeons looked at these patients in their clinics, they watched the patients in the OR, and they tried multiple things to try to realign and address the MTP instability. For mild deviation, extensor lengthenings and transfers, capsulotomy releases and reefing laterally, moderate deviation, continuing flexor tendon transfers, freeing up the plantar capsule, akinets in addition to help fine-tune the position of the toe, condylectomies to decompress the joint, osteotomies. And so it was over the period of these two decades that really the signs and symptoms were documented more in the literature, and we had a further understanding and appreciation for the issues that these patients were undergoing, albeit even in a lesser toe. And then we began to understand the etiology, seeing the patients in follow-up, understanding the actual cause, lengthening metatarsals, and continuing to publish that data. First in 1987, and then in 1993, this was really one of the landmark articles which really coined the term second crossover toe, which was kind of a misnotion, because we now know you can get adduction drift through multiple lesser MTP joints, but it was really this paper that drew the attention of the rest of the orthopedic crowd, and from which the CPT codes were derived and the reimbursement. Around that time, the mid-'90s, the Academy became interested, and the JBJS article and ICLs were published trying to bring this to the forefront of the orthopedic literature and show an appreciation to MTP instability. Around the same time and throughout the mid-'90s, Lowell Weil Sr. was actually doing these osteotomies, these distal capital fragment osteotomies, and he presented that at the orthopedic meeting in 1998. And the orthopedic surgeons were interested, and so they added the Weil osteotomy to the soft tissue procedures and reefing that we were doing and felt like it improved our results, although it still wasn't a direct repair. And so there from 78 to about 2010, you can see that the techniques really didn't change a whole lot, particularly in the textbooks. And this was what I saw when I was a resident in 2007. I was told to memorize this, these complicated algorithms that until you actually do and perform a substantial amount of lesser toe surgery, it's hard to know what to do, and sometimes I still don't feel like I have a full understanding. So fast forward to Barcelona in 2003, Dr. Coughlin was a guest professor, and they wanted to look at this notion of hypermobility of the first ray. And so they had these cadavers, a few studies came from this with the fellows, and they had such a good time, Paul Galano and Ramon Villedo, two surgeons in Spain, said, hey, what do you want to study next? Let's collect some cadavers and let's look and see if we can publish some more results. And so this was about the time that John DeLand's paper came out in 2000, looking at the medial crossover toe in a cadaveric dissection. And so the orthopedic interest was sparked, but the problem was we just didn't have the cadavers and you couldn't really visualize to see what exactly was going on. So this was kind of forgotten, and then in 2010, again, Barcelona called and said, hey, Dr. Coughlin, are you coming back? Bring your fellows. We have these specimens with these crossover toes. We have multiple crossover toe specimens. Let's look at these. And so they went back, dissected out the specimens, looked at the pathology. Around the same time, Lowell Wild Jr. here in the U.S. and Kai O'Neary in Brazil were really working independently on their feelings of crossover toe and plantar plate pathology. And from those cadavers and from that group, they integrated their data so we could avoid having a podiatric and an orthopedic separate staging system. And this is really the paper that came out of that dissection where we really established the pathology of the plantar plate or at least appreciated its contribution and then established some sort of staging system. And so over the next few years, since 2012, began to refine the approaches. Dr. Bohe alluded to the fact that the wild osteotomy certainly is beneficial in visibility. There are some systems where you can do the repair without a wild osteotomy, but I think that there's some data that also suggests that perhaps the wild in and of itself is an important contributor to the loss of pain and correction of the deformity. And that's what I personally believe. Also the exposure, directly visualizing and then completely releasing and mobilizing the plantar plate when indeed there is true pathology there. There was an opportunity to take some of what we learned from the shoulder with passing sutures and meniscal repair to fine tune the instrumentation with industry, which partnered and developed some of the plantar plate repair systems. And so this was one of the more straightforward cases of my own early in practice, completely dislocatable MTP joints, which I think it's rare to see them that loose. Usually by the time they get to me, they're already completely dislocated or there's not that degree of instability. Doing wild osteotomies, plantar plate repair, and then certainly restoring the stability of the medial column to protect the lesser toes. 65-year-old male, more severe deformity, dislocated, doing a more aggressive wild osteotomy to get that toe completely reduced. Of course you have to correct the sagittal plane deformity of the toe as well or you'll never have a chance at the MTP joint. And then again, not a great result. He continued to deviate back into adduction, which is very difficult in the transverse plane. But you have to remember his biggest complaint was the shoe rubbing on the toe. And then there's a look post-op and so he was actually a pretty happy camper, although when you look at my x-rays, you feel like I could have done a better job. Here's a 48-year-old male, completely dislocated for two years. And again, what we found was these that were completely dislocated with no remnant tissue were probably the less and least predictable for a long-term outcome by just advancing what was left of the plantar plate tissue. And that's what we saw. In this case, again, better position of the toes, but really unable to get any purchase of the toes with the paper pull-out test. So this was published and pretty good results, but still 20% did not have a good or excellent outcome. Improvement in some of the scores. Certainly an improvement in stability for the most part with drawer testing. But again, you're trading that for a loss of motion, so you're trading a more mobile toe for a stiffer toe, but perhaps with more stability. So the thought was we need to do better. And so you go back again to the pioneers of forefoot surgery and you look at these algorithms and it's probably more of an art than we appreciated. And for me, I have a little bit different perspective than Dr. Coughlin, but a plantar plate repair is probably not a one-size-fits-all for all these deformities, and I think it's probably a little bit more difficult to perform than sometimes alluded to. And so I also feel that transverse plane deformities are different. I feel like anecdotally I've seen over the course of my career, plantar plate repair is perhaps a little bit less predictable for a deformity such as this. So this is one where I actually did this case yesterday. We fused the midfoot to significantly shorten the second and third rays, and I feel like Dr. Bohe alluded to, you really have to shorten the rays to decompress the joint, which is going to protect your soft tissue repair or you're not going to have a chance. This is another one with a little bit of adduction through the MTP joint, and again, I did not do a plantar plate repair, but rather decompress the joint. There is some suggestion that a while osteotomy in and of itself can help with metatarsalgia, and in a scenario where you don't have a positive door test or significant instability, I think this can be a predictable operation. Again, angulating your while and trying to fine-tune the while to try to position the toe can be beneficial, and then one of the other things that I've found to be largely beneficial but doesn't get a lot of press time is the EDB transfer. So for transverse plane deformities, I do this quite often now, and you can see it's really impressive how much correction you can get of the toe, even in a dynamic manner when you pull on that tendon after you've done the transfer. And then you can combine that with while osteotomies, and doing EDBs by themselves, I've found that there tends to be more of a recurrence when I don't combine those with shortening of the metatarsals. It's very rare that I'll pin the MTP joint, but in the most severe deformities, understanding that you're going to anticipate a straighter but stiffer toe and having that discussion with the patient preoperatively can give a better outcome or at least relieve some of their anxiety around the stiffness postoperatively and help them to understand that perhaps their expectations were met. Their toe may still be a little bit painful, a little bit of metatarsalgia, but if you go back and look at pictures or you discuss with them their symptoms preop, many of these patients will agree, hey, I'm somewhat better, I don't love this, but this is certainly better than what I started with. And that's what I've learned over the past couple years. These surgeries aren't perfect, and certainly is this the final frontier? Probably not yet. I think with innovation, we're on the cusp of a tremendous amount of technological advance with smaller incisions, minimally invasive surgery. Am I 100% optimistic? No, not really. Who's going to carry us there? This guy's always so serious. This guy's always too jovial. Where are we really going to get to go with all this, and who are we really relying on? And so, George, I have no idea what you're doing with that syringe. There's a guy who knows how to have fun. So, again, multiple studies are coming out, and some of the procedures are easy to perform. Some of the procedures in the author's hands are certainly more predictable, which has been discussed on the podium, but I think there are a lot of things we can do as far as releases through smaller incisions and then reefing laterally, and then we'll see where the plantar plate repair continues to fall in all of that. In the case of my own, less invasive, I think that's certainly a good option for some patients with certain types of pathology, but I think it's important to remember, again, it's not a one-size-fits-all. It's not always going to be fancy. This is a case of my own where we were able to salvage the MTP joints and do pretty aggressive shortening osteotomies to realign the toes, and then, again, sometimes those joints can't be salvaged. And, again, at this point, the plantar plate is probably less important. So when I see this, this is a case that came in last week. I used to hate it, but if you really look at these patients, their surgery is 10 years ago, and you cannot make this normal, and if you just tell the patient, and you're honest, and say, look, I can't make this normal, where are you hurt the most? If you examine the foot, put your fingers on the foot, it may be something as simple as taking the screw out of the big toe where she's getting a callus. And so when I look at this foot, I used to see this, and I would argue, as orthopedic surgeons and foot surgeons, sometimes I hear my colleagues suggest that they don't want to do forefoot surgery anymore, and I would say, look, just the fact that you would suggest that means you probably have a healthy understanding of the forefoot, and if you're more intimidated by lesser toe surgery or MTP surgery than a pilon fracture, then that's certainly the boat that I was in years ago, and it means that you're probably the guy who ought to be addressing some of these deformities and trying to help these patients. And so, and you have to learn, you have to manage your own expectations, and you're not going to change every patient, but if you can meet them halfway, sometimes it ends up being a happy patient, a happy camper, and this is a patient that my partners hated and refused to see, and, you know, I've done a couple things to her toes, but with trying to manage her expectations, she ended up being happy. And so, again, I never understood why Dr. Coughlin, in 2012, used to always say, you know, I wish I could have a forefoot-only practice, and I thought that was the stupidest thing I could ever hear anyone say at the time. I was miserable, and we were doing a ton of plantar plate repairs on all the MTP joints, but now I understand, in 2021, just having a better understanding of seeing these deformities and seeing that the sacrifices he made from his family, and really, as his career spanned decades of publications where we went from not knowing what caused a crossover toe to considering that it was probably from a neuroma, to really defining the pathology of the capsular instability in the plantar plate, along with a group of other really smart doctors, but then able to collaborate and find some sort of solution for the problem, and so that's pretty cool, and I think that gives us, we've all gotten to see an aspect of that, the development of the pathology and then some sort of a solution, but I think we're still probably headed for more in the future, more developments, and we'll see what that brings. And Jason, you'll follow right after this. Any quick questions while we're rebooting? So, there's no question that mid-shaft osteotomies work. This is a John Anderson case that he was kind enough to give me. You know what, it's not advancing again. Man, John, you do it every time. Okay, if that's the case, we're going to... We're going to give this one shot, and then Jason, you're going to be on here if this doesn't work. Okay, so let's put up Jason So what so as we bring up Jason Jason Barreto is going to talk on Freiberg's and other lesser metatarsal osteotomies. I mainly was going to just talk about the fact that Midshaft osteotomies leave do leave a lot of incisions, and you have they're not as extensile But that they certainly give you a way to shorten the lesser metatarsals But don't forget the list Frank joint where you can absolutely realign the whole forefoot with doing two three and four Rarely, do you have to do four and five as far as a metatarsal? osteotomy and or the or an MTP arthrodesis, so Now it's my pleasure for Jason to come up and just talk about Freiberg's another lesser toe MTP joint Thanks a lot. Thanks for everybody sticking around So Freiberg's and lesser MTP arthrosis These are my consult my disclosures so overview of the talk We're gonna do some cases talk about the pathophysiology think about the treatment options talk about some of the latest literature And then go through those cases again So this for me was a 55 year old painful second hammer toe significant pain at the MTP joint Fail conservative care, and you see some significant arthritic changes. You know how do we work it up, and how do we treat it? Another one this was after a previous plantar plate repair with a while osteotomy hammer toe correction Shortening and pain can't get back to activities And then a avid runner pain at the base of the second toe again with this arthritis previous bunion surgery Where do you go to treat this and so what's the pathophysiology? Freiberg's infarction is the second most common osteochondrosis of the foot we see it in young female athletes It has actually a five to one female to male Ratio the risk factors in diabetes lupus or hyper coagulable state There's multiple biomechanical thoughts that how this occurs You know a rigid second ray due to stability of the lisfranc joint and that keystone can lead to overload Often the second and third MTP or metatarsals are the longest and some people have postulated a gastroc tightness and high-heeled shoe Wears high-heeled shoe wear can be contribute If you look there, there's some postulated Mechanisms one of the articles talked about this five stages of compression of progression where you get more mechanical arterial compression with arterial spasm Leading to epiphyseal ischemia vascular occlusion and bone resorption and this sort of goes along with the classification That they talk about where there's this fracture through the epiphysis then you often see this central depression The central depression then can lead to these medial lateral projections Later there's this hinge and collapse that occurs and finally the whole head flattens And this is examined here again with just another example of the classification for Freiburg's But if we think about the pathophysiology of the lesser MTPs, it's a little bit different I found that that doing a literature search It's very difficult to see people talking about lesser MTP away Without talking about the other problem that it may be associated with and so for me It's often associated with metatarsal phalangeal joint instability and a lot of those cases where there's that dislocatable joint when you get in there That dorsal part of the metatarsal head may be sort of worn away. I've actually seen it with shortening osteotomies as well And so, you know and then when you're doing these osteotomies a lot of us pin the MTP joint Does that play a role in the arthritis developing and for me? Inflammatory arthritis has to be thought of when you see this second MTP because that synovitis can lead to wear of the cartilage and instability On some of these patients present pain over the MTP joint predominantly pain plantarly with walking Exacerbated when they're barefoot, but focal pain on the tightness I look for gastroc tightness to see if there's overload for me the toe deformity if it's later finding is often associated with maybe Freiburg's But in a way it may be the underlying cause that hammer toe deformity and instability contributing We actually looked at our radiographic parameters and looked at patients who had Pre-operative OA versus not pre-operative OA and we found that they had longer OR times longer tourniquet times But we were able to get them an equivalent outcome And they even had a trend towards a larger improvement in pain and a larger improvement in physical function But our study was a little bit underpowered And so what is the workup for these patients you want to get three views weight-bearing of the foot obviously But then the MRI is important for me for differentiating that Freiburg's that may be going on from primary OA Also, I think a rheumatoid or inflammatory arthritis workup is often needed It's often under appreciated and I've definitely a patient's when I've gotten in there the amount of synovitis at the second MTP joint Can be remarkable and definitely will affect surgical planning So what are the conservative treatment options for this group for Freiburg's you want to think about an offloading orthotic a four-foot rocker can be Used I've actually used bone stimulators and anecdotally it helps with pain. Do I think it actually heals the bone? I'm not really sure but often it's something to do to sort of see where the patient is going if they're getting worse is There more collapse coming on that type of thing What are the others conservative steroid injections is often a temporizing measure although? I do have some concerns because you're gonna make or at least be at risk for making instability and degeneration worse I definitely have lots of non-operative partners who want to try stem cells and PRP, but we're at this point of unclear benefit I know really current studies that it does anything at this point For an isolated OA though, that's not Freiburg's you know is there a hammer toe part present for me if there's a hammer toe present getting that toe down and trying to Get some stability at that MTP can be helpful the challenge is to determine where the pain generator is is the pain from the MTP joint or is the pain from the toe itself and Always an important consideration is there a hallux issue contributing is there a large bunion leading to overload of that second MTP? And so what are our surgical treatment options for this lesser toe OA? I think really dividing it into two categories joint sparing you think about to breathe into microfracture Osteotomy is to realign especially in Freiburg's early to bring that good cartilage up Can you do some type of cartilage restoration using allograft or autographed? Definitely been written about and then we think about the joint sacrificing for those more advanced or arthritic changes There's interpositional arthroplasties there are implant arthroplasties For me for some of those patients metatarsal head resections is still a good operation And does the future talk about 3d printing and some other types of options so? Surgical planning I think you're gonna think about Before getting into surgery is the second metatarsal long does an osteotomy make sense how much of the head is left? Can you do local interposition or do you need a joint sacrificing option for sort of primary away? That's not related to Freiburg's I think you need to address the hammer toe you need to address the bunion and then instability the plantar plate Needs to be used to be repaired and often with the decompression like Jesse talked about from the while can definitely help with the pain And so what does the literature tell us about this? You know this was 15 consecutive patients treated with the reedman and microfracture with a mean of 11-year follow-up And they had 80% of their patients satisfied. I mean, I think just doing some simple things can be helpful Other others have talked about using an interpositional arthroplasty with the extensor digitorum brevis tendon They had 24 patients 130 month follow-up most were grade three four and fives And significantly improvement in range of motion AOFA a score and improvement in their joint space on x-ray, and this was an interesting technique I thought they took the extensor digitorum brevis. They then ran it through a bone tunnel and then balled it up I don't know if we all remember doing LRT eyes In the in our hand rotations as residents, but that's sort of a similar idea here, and they had good results These are next two articles are two of the really best articles on Freiberg's that are out there These are comparative studies looking at a dorsal closing wedge metatarsal osteotomy versus an autograft transplant And they investigated AOFA a score range of motion and surgery and they're the the Allah the autographs actually did best They had slight improvement in pain slight improvement in AOFA scores similar ranges of motion and less complications a similar study It was here and a randomized study looking again at dorsal closing wedge osteotomy versus autograph Transplant and again slight improvements in the Autograph group and actually a quicker return to sporting activities if you look at the most recent systematic review because there's been a Bunch out there this look at 50 different studies the challenges is only two of the studies had level three evidence there was really poor evidence or just case series for all the rest of the procedures and unable to differentiate at this point differences between joint sparing and joint Sacrificing procedures. So what else is going on out there? This was a interesting study looking at polyvinyl hydrogel implants in the lesser metatarsal heads And basically they did a cadaveric study where they sort of sequentially reamed up to eight millimeters and just went from metatarsal Metatarsal to see and basically for the second and third metatarsal They showed safety in the medial to lateral plane all the way up to eight millimeters Although it gets very concerning for that dorsal rim And so that's something definitely to think about if you're going to consider this for the lesser MTPs What are the outcomes of this? The first study that was published was about five patients They had no complications and significant improvement in pain for multiple issues looking at The polyhydrogel for lesser MTPs. However, as we get more bigger series, we're starting to see some issues This is 13 patients five with Freiberg six with primary. Oh a they all had significant improvement in pain But five of the 13 patients had complications in three required surgery And the interesting the one that they show in their article shows definite significant collapse here Used that both the first and second MTP, but the patient was asymptomatic And so the question is is what is the longevity? For this and so thinking about those cases I talked about earlier this 55 year old female with painful second hammertoe failed conservative care MRI showed an isolated small area of avian consistent with Freiberg's which you can sort of see some of the collapse and the instability We elected to open her up and she actually had sort of more loss of the cartilage than I expected It was very little on the plantar aspect We repaired her hammertoe and so I elected to try a car Tiva implant to try to maintain her length and maintain her distance And so after surgery you see she's got you know, pretty good joint space. She's well aligned. We'll see how she does She's only about six months out at this point and follow her This was a 48 year old female previous complex hammertoe correction I did this five years ago At the time MRI showed significant arthritic changes at the MTP joint a little bit of dorsal dorsal subluxation And so at this point I did an interpositional arthroplasty with a dermal matrix because this was before I think if I did this case now I probably think about a car Tiva or Polyvinyl hydrogel type implant if it was big enough, but the challenges is she's small So I'm not sure but this patient got back to exercise Maintained her joint space and is back to doing the things she wants to do This are my 45 year old avid runner second toe fail conservative treatment So we took her we did a shortening osteotomy micro fracture try to rotate the joint space But even here you see even at these one-year post-operative x-rays There's definitely some loss of that joint space in comparison to her other toes, but she's active She has significant improvement in pain and running and getting back to it. And so I always When I sat in those seats when I was a resident and more recently I always thought you know, nobody ever presents a bad case So I thought if I ever got an opportunity up here talking about cases, I present this one's just a word of caution This is 65 year old saw me a year ago. She had MTP pain second MTP Bain I tried to car Tiva implants and she hates it. She absolutely hates it. It has collapsed She has pain and now the question is what to do probably an MTP fusion, which she doesn't want Is it a met head resection? Is it a 3d printed second MTP joint? We're not sure we're still working up that discussion with her to try to figure out what's going on next And so what's my algorithm? So a lesser MTP OA if it's Friberg's, you know, how much of the head is involved? Is there a long second metatarsal thinking about an osteotomy with a local interposition if it's a shortened and collapsed second MTP I often think about Corteva or a dermal matrix if this is post-traumatic instability post-surgical If they don't have previous surgery, I really need to address the hammer toe address the instability and often doing that will allow addressing of the arthritis and then if it's a revision setting Often a Hoffman still really does good for these patients who just want pain relief underneath their second MTP joint, so Conclusion important to recognize arthritis and avian at the lesser MTPs has a significant impact on patient outcomes And if conservative treatment pair fails, there's multiple surgical surgical options But none of these are definitive or currently best and we really need some larger studies to figure it out Thanks so much Alex you clear So we have a just a few minutes left and I want to just throw something out the eye to my panel here We're not gonna have time for cases I'm gonna have Alex just bring up a single slide from our cases and I want to just talk to you about Hydrogel implants because we didn't really have any cases to speak of Jason mentioned a little bit on lessers, but I want to know We talked about earlier with Steve about the fact that nobody could really duplicate the level one study just because the level one study doesn't mean it's a just an out-of-the-park home run and Number 23 right there is the one I want So what I'm interested in so Don, where are you on hydrogel and and so forth in your practice? Okay You're right, I mean I am right now in 2021 in my practice when I have a patient with End-stage MTP joint arthritis, and I'm telling them that they probably need a fusion They said I don't want a fusion and I say well we can do this hydrogel implant It may last six months. It may last a year. It may last six years, but it's probably gonna fail You'll need a fusion later. And if they say that's okay. I don't care if I have another operation I want to have some motion then I'll do the implant. They say I don't want another operation I want to be done then I do the MTP joint fusion Mistake would be taking some of that could just simply have a chylectomy and be okay and think that well I'll just add this thing because it's really fancy and now they're worse is the mistake So I really am very cautious about that. So Scott and Joe Here's the interoperative photo you're doing your bunion procedure and you really didn't see it. I know it's hard to see there but it's a It's a big strip of basically delaminated cartilage from about Straight across all the way underneath which is not uncommon we found and so that's so you're doing a bunion procedure This sort of blindsides you in the middle of the case and this is what you've got Okay, and this is probably more common than we think. What do you think? What's your answer here? My answer would be I get to the cartilage back to a stable rim. Make sure you don't have any further delamination and then Potentially just drilling do some essentially Through the subcontra bone and leave it at that so micro fracture. Yeah. Okay. All right Joe how about you? You know, I think I think these are always tough clinically when you find something you don't expect but truthfully I think one thing that I've learned in my 11 years now doing this is Sometimes calling the family and saying hey, I found something. I really wasn't expecting and here's what I would do if it was my Wife or whatever and so in some instances I've done that actually and you I've done a Medial sometimes you can do like a capsular Inner position, which I think works. Okay But in several the cases I've just called the family and said look I would it looked terrible I would prefer to fuse this and they've been very understanding of that and I think that's part of the discussion pre-op Just saying, you know, here's what I plan to do, but that it doesn't always work out So if you hear get a call from me, please be available and sometimes they'll say oh I'd rather just go with the plan and see how it goes, which is fun. So Bob in your practice Do you do much in the way of hydrogel implants? I Evolved I am very small indication now mostly just straightforward OCD Repair with a with the hydrogel. I think there's a very narrow window where I find it successful in my hand I don't mind what Don said, which is if you the patient is adamant about Needing MTP motion to be preserved for a period of time of a few years. I think it's a reasonable option But overall I have all to a very narrow indication. Okay. I Do like going back to the recent HSS article that came out looking at MTP fusions And what actually it limited and I'll sometimes even give that to the patient and go, you know, here's your limitations afterward so I can just tell you I was asked to be on that study and I renege because it was You were basically doing the case and you were deciding what you were going to do on the table whether they got an MTP Arthrodesis or a Carteva and they did Sureness Coughlin level two threes and fours and the problem was is that if you get a fusion for a level two Arthritis, you're probably gonna be that happy You're gonna be really happy with a four but not with a two and I think that's the fatal flaw of that study Was that they didn't that they really incorporated people who normally wouldn't have an arthrodesis and that's why Carteva did as well as it did The other thing I would tell you is in my experience and I sort of jumped on the bandwagon as well thing It was this pretty cool. And what I found was that in females who were osteopenic We had a lot more subsidence the guys with a little more robust bones seemed to do better Don You mentioned a little bit about just a little thing you will do to keep that dowel from penetrating and what do you do? Well, you can use a little you know Calcium carbonate or some kind of a something in the in the base very you got to be very thin though If you put it, yeah some not cement, but yeah But if you put too much in then the implants sticking out and you hurt yourself, so it's very very thin I've done it twice. I don't know if it makes any difference last question. Sure So last ten years Just been using interposition arthroplasty the capsular arthroplasty along with the colectomy for these patients that you'd normally Consider for fusion, but want that motion. I've had good success with that. It's cheap You can actually make that decision, you know at the time of surgery if you're planning on doing say some other procedures say a simple colectomy and I don't know why that's just not talked about more. Do you add a Keller or Moberg when you do that? No, I'm kind of using that technique that was originally published back in the 90s I don't remember the authors, but you you don't really decom you don't really destabilize the joint you're You're taking off some of the proximal phallic dorsally a wedge and you're doing a you know Fairly generous colectomy as you normally would do and then just bringing that capsule down suturing it to the plantar plate I've had no evidence or no episodes of instability. The x-rays look terrible patients have motion and they're painless. So So I actually that was Bill Hamilton the published that and I found that Tissue to be pretty thin and what I do is I use the cup-shaped reamers and just ream the metatarsal head a bit then I take like some type of dermal allograft and put a cap over almost like a little condom over the top of the Metatarsal head. I think the reason has caught on is because they're not big numbers. It's like midfoot fusions You don't get paid very well for it. You do it's a long run for a short slide economically So if you're really on an RVU basis It doesn't pay well at all and it takes time the results though. I totally agree with you I think they're they're very gratifying. So we're right at the button here. I don't want to get in trouble with with our Carol Jones and company here, but I want to thank the panel. It's been fantastic to have you all together and thank you all as well

osteotomies

foot surgery

shortening osteotomies

metatarsal osteotomies

lateral transfer metatarsalgia

abnormal metatarsal parabola

second MTP joint pathology

long second metatarsal

plantar plate pathology

open repair

improving foot pain

complications

success rates

surgeons

insights