Good morning. Everyone can take their seats. If you're here this morning, welcome back. If you weren't here this morning, another warm welcome to Charlotte. You know, we were all supposed to be in Vancouver. That didn't work out, but I think everyone's going to really, really like the Queen City. So, it's got a lot to offer. It should be a fun week once this weather clears out. So, I'll turn this over to Dr. Serrato, the MIS Symposium. Thank you so much for you time and all the speakers. I know they put together some great talks. Take care. Thank you. I appreciate the invitation to moderate this session. If any of you guys are familiar with me and the speakers on this, I think, as you know, a lot of us have been pretty passionate about MIS techniques and how this has really just changed my practice and those that are going to be up here and speaking. So, hopefully you guys, if you haven't seen any of this, I'm excited to kind of introduce some of these topics and techniques and stuff like that. So, we have a fantastic group of speakers today, and we'll start kind of right at the beginning. Like, how do you get started with this type of technique? And so, our first speaker is Dr. Jonathan Kaplan. Come on up. Thank you. Alright. Good morning, everyone. My name is Jonathan Kaplan. I practice in Orange County, California at Hoag Orthopedic Institute, and like Dr. Serrato said, I'm here to talk about how you get started in minimally invasive surgery. These are my disclosures, and I really try to avoid bias, even though I absolutely drink the MIS Kool-Aid, but I think you'll see that with a lot of the talkers here, that we do believe in these techniques. So, where do we begin? And I know this quote is kind of cliche, but it's really true for us as surgeons when we're trying to implement a new surgical technique. A journey of a thousand miles begins with that single step, and it's because if you have a busy clinical practice, I absolutely understand and recognize that it's hard to take a step back, slow down your practice a little bit from a surgical standpoint to do something that may challenge you a little bit, may take more time in the OR, but I do think it's worthwhile in the long run, and you'll hear all of the speakers talk about that learning curve and how they've evolved and how they probably went from things taking longer early on to actually saving time in the long run. And a lot of people may say, well, my open procedures do fine, but just like everything else in orthopedics, we've transitioned from maximally invasive to minimally invasive. Our sports colleagues have really led the way in this, in shoulder scopes and ACLs, and now we're doing superior capsular reconstructions and arthroscopic latergies. We're seeing it in the hand with endoscopic carpal tunnel releases. Trauma doctors are doing these complex fractures more minimally invasive, and even our spine colleagues are doing things much less invasive, so why not foot and ankle? We've already seen that transition in arthroscopy, so I think percutaneous transitions are reasonable as well. What are the benefits from a patient standpoint? Well, these smaller incisions allow for less scarring and less tissue swelling. It's a shorter recovery. I think it's especially important for our patients who have high risk factors like diabetes or if you have to do a surgery on someone who smokes cigarettes, people who might have wound issues. There's less pain, which ideally translates to less narcotic use, and that's especially important in this day and age. And while we as surgeons don't worry about cosmesis, we're obviously not doing surgeries because of the cosmetic component. It is important to patients, and you at least have to understand and recognize that. So what are the surgeon benefits of minimally invasive surgery? Well, you get to be on the forefront of innovation, as you'll see with a lot of the speakers here. You get to be involved in marketing and outreach, which I think does help build a clinical practice. It's patient-driven, so patients will seek you out and find you, and they appreciate your technique and your skills. You get to be involved in research. I mean, there's a lot of publications coming out now, and so if you practice in academic medicine or you're involved in research, this is a great avenue as well, and I think for me especially, you get great peer collaboration. You're going to see that amongst all the speakers today, that we really love to engage and interact with each other because we can learn a lot from each other. So there's a lot of benefit outside of the actual surgical procedure as well. What is minimally invasive surgery? And this is the case with everything else in orthopedic surgery. It's not a deviation from your surgical principles, so you have to understand your anatomy. That's going to guide your locations for incisions. You're going to hear that as the other speakers talk. You want to understand those principles of osteotomy. It's not just how you're doing the osteotomy, such as with hallux valgus or calcaneal osteotomies, but also the principles of fixation so as to optimize healing, and understand soft tissue management. You want to protect those soft tissues. Minimally invasive surgery is not just slapping a plate on the outside of the fracture and saying it's fixed. This is a patient who was sent to me from an outside doctor. So general tips, and I think this is important as you listen to each of these speakers. You're going to want to try to pick up on how they approach that procedure. You know, what is your setup in the OR, and it'll evolve as you go. You may do the procedure on top of the C-arm. You may do it aside from the C-arm. You want to figure out how you're going to position the patient. Everyone has their own little subtleties and techniques and tricks, and so you really want to think about that. That will streamline the actual surgical procedure, and you'll learn that as you go. I personally think it's especially critical to draw your anatomy with any procedure, but especially something like a bunion procedure. This helps give your mind's eye a visualization to help streamline and reproduce the procedure to make it quicker for you. You want to have a backup plan, and this is the case with any other surgery you're starting with. So even now when I'm doing a minimally invasive procedure, I have the equipment and the implants that I'm going to use for that minimally invasive procedure, but I make sure that at least at my facility I have all the things I would need in case I have to convert to open. You want to overbook your surgical time, which I understand is hard to do. I mean, if you already have a fully guided surgical practice, and maybe a bunion takes you 30 minutes to an hour, give yourself two hours to do this. You will appreciate it in the long run. You're going to feel less stressed, less worried. You're less likely to just bail and convert to open, so I think just give yourself extra time as you go. And you can even work backwards. I mean, you can start doing the procedure open, but using the burr through the open procedure to get used to using this. Kind of go more mini-open, where maybe you make your incision smaller and you still use the burr, but you put your fixation in percutaneously and then transition to full MIS. So there's lots of different ways you can do this. The key is you want to understand the equipment you're using. So there's a whole array of different burrs. There's Shannon burrs and wedge burrs. The Shannon burrs are designed for cutting the bone, whereas the wedge burrs are designed to remove the bone. And this is just an imagery that shows you have different size burrs for all sorts of different procedures, and you'll kind of hear the speakers talk about that, I would presume. Understand that the box really protects the soft tissues. It's a high-torque, low-speed box that helps protect those soft tissues, but cut the bone. And there's different options. So there's company-specific boxes where they will bring them in for you. Or, in a lot of places, you can use a TPS or a TPX, and I think this is especially helpful. Let's say you do some surgeries at a surgery center and it's surgeries at different hospitals. Well, most of those facilities will have a TPS or a TPX, and you can use it with a 4-in-1 reducer. And I actually have the settings on top of our TPX box. That way, if I have any nurse who hasn't worked with me before, they know how to set those settings and do it in a safe manner. Just know that irrigation is especially critical. You'll hear some people talk about that. Dr. Schipper loves chilled saline. You'll hear him rave on about that. But it is really important because you're protecting the soft tissues and you're trying to protect the bone as well. There's hand-pieced attachments for irrigation or you can just have your assistant do bowl irrigation. And then there's variable speeds for the burr, and think about it like driving a car. So if you want to go slow, you can go slow. If you want to go fast, you can go fast. And you're going to use that interchangeably depending on what you're doing. There is a learning curve with a lot of these procedures, and I'd be intrigued to hear what my colleagues think because I kind of just estimated these learning curves. But understanding that practice makes perfect. And so there's a lot of access to saw bones, cadaveric labs that I would assume that there's probably some courses going on at this meeting. And reach out to your local reps because they're probably going to be happy to set something up for you because you really want to practice. This was the learning curve that I estimated. I think the most straightforward ones are exostectomies and chiolectomies. Small number, probably two to five are sufficient before you at least have a baseline comfort level. With calcaneal sciotomy, it's probably about five to ten. The forefoot stuff, maybe around ten, like hammer toes and lesser toes procedures. And then I put kind of a trimodal distribution for hallux valgus infusions because you go through these different phases. You know, the first five or ten, you're most uncomfortable. You're a little bit more nervous or anxious during the surgery, and then you feel more comfortable at least with the basics of the procedure. And about 15, you realize, okay, I can streamline this a little bit more. But then after about 25, that's when you really hit your groove and get going. And these are just averages. It could be quicker, it could be shorter. So I equate this to learning to drive, and I think you should look at minimally invasive surgery like learning to drive. And I got permission from Dr. Shipper to use him as an example here, but I think he's a really good example. So if we look back and he's in high school and he's learning to drive, you know, he's 16 years old, he's got his new driver's license and he's saying, okay, I'm ready to drive. What car should I get? Well, at that time he's six foot seven. He's a tall guy, and I envy that. I wish I was taller. But he's going to look to start with something that's probably comfortable, probably easy to use, and gets him from point A to point B. And you can look at MIS that way, and so he's probably going to choose something like a safe minivan. These easier, straightforward procedures, these are the exostectomies and the chiolectomies. And the key to understand here is that they're pretty safe, they're easy to learn, they don't require perfection. There's a lot of wiggle room for accuracy and efficiency. They may not be the coolest procedures to do, but they're certainly ones to start with. Just some case examples, the anterior tibia and tailor neck spurs are relatively straightforward to do. You can position them supine. And on all these slides, just to be brief, you really only need a small amount of equipment. You need something like a freer elevator, a C-arm, whether mini C-arm, large C-arm. You're going to use a wedge burr. And then you want to have some way to get rid of that bone debris that's in there, and so you can use a rasp, and I use an angiocap attached to a syringe to irrigate it out. And so you can really resect a good amount of bone. You can do it under fluoroscopic guidance where you can take out these spurs. And I think the nice thing is it's a very small incision, so the recovery is much more straightforward for the patients. Less pain, and they're back to life a lot quicker. Haglunds, you can do these as well. You position them laterally, very similar procedure. You'll hear Dr. Volcano talk about some variations of osteotomies for insertional Achilles tendonitis, but a true haglund is pretty straightforward with resecting this under fluoroscopic guidance as well. You just want to be cognizant of the Achilles tendon and protect that. Calcaneal spurs, and I know that we all know that these calcaneal spurs are not the true source of pain, but we probably have all had patients who have failed non-operative measures for plantar fasciitis, and it's been a year or two years, and they're going in and they still want you to take that spur out. And I think that you can do all of this minimally invasive. You can do an endoscopic plantar fascial release, or you can do it open, but then you can also resect the spur with these burrs. So the nice thing is it's a pretty straightforward procedure as well. Charcot, I think this is a great example of how you can remove excess doses, and I actually think these are one of probably the best candidates for a straightforward procedure. It's a small incision in a relatively high risk population, and you can resect these Charcot osteophytes that are causing these ulcers and calluses, and they're able to walk right away, and there's a quicker recovery. Midfoot spurs are a little trickier. You just want to make sure you understand where they are, because there's obviously pertinent anatomy there, and so if it's over the first TMT or the second or third, you just want to make sure you're looking at that. So, moving on. Chylectomies are another great example, and I kind of do them a little differently than I think most people do, because I add a Halox MTP arthroscopy with it, and I'll talk about that in a second, but chylectomies are pretty straightforward. They're supine. You can resect these spurs pretty easily. I think part of the learning curve there is getting a feel for taking enough bone, but not taking too much, and making sure you're getting really good visualization radiographically, so I'll do it with spot checks with the floor to make sure I'm not resecting too much bone, and also making sure I get sufficient amount of bone removed. And you go from a large incision like this to a much smaller incision, and I think that helps decrease swelling and pain and inflammation. I talk about Halox MTP arthroscopy because we published a paper in Foot and Ankle Orthopedics, and we looked at this, and it was a relatively small sample size, but we found that it does help reduce pain. Patients are able to get back to activities quicker. They were back in regular shoes at about two to three weeks. There were low complication rates. It's three small incisions, the kind of proximal dorsal medial incision for the chylectomy, and then the dorsal medial and dorsal lateral portals. Very low to minimal complication rate, but I think it really allows us to evaluate the intra-articular pathology because I would bet that most people here have had those stage one Halox rigidus that actually has more joint erosion than the x-rays put on, and so it allows you to look at that intra-articular pathology, and we found about 30% had some chondral flaps, so you can debride those arthroscopically. 10% had a loose body. 100% had synovitis because it's an inflammatory process of the joint, and despite irrigating it out, I irrigate it with angiocath as I'm removing the bone, but despite doing that, there's still some intra-articular bone fragments, and so it allows you to remove that as well. So I think these are things that you can kind of add on as you go. So now we have Dr. Shipper. He's more comfortable driving. He's now in medical school, and he's looking for something that's maybe a little bit more challenging, but not too challenging. Still pretty comfortable, but kind of more cool looking, and that's when he chose this tricked-out Jeep with the flames coming out of the back, and this is the transition to the other talks. So you'll hear Dr. Vulcano talk about the calcaneal osteotomies. Dr. Johnson talk about forefoot, whether hammer toes, lesser toes, maybe bunionettes. The key to understand with these is these are pretty safe. I think this is the next step that you can take in MIS. They're relatively easy to learn. They don't require absolute perfection, and they are a little cooler, a little more challenging, and then we get into the cool driving. We have Dr. Shipper, who's a new attending. He's looking for something nice and sleek. He wants to get something that's maybe challenging, but the truth is at this point, he's really comfortable with MIS. It's really not going to challenge him that much, but it's cool and innovative, and I think really helps advance our care for our patients, and it's kind of cutting edge, and this is where you will hear about Dr. Shipper driving in his nice tricked-out older car with the feet coming out the back. You'll hear him talk about the hallux valgus deformity and other things that you may or may not hear today, but are important, and I think you can talk to a lot of us about. This is Charcot reconstruction, dare I say it. Cavus midfoot procedures, hallux MTP fusions. One thing to know about these are that they are safe procedures. You just want to have a decent amount of experience, at least comfort level with the MIS system. A reasonable learning curve. It's not impossible. It doesn't take forever. You want to shoot for perfection, and they are kind of more enjoyable procedures, and then we come to present day where we have seasoned MIS veteran Dr. Shipper. He has experience under his belt, and he wants to see how far he can push this, and that's when we get this maximally invasive person into this minimally invasive car, and that's where you can kind of start to push the limits a little bit, and you may see people doing ankle fusions, maybe some hindfoot fusions, midfoot fusions, and complex deformities. Also know that there's a whole potpourri which we'll hear Dr. Miller talk about, whether MIS related to percutaneous and arthroscopy, and you can combine these types of procedures. Also know that as a surgeon, just like any other procedure, that there will be complications. This is a patient who actually, of course, is a physician in my community who had a MIS bunion, and you can still get infections, so understand that there's skin burns, there's non-unions, there's wound infections, there's nerve injuries, recurrence and failure. This is not void of complications like any other surgery that we do, but just like any other surgery you do, we'll hear about experts like Dr. Acevedo talk about how you handle these, and as skilled orthopedic surgeons, it's nothing that you can't overcome. Thank you all for listening, and I hope that this helps get you into minimally invasive surgery. Thanks, Jonathan. That was a great introduction, and I think he speaks on that. I think once you guys get comfortable, this is absolutely something you guys have to practice with your hands in the lab, bringing your reps in, practice, practice, practice, and then moving on to some of those procedures will certainly make you feel much more comfortable, and then before you jump into some more of the advanced techniques. So on that note, our next speaker is going to be Dr. Oliver Schipper, who's just down 95 from my way in D.C., and he's going to speak on the minimally invasive hallux valgus. Thank you. So we'll kick this up a notch here, talk about minimally invasive hallux valgus correction using percutaneous techniques. So to focus on today, we're going to be really discussing the minimally invasive, or percutaneous, mica or pica technique, and really at this point I tell everyone here that's really a misnomer. This technique certainly started with a distal first metatarsal chevron osteotomy combined with an acan osteotomy, but I'd say a lot of us have moved to even doing a transverse distal first metatarsal osteotomy with an acan osteotomy. So again, we're really talking about a percutaneous distal first metatarsal osteotomy with an acan osteotomy. Here are my disclosures. So we're going to run through why I consider MIS. I think Dr. Kaplan did a great job giving everyone here an overview of that. But again, I'll add to it and add some literature to support it. I'll go through outcomes briefly and then we'll touch on points that I think people struggle with or need to think about when they're starting MIS as they go on this kind of voyage toward perfection with MIS, trying to mirror their open outcomes. So we'll go through burr trajectory. We'll discuss heat generation with the burr, wire and screw placement and then benefits of chevron versus transverse osteotomy. So why consider MIS? This should look pretty familiar. It's a lapidus bunionectomy, but obviously multiple open incisions, significant periosteal stripping. We know these patients have a lot of pain after surgery. We know they have a long recovery. You could be doing an MIS, right? You can see here, this is just stereostrict foreclosure, small incisions, minimal periosteal stripping and less pain. So these patients definitely have a faster recovery. You won't believe it until you do it. I couldn't believe it. My first couple of bunion patients that came in, they just weren't complaining about their bunion procedure. It felt like a barostrum. And that's when I knew, hey, maybe there's something to this. These patients have less pain and that's been borne out in the literature. They definitely have less stiffness, a lower wound complication rate. I think that's pretty intuitive given the smaller incisions. Better cosmesis, as Dr. Kaplan said, that's not a reason for a surgeon to do something, but nonetheless the patients love it. And then quicker return to work and minimal opioid use. It's not uncommon patients come in and they've taken no opiates, one opiate tablet. And full disclosure, I give everyone ibuprofen and Tylenol as part of my post-op pain protocol along with only about 10 to 20 tablets. So this patient was definitely when I knew there was some different MIS. This was a large, adult, military male, totally non-compliant. This guy came in. This is two-week post-op film. He's weight-bearing here. He'd come in, regular sneaker, taken off his dressing two days after surgery, took no opiates. Said, Doc, this was great. Hadn't lost his correction. You can see the incisions look pretty well healed. And that's when I said, hey, maybe there's something to this whole MIS thing. So what about the outcomes? First study here, two-year follow-up, less pain, lower wound complications, shorter OR time. Similar radiographic outcomes compared to open scarf aching. Second study, only six-month follow-up, but still showed less pain, similar radiographic outcomes, again to open scarf aching. And then the third study, two-year follow-up, no significant difference in clinical radiographic outcomes versus open chevron at two years. This is what I tell people about MIS. I'm not here to say in the medium-long term you're going to have better radiographic clinical outcomes with your bunion patients. What I tell people is, hey, they're not going to hate you for removing that medial eminence and making them feel better after surgery. So we'll start with BERT trajectory. In order to discuss this, you've got to understand this technique, what you're doing is you're locking out the first tarsal metatarsal joint in varus and then shifting the first metatarsal head laterally relative to the shaft. So your BERT trajectory matters. The more distal you angle, the more you're going to lengthen the first ray. The more proximal you angle, obviously, the more you're going to shorten it. And I've got this, you know, this was me at my best here with images, but you can see here I'm just trying to show this difference. And so you also need to understand that typically with this technique, there's a two-millimeter BERT, right? So you're losing two millimeters of length. Our goal is to maintain the length of the first ray. And in orthopedic foot and ankle surgery, I think we are always obsessed with not losing length. So the tendency is always angle distal. So we maintain stress on the first ray and don't develop second metatarsalgia. But I would just caution everyone here, don't go nuts with this because you can over tension the first ray. And right, if you over tension the first ray, well, that stress has got to go somewhere, right? And we're not fusing any joints here. So ultimately what's going to happen, right? You can develop first TMT instability. You can lose first MTP range of motion. You can see here this patient has metatarsus seductus. So obviously, they're at increased risk to begin with. But nonetheless, a pretty nice initial correction early on. And then you can see it fades over time as they develop progressive first TMT instability. If you look at their preopture, there might be some initial instability there. Maybe this would have been better served with a lapidus. But nonetheless, I'm just trying to highlight the point. Be careful about over angling distal. So at this point in my practice, what I use as a guide is the second metatarsal shaft. I think that's the best guide. And I'll angle distal 10 degrees. If you're doing a chevron osteotomy, you may want to also angle plantar as well. With a transverse osteotomy, you have the option to translate it in the sagittal plane. So what about heat generation? Well, as Dr. Kaplan mentioned, these are high torque, low speed burrs. So they've got a high rotational force at lower speeds. And that allows us to cut bone effectively without cutting soft tissue and also allows us to generate less heat. My preference is to use 5,000 RPMs for this technique. In experienced hands, and this is based on a great study, large study here published in JBJS recently by Dr. Gordon and Dr. Ray, who have ample experience in MIS techniques. But they had a risk of non-union about 1.2% and delayed union 1.5%, as well as obviously there's a risk of skin thermal injury. Heat generation really is an issue for newcomers, people in their learning curve. When they're learning how to use the burr, they're dabbling with, should I use tourniquet or not? How much irrigation should I use? This is really a problem early on. And so I'll go through this one by one here. So first of all, I really advocate against using tourniquet. Some of my MIS colleagues will disagree. The literature I draw upon for that is twofold. So one, we know in the tibia with tibial shaft fractures, we know reamers generate heat. And under tourniquet, you can develop osteonecrosis. So it's typically taboo not to use, or sorry, to use a tourniquet for tibial reaming. We all the time use saws and burrs and sometimes start to see blood or a little bit of irrigation boil. And then also in the dental literature, they often use high-speed burrs. And there's plenty of support for heat generation with these high-speed burrs. So again, I advocate against tourniquet. And this is really amplified when you're doing a calcaneal osteotomy because you just can't cool the distal extent of the burr, which is buried deep in the calcaneus. And the same goes for your distal first metatarsal osteotomy on the lateral side of the bone. I really recommend using copious or saline irrigation with a bulb syringe. A lot of the companies out there have a very fine irrigation spout on their handpiece, and that's just totally inadequate. Half the time, it's not even hitting your skin portal or the burr. It's a very fine feed. The whole time when I'm doing this procedure, my tech or my PA are sitting there irrigating with saline. And I took this a level further, and at this point, I used chilled, refrigerated saline. And I drew inspiration from that from one of my mentors, Dr. Adad, who did this nice study effect of continuous irrigation during burring on thermal necrosis and fusion in a rabbit arthrodesis model. But this is easy, right? The circulator has the saline in the fridge. They pull it out when I'm ready to go. It just helps reduce my risk of a heat issue in surgery. And it's a little counterintuitive doing MIS-Halix-Valgus. Usually, we're like, great, you know, young patient, great bone. But those are the ones you need to be careful with. They've got great bones, so you've got to go a little slower with the burr, and you want to pause and clean your flutes, let the irrigation catch up, reduce that heat formation, because those are the ones you worry about burning the bone. So now we'll switch gears and talk about wire and screw placement. And this is just incredibly important. You know, we talk about this all the time and try to harp on it. And initially, when everyone started doing MIS, you know, there wasn't necessarily total consistency, but I think we're really kind of honing it down to some key points here when it comes to placing your wires and screws. So number one, you can see here the green circle. Ideally, your proximal wire and screw should enter at the first metatarsal. That gives you the best angle to capture as much first metatarsal head laterally as possible. And in this situation, you can see I'm riding that lateral cortex. I've got great purchase throughout the first metatarsal head. The second point here is this wire and screw ideally are about a centimeter from your osteotomy site at that lateral distal first metatarsal cortex. That bridge is what gives you the stability with this technique to weight bear right away. And I'll discuss why that matters, right? If you have a thin bridge, you've got to remember you're going to over over drill this wire, right? So you're going to lose a little bit more bridge. You create a very thin bridge. You could lose your initial reduction, and that's an early mode of failure for this technique. You obviously want to space your wires out. And then your second wire is really a rotate for rotational control. That's why it's placed. I typically like to straddle that distal lateral first metatarsal shaft cortex, so I'm not removing any of my bone bridge. And then finally, on my lateral view in the sagittal plane, if possible, it's not ideal or not, not like you have to do this, but I'll try and also get some spread between my wires so I'm as close to the cortex as possible with my screws. And this is just comparing, contrasting. This is earlier on in my experience here on the left side. You can see I've got a little less purchase of the lateral first metatarsal head. My screws are very close at my bone bridge. It's a little smaller. You can see my proximal screw may even be exiting that lateral cortex. And then you compare the image on the right. The other downside of starting more distal with your screws is you can't excise as much of the distal medial first metatarsal shaft spike. And so obviously a patient could feel that if you don't do an adequate excision of that spike. But on the right, you can see there's just nice thick cortical bone bridge at the distal lateral shaft. I'm in parallel with the lateral cortex of the first metatarsal head. I've been able to remove a ton of that distal medial spike. This is what you're looking for. Again, it takes time in your learning curve to get the muscle memory to be able to place these wires adequately. But you will get there with practice. And so what can happen, right? You have that thin bridge. You don't get enough of that lateral first metatarsal head. Well, you can lose fixation and lose correction. And it's interesting. So you see here, it's really in the axial plane where you'll lose it. You look at your lateral. You think, hey, this doesn't look so bad. But obviously on the AP view, you've lost correction here. And this is an early mode of failure for this technique. You shouldn't see this if your wires and screws are placed appropriately. So this is really a learning curve issue. And once you place your wires appropriately, you should not see this. Again, everyone's immediate weight bearing. And where are we going in the future? Well, in the future, we're going to have jigs, and these will be out soon. But just to number one, help you shift the head maximally. And then number two, place your wires with that correction. So it's just going to help people in the learning curve to get through it quicker and really place the screws where they should be. I'll show you here. This hopefully will play. But this is just showing that this tool will help to shift the head. And obviously, you can see on the right how you can place your wires then easily through the jig where you want. All right. So now we'll talk about Chevron versus transverse osteotomy. Dr. Acevedo will be up here. This is a valiant attempt to take a look and biomechanically compare these two osteotomies for this technique. So, you know, the challenges were they were using cadavers. They're obviously very stiff. These patients didn't have hallux valgus deformity to begin with. So it was just challenging to adequately assess this through this study. And so a couple problems here. So the screws were certainly placed a little more distal. And as a result, you've got less purchase in the first metatarsal head. We're not riding parallel to that lateral cortex. And on the right side here, you can see they didn't even capture that distal lateral cortex, right? So how can you really compare in this case biomechanically Chevron versus transverse osteotomy? And, you know, as they adequately noted, they noted these flaws of the study and therefore kind of jury's still out. Further studies need to be performed. But again, I'll discuss why I think transverse is better. So first of all, everyone needs to understand we're shifting the head 80 to 100 percent. So there really is minimal cortical contact between the shaft and the head with this technique. And so as a result, you could say, well, with Chevron, I've got maybe some better sagittal stability. But the reality is there's really minimal cortical contact. So in my opinion, transverse is superior for two reasons. Well, number one, obviously it's easier to correct rotation, right? It doesn't make sense. We are correcting rotation. We know there's a pronation deformity typically with hallux valgus. If you've got a Chevron, it's going to be that kind of awkward alignment of the shaft and head, whereas obviously with transverse, that doesn't matter. And then number two, you preserve more bone on either side of your osteotomy. So the challenge is – and this, again, was my best attempt at using shapes in PowerPoint. I really need to do like a lecture on this separately. But what can happen is on your AP view, it's going to look like you've got great purchase of the first metatarsal head. But the reality is if your screws are central within the head, you may have only two threads within the head itself because you're within that apex, or you've totally missed the head in its entirety and you're putting yourself at risk to lose your correction. And likewise, well, obviously with transverse osteotomy, you're going to have much more bone, much more purchase there. You don't have to worry about being within the apex within the head. And then number two, on the other side of the osteotomy, you've got more bone because you haven't removed it dorsally and plantarly at your cortical bone bridge. So for those reasons – and again, I've done tons of both techniques, chevron and transverse. For those reasons, I really feel like transverse is superior. Again, more biomechanical studies need to be performed to really know for sure. But in my hands and with my experience, I really preferred at this point the transverse osteotomy. And I'll just end on a couple closing points here. So number one, anyone who's looking at MIS, they take a look at the x-rays, they go, oh my God, does that really heal? And I'm showing you this. This is a pre-op. And this is also the other kind of impressive part. But you just see the mobility in the first ray here. And you are removing some of that hypermobility when you do this. It's obviously not a moderate severe bunion in this case, maybe more mild moderate. But you can see how much I was still able to shift the head. And then you see at the one-year mark on the right, you see that nice bony remodeling. I don't wait to see that to let patients wait there. It'll take about three to nine months for that to totally mature. You don't need to wait for that. But this is what it looks like over time. It does heal. Don't fear the shift. Don't shift less because you're worried about it not healing. These really do heal pretty reliably. And then a couple quick hits. You know, when I first started doing it, doing MIS four years ago, you know, no one had any clue. Well, you know, you look at the rep, how much do I subtract, you know, when I'm putting these screws in? So a couple months, you should be using a chamfered head because the reality is, especially in a thin patient, that medial cortex of the first metatarsal shaft, you know, patients will have pain in shoe wear if you leave your screw heads prominent. And there are some studies out on this technique. They show hardware removal rates as high as 10 percent. That shouldn't happen if you're burying the screw adequately. So what do I do? I subtract five millimeters from my measurement. If it's an odd measurement, I subtract six from even. And since I started doing that, I can't remember the last time I've had to remove a screw for this technique. And finally, just this is a quick point, just I always recommend distracting the osteotomy to really release that periosteum across your osteotomy. This is like a little Cobra tool. You could use a free or just put it across and just distract it out. Free up that periosteum so you can maximize your shift. So finally, smaller can be better. All right. Use a second metatarsal guide as a guide for your burr. I really recommend avoiding tourniquet. Use copious bulb syringe irrigation. Don't rely on the handpiece. And even take it to the next level. Use chilled irrigation. You really should never see non-union skin thermal injury if you're doing this right. Start at the base of the first metatarsal with your wire and ultimately your screw. Preserve as much of that first metatarsal bone bridge. And really, I think transverse is the way to go with this technique. So again, MIS Hallux Valgus Percutaneous Techniques have made forefoot great again for me. I hope in your practice it can make it great again for you. Thank you. Thank you, Dr. Schipper. That was a great review on the MIS technique. And I have a couple of questions I think we'll follow up at the end. I'm sure we'll invite any questions after we've finished all of the talk. So please, you know, save what you want to ask for the end of this. So now we're going to move on from the forefoot. We're going to go back to the hind foot. And Dr. Ettore Volcano is coming up to speak on MIS Calcaneus. Good morning, everyone. Thanks for having me here today. So I'll be talking about percutaneous calc osteotomies. These are my disclosures. So what is the problem with open osteotomies? In the literature, the complication rate associated with these type of osteotomies ranges from 15 to almost 28 percent, with wound dehiscence and wound infection really being the number one complication. But then some patients might complain of postoperative pain, maybe because of all that scar tissue at the lateral aspect of the heel, sural nerve injury. And then in medializing calc osteotomies, there's this lateral bone overhang, which we typically always obsess over. So why convert to MIS? I think Oliver and John have made this very clear, but there's a faster recovery. There's evidence demonstrating that there's less postoperative pain and therefore less use of opioid after the procedure, a lower wound complication rate, better cosmesis, and a quicker return to work. This is actually one of our studies on opioid consumption after percutaneous foot surgery. And when we focused on hindfoot, the mean number of oxycodone tablets taken postoperatively was only five, which for any of us that have done open hindfoot procedures, we know it's actually shockingly low. What type of osteotomies can you do at the level of the calc? Virtually anyone you want. These are the ones that I perform most commonly. Malerbas, I've only done a few, but it can be done. It's a little bit more tricky, but the other ones I really do pretty much routinely. How do you position the patient? So it really depends on your preference and it depends if you're doing the calc osteotomy in isolation or in conjunction with other foot procedures. I like the patient to be positioned supine with the foot at the end of the bed, but not over the end of the bed. I like to bump the hips so that I can internally rotate it. The mini C-arm, I always have come from the right side of the patient, no matter what the laterality. The contralateral leg, you can either just leave straight or you can put on a frog leg position. I always have my staff on the contralateral side of the, I'm sorry, on the ipsilateral side of the leg I'm operating at. I never, ever, ever use tourniquets, so my philosophy is similar to shippers. And I use a 3mm Shannon burr, which is the cutting burr as opposed to the wedge burr. And companies now have it available in a 20mm or 30mm length. The RPMs are usually about 6,000. In harder bone you might want to consider going to 6.5 or 7,000. So this is the typical position, at least in my hands. I like a little bump under the leg to make it easier to work with the burr around the hind foot as well as to get better views on the x-rays. So starting with the medializing calc osteotomies, you plan them exactly the same way you would plan the open procedure. I typically tend to angle my burr perpendicular to the axis of the valgus calcaneus. That way I make up for any shortening of the calc when I'm translating. I use a 3x20 or 3x30 cutting burr. Again, 6,000 to 7,000 RPMs. And irrigation is absolutely crucial. No matter what system you have, make sure that the burr skin interface is always well cooled down. As Oliver said, it's very hard for that irrigation to go all the way deep into the calcaneus, given the size of the bone. And so to me, using no tourniquet is absolutely crucial in helping prevent thermal necrosis. The way you do the osteotomy, again, varies between surgeon and surgeon. I usually do the near cancellous first, then I do the far cancellous next. I poke hole the far cortex, and then ultimately I connect the dots. If you try to cut everything together, it's going to be extremely difficult. You're going to generate a ton of heat, and the burr will just keep jamming, and you've got to pull out and start again. So take your time. The first few, it's probably going to take you about 30, 40 minutes just to do the osteotomy. But as you get more experience, I'm really able to do the osteotomy in probably about five minutes. To translate, you can use whatever you want. You can use a Simon pin. I like a free elevator because it's got a little curve, and it helps me translate the calc even more. And then you can stabilize in whatever way you prefer. I usually use a single seven millimeter headless compression screw. In a more osteopenic bone, I augment it with a five millimeter headless compression screw. Dwyer osteotomy, actually rather modified Dwyer osteotomy. That's the correct hindfoot varus. It's a wonderful biplanar osteotomy that allows you not only to get lateral shift, but also correct hindfoot varus by performing a lateral closing wedge. The way you do it is exactly the same as the medializing calc osteotomy. So you mark your osteotomy, make a small three millimeter incision at really the middle of your osteotomy line. Make sure you do blunt dissection with mosquitoes, and then you advance the bur. And you perform a single osteotomy just like the medializing calc osteotomy. And then I shave down, I switch burs. I go to the three millimeter wedge bur, which is to shave bone rather than cutting it. And I start removing bone on either side of the osteotomy. And then I just manually close it down. So this was a patient I did an ankle replacement on, and he was pretty calvarous. I added this Dwyer osteotomy, and then also a percutaneous first metatarsal dorsiflexion osteotomy. Zadig osteotomy, it's become one of my favorite procedures. I'm not sure how many of you are familiar with it. It's essentially a dorsal closing wedge osteotomy of the calcaneus that is indicated in patients with chronic insurgent Achilles tendinopathy. You do not touch the Achilles tendon with this procedure. What I do is I remove about eight to ten millimeters of dorsal bone. And there's two ways, really, you can approach this. You can either do a flat cut, just like for MDCO, making sure to keep the plantar hinge intact. This is absolutely crucial. I'll tell you why in a second. And then you can decide, do you want to use a wedge bur and just shave the osteotomy, or do you want to make two separate osteotomy cuts and then with a wedge bur shave in between. I started off with the latter, but over time I've converted to the former. So always leave about a centimeter of a plantar hinge. The one complication I have had with the healing was a nonunion in a patient where I violated that plantar cortex. To close the osteotomy, you just hyper dorsiflex the ankle, and then you stabilize it. Usually do a single seven millimeter headless compression or two five millimeter headless compressions depending on the bone density. And you can see that's the incision at the bottom. In a retrospective analysis of my patients over a two year period, on 118, 65 with a medializing calc osteotomy, 32 Zadex and 21 Dwyer's with a minimal follow up of 12 months, we found that the overall complication rate was 3.4, so substantially less than the 15 to 28% reported in the literature, and no significant difference between the three types of osteotomies. Two patients had a transient neuritis of the sural nerve that resolved in both cases under three months. One patient with a prolonged wound drainage from thermal injury at the skin level, the one nonunion in the Zadex osteotomy, and interestingly, no lateral bone overhang pain in any of the MDCOs. I think this has to do with the fact that that lateral overhang in a traditional open osteotomy just constantly rubs against that scar tissue. We don't have this problem here, and so we don't have to worry about shaving down that overhang to prevent pain. I'm not sure if you guys have had the same experience, but I've not had a single patient complain about that pain. So in conclusion, the procedure is safe. You're obviously going to have complications just like you have with any surgical procedure, but it's very versatile. If you're an MIS believer, you don't have to do everything MIS. It's just one extra weapon you have in your armamentarium to tackle whatever pathology you need to do. You can mix and match. You can do open procedures like in a flat foot reconstruction. Do the FDL tendon obviously open, and then the percutaneous cal costeotomy. The learning curve is so much easier than with other types of MIS procedures. So if you need to get your feet wet, start with the cal costeotomy. Take your time. Don't get frustrated. It's easier than it seems, and it's also very forgiving. Thank you. Thank you, Dr. Vulcano. So now we're going to take it back to the forefoot, my ortho sister, Holly. So great to finally see you in person again. So she's going to be tackling what many of us just fear the most when we're talking about forefoot surgery, and she's going to tell you why adopting this technique to treating lesser toes is probably going to change your life, change your practice, and those of your patients as well. So, Dr. Johnson. Thank you. Okay. It is great to be back here with all my friends. Probably the best part about this adventure with MIS is the amazing colleagues I've met, and I've become closer with my MIS colleagues than really anybody else, even internationally. So it's great to see all you guys. I am a consultant, and I get royalties from Novastep. So when you put socks in the dryer and you end up with one, I consider that a mystery of life. Accordion traffic. How does it start? Why does it spontaneously stop? How about this? How on earth does the body contort the foot into these crazy positions, and why would it ever do that? So, you know, hammer toes to me just absolutely remain a mystery of life. The etiologies are endless. They can be isolated or combined with other deformities, and every single day I'm in clinic, I see a new variation on the hammer toe deformity. It's things I've never seen before. It just continues to amaze me. Patients try everything to try to avoid surgery, right? They're taping, cut out their shoes, these toe sleeves, and nothing really works. I hate hammer toe surgery. I think probably most people in the audience hate hammer toe surgery. It's unpredictable. It has a high recurrence rate. Patients have completely unrealistic expectations, and that leads to low patient satisfaction, and ultimately, I'm dissatisfied with a lot of these cases. So what can we do to make it better? There have been a million procedures for every piece of the soft tissue and bone of the toes to try to get this surgery right. Oftentimes, the surgical choice is based on the deformity itself. When I compare open to percutaneous, I think open at the beginning is technically easier, and mainly that's because we were all taught how to do it. There are multiple tendon transfer options. You can repair the plantar plate, and you get arguably a more anatomic correction. There's no question. It usually requires some fixation, such as a pin. There are far more wound complications, and stiffness is not only common, it's essentially ubiquitous. So with percutaneous, as we've heard the mantra, there's less wound complications, less pain, stiffness, less time, but they're technically difficult, and it requires really understanding the anatomy of every part of the toe to get it right. I thought I understood hammer toes, and then I started to do MIS, and then I really understood hammer toes. It does also require more post-operative taping and strapping, and maybe less reliable without pinning. I'm not really sure about that yet. However, there are certain aspects that have been absolutely life-altering for you. I always like to acknowledge my mentors, and Joelle and David and Barbara Piclay have taught me more about percutaneous hammer toes than I would have ever thought anybody could, and my colleagues at MIFAS. So this is a slide I stole from David Redfern, demonstrating all the percutaneous surgical options, and I'm not gonna go through each one of these, but this is probably the most, literally, I still study this. This is the most important slide of my whole talk. I'm happy to share it later. MIFAS, the International Minimally Invasive Foot and Ankle Society, has come up with multiple algorithms for percutaneous procedures. This is for flexible hammer toe deformities. I'm not gonna go through it. I'm not a big classification and schematic type person, but I think that if you look at this carefully, if you follow the, understand the anatomy, it makes a lot of sense, the different steps to take when you're trying to tackle these percutaneously. So for simple, mild, flexible deformities, I'll often just cut the extensors at the hood. So it's really critical to see where that beaver blade is cutting. You don't wanna cut too proximal, because then you get a big gap, and you lose all the extensor power. So try to keep it a small incision. I usually steristrip these down for anywhere from two to six weeks. This is a case, actually, this happened to me in the operating room, I think this was two weeks ago, where I did a percutaneous lapidus, and then I noticed that the toe was laterally deviated. I didn't pick this up ahead of time. Knowing that the patient was gonna be unhappy if that's what her foot looked like at the end, I did a simple EDL and EDB tenotomy through that small incision, and really had a nice result. So I made these little drawings up. They, again, help me kind of understand things, so hopefully you guys can follow this. So for sagittal deformity, you just have sort of your straightforward hammer toe. First, I release the plantar plate of the PIP joint and the FDB, okay, you don't wanna release all the flexors or you get a floppy toe, or a floating toe. Then I'll take the burr and do a plantar flexion osteotomy of the proximal phalanx, and maybe a dorsiflexion osteotomy of the middle phalanx. You do this in a stepwise fashion, and what I've learned, actually, is that I've shifted a little bit, and oftentimes I'll start with that PIP joint, release plantarly using the beaver blade, and I won't release the extensor until the very end, unless I need to, and then you get this result. This is a picture I stole from one of Barbara P. Clay's papers, really looking at the anatomy of that PIP joint release, and I suggest everybody look at this paper. So this is an example of a case, and just sort of the entrance points along the plantar portion, where I did the extensor lengthenings, the PIP release, and the phalanx osteotomy. So for the coronal deformities, this is a really nice way to treat metatarsus adductus. I use this for a lot of revision cases, where you're basically taking a medial or lateral wedge, almost like an acan, and you're green-sticking it to whatever direction you're trying to correct it, and it can be very powerful. If it's not enough, there are other osteotomies you can add, but it's a nice little trick. This is an example of doing that osteotomy. You can do it through a plantar approach. I'm not gonna get into the specific exact details of that. I'm happy to talk to anybody about it further who wants more details, and then you can see that I green-stick it there, and the toe goes in the preferred position. This is just an example of a metatarsus adductus patient, where we got a great correction just with that technique. So crossover toe. This has literally been life-altering for me. So for crossover toe deformities, I used to routinely do an open macera, or shortening osteotomy of the second metatarsal head. I would try to shift it towards the medial side to move over the deformity. I would do anything. I'd try tightening down the EDB to pull it over laterally. I just found it to be a very frustrating, unsatisfying case that usually ended in the patient being quite stiff. Well, with this osteotomy, if you do an oblique osteotomy of the proximal phalanx, it allows the toe to shorten through the osteotomy site and shift laterally. And what that does is it releases the extensors and the flexors, so you get a great correction. And you end up with this overlap of bone here, and that all fills in over time. This is an example. I like tourniquet. I don't like blood on my shoes, but I do copiously irrigate. So I didn't irrigate in this case, because this is just for the demonstration of the video, but you can see after I cut it, I was able to shorten and reposition the toe. And I most of the time do not pin it. If I have a very unreliable patient, I will pin. This is an example of bilateral hallux valgus and crossover toe deformities. And you can see the right foot was done three months ago. The left foot was six months, and the correction looks great. And even at three months, there's minimal swelling. This was a patient who had multiple surgeries, the forefoot and the midfoot at outside institutions, and came to me with the chief complaint of her second and third toes crossing over. She couldn't fit into shoes. Her foot was irritated, RSD-like. I did these simple osteotomies through her prior PIP fusions, and she's extremely happy. You can even see the color on her foot improved. For rigid deformities, I still do a PIP fusion. I really haven't mastered the sort of tissue releases and osteotomies for this. I use a two by eight millimeter burr. I use copious irrigation and use screws or wires to fix. If I need to shorten, though, if you need to shorten the toe, I still do a little mini open approach. I use the burr to resect the joint, and then I close it up. I think I have an example of that later. To hold the reduction, I use this wet dressing. I also try different suturing techniques, dorsally or plantarly, to hold the toe down. I use a lot of Steristrips. Oh, the picture on the bottom right side, that was an open PIP that I did. Sometimes pin fixation is necessary. This is an example of a patient I was worried about compliance or stability of the toe, and I added a K-wire. Post-operative care, this is the best part of it. This is immediate weight bearing in a hard-soled shoe. I don't think these guys talked about enough how with MIS surgery, these patients can weight bear right away most of the time. Obviously, with the calc osteotomies, you're doing common procedures, maybe not, but for all the forefoot stuff, we encourage patients to walk right away. The hammer toes do require dressing changes every two weeks or these prefab splints. I've just started to employ this arthroplast sort of silly putty type splinting that I learned from my European colleagues, and I'm excited to get that into my practice. This is a slide from Barbara P. Clay again, and she's arguably the master of percutaneous hammer toe surgery, universally recognized really in the world. I'm trying to do every, I'm really trying to employ her techniques with this type of splinting post-op, and it seems to make a big difference with swelling and healing. The literature's totally limited. There are literally two studies that I think are even reasonable. The one takeaway from the first study is that there's a higher complication rate with the addition of tenotomies, and so I think if you're gonna do the percutaneous surgery where you're cutting the bones, cut the bones first and then do your tenotomies, this is really the extensor tenotomy, not so much that plantar release of the PIP joint. Anything that can happen with open surgery can happen with percutaneous surgery. I think every time I see another complication, I think I've seen it all, but they keep coming. Nonunion, malunion, recurrence, swelling, numbness, pain, We've seen it all. I think that I have less complications with percutaneous surgery now. You have to avoid all the things that you have to avoid when you do an open approach. Avoid poor technique, try to avoid patients with poor compliance, and make sure your fixation or your strapping is reliable. The limitations of the percutaneous approach in my hands are rigid PIP joint. I mentioned this earlier. I'll still do an open fusion for these. I feel like I can shorten the toe and fuse it more reliably. I can move to a screw now. Sometimes I use two K-wires, but again, I often combine it with other percutaneous procedures. If I have an un-reducible MTP joint with a hammer toe, I still open those. I can't figure out how to reduce the MTP joint percutaneously. If anybody knows how to do that, please teach me. I still can't figure that out. Also, beware. When you do a simple extensor tendon release, like I showed in that case of the lapidus where the toe deviated laterally, you have to make sure that the PIP joint is flexible because if you release the extensors and the PIP joint is rigid, you're gonna create a more rigid deformity where you don't have the counter pull of the extensor digitorum longus to extend the PIP joint. And if all of those words just went over your head, you need to really study what the short and the long flexors and extenders do to the toe because that's absolutely critical for understanding how to do this kind of surgery. These, I'm gonna show a couple complications I just saw in my clinic yesterday. I added these slides last minute. This is a DIP joint that I did percutaneously in a patient who had multiple other surgeries. There's clearly a non-union here. Luckily, it's stable. She loves her second toe and I'm not planning to revise it at least yet. These are two patients that I over-corrected. So the bunion correction looks good, but the second toe looks terrible and the patient on the right is unhappy and I'm gonna have to figure out how to fix that. That was one where I used a screw across the DIP and the PIP joint. So what I think I need to do is simply remove the screw and most likely we'll do an oblique osteotomy to try to shift that toe over back a little bit laterally. But again, complications happen. Complications avoided. So since I've been doing hammer toes since the beginning of 2018, I've had no hammer toe infections. I use far less K-wires, which I think led to many infections. Patients have less pain. The surgery is so much faster and I have less issues related to non-weight bearing. The crossover toe surgery has literally changed my life, my patient's lives. I'm more than happy to talk to anybody about my experiences with this. I think that's one thing about MIS is that we're sort of a cult now. We really believe in things and we're really excited to share what we know and what we've learned. So I'm happy to go into any more details about anything I've talked about. Again, it's another tool in your toolbox. Can accompany open surgery. But as with everything else with percutaneous, we need more studies to compare the open and percutaneous results. Thank you. Thank you. Thank you, Holly. I think we all agree this is a little cult getting bigger and bigger every year. That being said, it really has improved outcomes on my patients. But it's not without its issues, right? Anything, any surgery is gonna have complications. And so who better to discuss complications and how I've addressed them than my colleagues after Acevedo? Because clearly he sees more than me. That's right. I hope I didn't steal your thought. I want you to know I asked all my friends for examples of this. And I want to thank them for. All right, there we go. So again, I'd like to thank my colleagues that contributed cases along with my own set of complications. I've acknowledged those that wanted to be acknowledged and not acknowledged those that didn't want to be. Disclosure, the only relevant one is probably that my Arthrex disclosure. Anyway, I think it's important to know the history of MIS. I think a lot of you that are into this probably know it already. I'm not going to belabor it, but really, there's nothing new here as everybody here has pointed out. We're just doing it through smaller incisions, and the first generation techniques were greater than 30 years ago. Dr. Isham used these micro techniques, but there was no fixation, so it led to a lot of complications and failures. The second generation techniques that those of us that are my age and older remember, we looked at this and said, oh, God, because it lacked stable internal fixation. And then Dr. Meyerson, who trained a few of us here, published his initial results of these second generation techniques, and I should say, Anish published them for Mark and noted the unacceptable rate of complications with a 69% dorsal malunion recurrent Hallux valgus, and you can read the rest of those. So they decided to abandon it. So it wasn't until 2011 when Joelle and David Redfern, it published their improved results with these percutaneous techniques, merging it with the AO fixation. I think that's what really has made the biggest difference. Shortly after that, Joette published this study where they looked at the first 53 compared to the next 53, and there was a significant amount of complications in the first 53, twice as many, and they felt there was a steep learning curve, which I think all of us agree here that with improved technology, we're significantly improving these complications. But why does MIS fail? And so, you know, several general reasons they fail, as some of the authors have pointed out. You know, if you're extending your indications and really you don't know your limitations, especially when you're starting, that can lead to potential risks of nerve injury, fracture, thermal necrosis, et cetera, and I'll show you some of these in my talk. Obviously improper technique, especially when you're learning, and obviously there's the patient factors that we can't control, which is, we'll get into a discussion about weight bearing in a second. But anyway, I've divided this into basically complications related to hallux valgus, MIS osteotomies, and then lesser toes, and then we can debate whatever. But as far as hallux valgus, as Dr. Schipper pointed out, you know, there's reported up to 27% increase in reoperations, and most of those are probably due to removal of hardware. Fourteen percent conversion to open surgery, and I think most of us would refute that. Delayed union, nonunion, pin site infection, and we'll see where all these come from. This is a systematic review from BIA et al., and they looked at 18 studies from 96 to 2015. That's 1,500 procedures, and found many of the complications were due to the first and second generation techniques, not so much in the third generation techniques, so I'd keep that in mind. Here's a Siddiqui and Laporta study. This is also a second generation technique, and they reported 27% complication rate, so a lot of these high complication rates are in these earlier generation techniques, including, as you see, the pin site infection, which have been observed in many of the other authors' talks today. But, you know, obviously there's hardware failure, bunion recurrence, and then Frigg and others reported on comparing open to the MICA, and basically showed that there was a slightly improved range of motion with the MICA, and obviously the scar length and the wound complication rate was significantly lower with the MICA technique. Our colleagues from Barcelona have nicely delineated the location of the dorsal medial and lateral cutaneous nerves, and I think this study, if you're going to venture out and do these, you really should pay attention to this so you avoid some of these nerve injuries that occur with Hallux valgus. Some of the improper techniques, remember, you know, this is, I think we all know that metal fatigues, and I think this has probably happened to most of us in some way, shape, or form. It's not mine, but I've had it happen to me, so just remember, when you're overusing that burr, this burr can fatigue, and you may have to fish it out if you're not careful. So, Dr. Schipper, here's our MEDA versus MICA, and we looked at this biomechanically, and I'll point out that in a cadaver, it's sometimes hard to get bicortical fixation, and so, but it was evenly distributed between the two. So, you can still question the power of the study, though, I'm sure. But what we did find was that there was a, the biomechanical strength of the chevron versus the transverse were not statistically significantly different, although there was a trend towards the transverse osteotomy being, having higher ultimate and yield load to failure. We did find that the failure modes were most commonly through the screw entry site, although the next most common was through the osteotomy site. I just put this in here so we remember that the proper technique is more of a pronation supination rather than a translation, and you can see why. We looked at our first, Dr. McWilliam and I looked at our first 77 cases. We had 50 chevrons and 27 transverse osteotomies. We showed that there was a significant improvement in Halleck's valgus angle, IM angle, and sesamoid station. Our complication rate was slightly lower than some of the studies you saw, 10.3%, but we did exclude the removal of hardware as not being a complication, but did report them as 3.8%, as you can see there. We really only had two that had to return to the OR, one nonunion, one bony overgrowth, and as you'll see in this much more extensive study by Lewis, they break them down into three grades of complications, and really the grade 3s are the ones that require a trip to the OR. There was about 7.8% complication rate in this pretty extensive study. So bottom line is know your indications, know your limitations. This was a 50-year-old with severe metatarsalgia after multiple surgeries performed elsewhere. I wasn't sure what I could do for her, but I said I'll try my best, and I thought I did an okay job. I did a MICA and DMMOs, which was probably a mistake doing both of those at the same time, and then three weeks later, she fractured through that metatarsal, and I gave her the option of going back in there and revising it or letting it heal and then taking it from there, and three years post-op, she was asymptomatic, and even though that x-ray doesn't look very pretty, she's quite happy with her result. Question that always comes up is can you do it for revision? So this patient had a prior chevron osteotomy, and I think as long as the osteotomy's healed, at least six months post-surgery, I think the MICA works quite well to correct these deformities. This is one of my first cases, and you can see the screws are way too far distal. In addition to that, this is a patient with a large BMI, weight-paired right away, just like you guys like, and you see the loss of reduction. So my post-op on Hallux Valgus, I put them all in boots. I trained by the Europeans, and they told me to put them weight-pairing right away, and I did that, and I had a couple of delayed unions, so I've since. I do let them weight-pair, but I protect them in a boot, is mine. So anyway, this is three years post-op. Fortunately, she was a little plump, so she thought I did a great job, even though I didn't like my x-ray at all. So again, another one I did not have to revise, so I'll show you some that we did revise. Here's a patient of Dr. O'Dalley's, and one of his first cases, I thought he did a really nice job, had that spread of the screws, like Schipper pointed out, and however, she was doing so well, she tripped over a garden hose, and again, had a fracture similar to my patient, and I think he did a great job at handling this complication with a dorsal plate and fixing that metatarsal fracture. Here's a minimally invasive lapidus, which is not my own, but I thought it was done technically very well, except maybe we had too many holes in the proximal metatarsal, because it started to gap, got a CAT scan, and you can see the fracture of the metatarsal, and this was nicely salvaged with a plantar plate. So moving on to the MECO, many of the same complications you see, as Ettore pointed out, wound complications, infections, nerve injury, and calcaneal displacement. I think if we stay in line with what Toulousan and others told us to do, you know, if you stay within that 11 millimeters in front of that line between the posterior superior, the posterior inferior tuberosity, the calcaneus, I think you can avoid a lot of the nerve injuries related. Here's a Kendall et al. study. It's a level three study, and they found that, indeed, it was a safe technique with fewer wound and nerve complications. Guttick and others also did a level three study, and again, less wound complications than with open procedures, less sero nerve injury, and less revision surgery. Here's an example of what I would say is a technical error. The osteotomy is a little bit too anterior, and perhaps these screws were not drilled all the way, and with some of these compression screws, if you don't drill it completely, as we all know, you'll get some distraction of the osteotomy or lack of compression. So this is probably the worst complication I've seen of a calc osteotomy. This is the only one I've seen, and it's not mine, but still, I show it to you, especially if you're training residents and fellows. Don't forget about the irrigation, and when you're starting off, I would adhere to what Oliver said, and make sure that you even supplement the irrigation so you don't run into this problem, and don't overuse that burr, because the temperature can be increased, because even though Robinson and others showed that the temperature is actually relatively low, because of these low-speed, high-torque systems that are irrigated, nevertheless, you can see that complications still can occur. They recommended maximal use of the burr five cycles for 20 seconds. I think most of us probably use it more than that, but just to highlight the concern. Here's a 55-year-old with severe, rigid valgus deformity, status post-triple. So we did a revision triple MIS, and did the calc osteotomy, the mid-foot osteotomy. I thought I got a pretty decent correction, and I'm checking the post-op x-rays, and you see there's some residual instability that wasn't really noted preoperatively, because he had a valgus deformity. So the salvage for this was a limited incision approach, and basically doing a limited incision brostrom, and we were able to stabilize that quite nicely. Here are the incisions, and three weeks post-op, that's what it looked like. So lastly, I'm going to just touch on the lesser toe and metatarsal deformities. Again, you know, common complications that we see with open procedures, nonunion, malunions, of course, the floating toes are ubiquitous, depending on your osteotomy, skin complications, and possible interarticular damage. I'm quoting this from Dr. Kasson and Wagner's study. The editor rightly pointed out that, you know, the technique has potential for serious complications, and these can occur even in those of us up here in the panel. This was one of my first hammer toe corrections, and I thought I did a pretty decent job, and yet, you know, I had this sort of dysvascular toe, and what do you do at this point? Well, I kind of watched it closely, because there was not a wonderful bailout like take out your K-wire, because I had a screw in it, and fortunately, I escaped this one. But I point this out so that you guys, you know, just because you're doing it MIS, that doesn't mean you ignore the, you know, the vasculature, and you've got to keep this in mind, especially lesser toes that are contracted. This is one of the few studies that are out there with DMMOs, and again, they had pretty good results, improved AOFAS scores, and really minimal complications, even though we all worry about transfer metatarsalgia with DMMOs, as well as delayed unions. I kind of stalled, and I shouldn't say I stalled, I asked Gabriel to, if I could show these, so just so I could highlight the fact that, you know, there is a possibility of injury to the cartilage when you're doing these DMMOs, so you've got to really get your technique down and make sure you don't violate, because this should be an extra capsular osteotomy, and extra articular, not intraarticular like you see here. And also be a little weary of the dorsal malunions, although it could be corrected through, as they did here, with a repeat osteotomy and dorsal fixation. Bottom line with DMMOs, what I adhere to is, I use them, they're fantastic in the elderly patients where you don't want to make big incisions in diabetics with refractory ulcers, and I would avoid doing single DMMOs, usually if you do the second, you probably should do the third, and if not, the fourth as well. So as we've all tried to belabor, you know, it's important to establish your competence with open surgery, proficiency in the saw bones, take a cadaver course, it's real important when you're trying to kind of rethink the way you do things from an open to an MIS approach, consider a surgeon visit, and then go live. Few pearls, just select your patients carefully, you know, don't be too cavalier with your surgical techniques, preoperatively plan the location of your osteotomy, remember that implant accuracy is important, have patience, because even a simple thing like putting in a wire through a metatarsal and trying to get the bicortical fixation can sometimes be daunting. So allow extra time for your initial cases, and have plan B and C. Thank you. Thank you, George, appreciate airing some of your and our dirty laundry for everybody to see. So we're going to follow it up, Dr. Chris Miller is going to wrap this up and talk a little bit about sort of MIS anywhere, everywhere, where can we apply this to, and approaching it both combining it with open techniques and stuff like that, and where this can be a nice adjuvant for your toolbox. So, Dr. Miller, come on up. Thank you, and thank you for having me and for all the great talks. And so it was amazing how much we, I learned listening to all of you guys talk. So this will, I wasn't quite sure what to do with MRS Potpourri, so I tried to have some fun with it and a little bit, hopefully more in the fun and a little bit less on some of the science here. But this is my disclosures here. I do work with Arthrex. And we've heard a lot today about what you can do with MIS, and we've seen a lot of pictures that look like this, and even better than what I've done here. And I echo what everybody said, this is really transformative for my practice and has made Bunyan's fun again, and has made Forfoot's fun again, and all the other things. So I mean, jump on board and get into it if you can. But to talk a little bit differently, a lot of times when I've sat in these where you guys are, and we've talked about MIS, and it's all about the burr, and it's this set of procedures that uses the burr. And what I'd like to talk about is MIS is more of like a philosophy of care, where our goals are same or better outcomes as open, but with less wound complications, less pain, and a faster recovery, which I think we've seen already today. But that means that we shouldn't be forgetting about all of our other limited incision techniques, whether this is your arthroscopy, tendoscopy, MIS fracture techniques with calcaneal fractures or using the burr, using the fibular nails, tendon and ligament reconstructions, joint fusions, deformity correction, and on and on. Every time I try to figure out what are people doing with MIS techniques, whether it's the burr or the scope, this slide just keeps getting longer, and it started off with sort of two columns, I've added a third, and I'm gonna need to go into another slide in the near future, because I think every time I talk to them, I hear new things that they're doing, and new exciting procedures to try out and test out. So to try and highlight some of the other things that we can do with a minimally invasive philosophy, I'm gonna talk about three cases, one for an Achilles rupture, and then sort of a combination case in the middle, and then ending with a Charcot case. So my first case here is a 50-year-old patient, diabetes. She had bilateral Achilles ruptures nine months prior to my presentation. They tried to treat her non-operatively on the other side. She ended up major, didn't do well, had a big open reconstruction, infection, flap coverage, and then was really tentative about considering surgery for the other side, but was also very limited. So for the right side, she saw my partner, who then referred her to see me, to say, is there something we can do that would be less invasive and maybe more soft-tissue friendly? And the MRI here shows a gap of about six centimeters. So I proceeded with a complete endoscopic FHL tendon transfer. So same, anybody who's scoped the back of the ankle, you find the portals at the tip of the fibula, about five millimeters on either side of the Achilles, and you're coming down looking for the subtalar joint, the posterior aspect of the talus, and then finding the tendon. Obviously, you have to watch out for the nerve. Here, you can harvest it either as it starts diving into the sheath or in the zone two, if you look percutaneously. And I do try to release the overlying fascia from the muscle as it comes up, because when you transfer it, you want that muscle to float back and hopefully provide some additional vascularity near the rupture site. Once you've harvested it, I pass a suture around the FHL tendon, and then I deliver it out through my incisions here, whip stitch it, just like with your open procedure. And now, everything else is very similar to when you're doing a standard FHL, although you're just working through your portals. So pass the beef pin, over-drill, and then a little suture management, make sure you're passing through the right incisions, but then bringing it out. And here, you can see our post-op, about a centimeter incision for both of them, and I've restored the resting tension for the foot. And this is her three months, and she's been able to get back to walking in all of her activities and had no wound complications, which was wonderful for somebody with her history on the other side. So Dr. Jordi Vega is a real master of arthroscopic techniques in the foot, and he published his series on 22 patients a few years ago. Similar tendon gap as this one. He did say, obviously we have to watch out for our anatomy, beware where the tibial nerve is, and if you're going to try and harvest in the zone two of the tendon, you have to look directly at it and localize it with a needle before you try to cut the tendon within the sheath. And 12 of his cases had MRIs at the six to nine month, 11 of those had regrowth of the tendon on that MRI, which is sort of fascinating. And they had postulated that this is because of the increased vascularity, bringing that muscle belly closer to the scar bed. So here's my second case. So this was a 55 year old, otherwise healthy. She has severe hallux rigidus. So I decided to work with an all-MIS plan here. So we started with the endoscopic strayer, which has been another fun addition to my practice. But I use a two-portal technique with a clear cannula. There's several other devices out there that can help you do this as well, but I make the incision about a centimeter or so distal to the medial head of the gastroc. And then as you come down, you can slowly dissect the soft tissue off the back of the gastroc, and you can see that on the left. And then once you're sure that you don't have the nerve in line, you can rotate upside down, try and see it in the soft tissues. You can then take the blade, and you can cut across, which you can see doing that on the right. And so looking at the results of this, 320 patients, no wound complications, substantially lower seral nerve injuries compared to the open procedure, and an overall decrease in complication rates when you include things like scar pain, infection, seral nerve injuries in these two studies here. I have to give an enormous amount of credit to Dr. Acevedo here. He taught me how to do this and has very nicely discussed this. And this is an entire talk in itself. I'm just hitting the high points, but he helped to find a safe zone at the lateral ankle where we can pass sutures percutaneously through, has to be 15 millimeters distal to the fibula to incorporate the inferior extensor retinaculum, and then between the SPN, the perineal tendons. You can see at two weeks of post-op, compared to a traditional open, the prostrum is much smaller and with less swelling. We know this is biomechanically as strong as the open. We've described trying to augment this with an internal brace or suture bridge as a technique tip, which is just coming out. And then... Although I would probably argue for somebody with ligaments dyslaxia, that'd be a great person to augment with some sort of suture bridge construct. And then the last part of her case was in the first MTP fusion. So this is almost exclusively what I do. The exception is if I have to remove an implant or something else I have to open for. But I'll use a two portal incision, one dorsolateral and one direct medial. And I use a burr and I come in and I do a first pass to remove the cartilage, rinse that out, and I'll come back and try and generate some bone slurry. And then use the burr itself as a drill to drill some holes in there. I found the scope is definitely helpful early in the learning curve. I'd say I use about 50% of the time now because you can usually tell when you've had enough resection just based on feel and on the x-ray appearance. And I'll use a freer to try to ensure I've taken all the cartilage off. So the biggest study I've found so far is from 2016. They showed over 90% fusion rate. In my personal practice I've had one person who did not heal so far. She fell on post-op day two and broke her fixation. She was also a doctor, which is not surprising. But she ended up doing fine. And then we're also looking at how is your joint prep open versus MIS? And you can see the differences here. And that was done with only the burr and the x-ray, no scope assistance. So this is at two weeks, very minimal incision. I usually let them heal weight for the first four and then progress to weight-bearing is tolerated. And you can see my progression here. And this was her at six weeks and very pleased and was basically getting back to all her normal activities at that point, at least as far as walking goes. So my last case was a 63-year-old gentleman, type 2 diabetes, neuropathy. He started with an atraumatic anterior calcaneal fracture. You can already see on the ankle he's starting to shift into valgus. He had this exact same presentation on the other side right before we shut down for COVID the first time in 2020. And he ends up with a sort of full hindfoot, midfoot dislocation, and then involving the ankle. So we decided to move forward on this one sooner. And so we planned for a triple arthrodesis. And here you can see we're coming in with the bur, removing the cartilage on their X-ray. I will sort of press up to make sure I'm collapsing the joint down to see that I've had enough resection. And then coming in with two portals, again, for the talonevicular joint. And again, once you've done the joint prep, you can use your portals just as if you're doing it with an open procedure. You can drill. You can put osteotomes. And then here I am bone grafting with a biologic. But you can also more slice and bone graft and inject that in as well. And this is our final images here. And this is one of my earlier cases. So I wanted to sort of, here are the incisions here. Subtalar joint bilge to the CC joint for prep. And then our team shot here with our resident fellows. And then this was sort of early in my practice doing this. And I wanted to see how was my bony opposition. So he was admitted. We got a CT scan, which shows that the joints were nicely opposed. And this was at three months with solid healing on both x-ray and CT. So he was back to walking. And again, same thing here. We're looking at the all MIS joint prep. So this is done without. So here, again, in 2016, this was a look at outcomes of isolated subtalar fusions, which showed an over 90 percent fusion rate. This was combined. Some of them used the burr, some of them used more traditional arthroscopic burrs and shavers, and then 14 and 14 in this study with triple arthrodesis had a successful fusion as well. I would agree with the authors here that this really does, in my hands, relies on being able to have some... That doesn't mean that you can't still use the burr. Sometimes you can use the burr to help get into hard to reach places with the, you might not be able to access with a, with a curette as well. And then certainly as, as I've gotten more facile with this, I find that doing a subtalar fusion with the MS burr is much faster than doing it open. So thank you. for Miller, that concludes the lectures. I invite any of you guys to come up to the microphone, ask any questions that you have to any of the panelists or us as a group together. So I invite any of you guys to come up. And right now I guess I'll start with a couple of questions. So let's just talk, because a lot of people obviously are interested in this because of the bunion. So let's talk about the mica. When you are starting this, do you guys have any helpful techniques for the surgeon who now has done a couple of chilectomies, they feel comfortable, they're ready to do a bunion. Who is the patient? So, I think for a lot of people, I echo what Tori said, you know, usually the CRM, for me, I'm right-handed. CRM comes from the right, right? And so, as a result, too, I'm always standing to the left, whether it's... Right in front of you. Whereas for a left foot you're kind of reaching over the medial board of the foot again You know you get used to either way all the time, but a right foot is easier the the unless you're left-handed Unless you're left-handed. That's the opposite correct The the other one I always hear is everyone always seems to think that oh I should start with a moderate or severe bunion Because then I can shift the head more it's gonna make it easier to place my screws I showed you guys up in my talk. I mean that was maybe a mild to moderate bunion, but you Again, I think if you're angling too distal, it's going to make it even harder to shift the head. of psychology of the patient. Holly, do you routinely take the eminence off before the shift? That's a great question. Shipper talked me into it. Yeah, it's sometimes hard to predict, you know, you'll get these patients clinically you're looking at you're like I'm definitely gonna have to shift, you know, it takes them off and then you shift them over and as Oliver explained there's not a meek of that at the minimum to get that first most proximal screw, which as he mentioned that is Absolutely going to guarantee the best success for fixation long term. You got to get that bridge You have to shift the head over like no less than sometimes I might have gotten away with 60% depending upon the width of the metatarsal, but it can't be less than that You're just you're not gonna get the fixation you're looking for without it Question thanks. Um, there's a great symposium all of you quick question on the on the minimally invasive Distal osteotomy of the first metatarsal. How common is it to get? patient complaints about that edge where that distal screw just distal to that distal screw because they're Often looks like there's a kind of carve out and then an edge So, I mean I'll tell you that spike is there right so you don't see the post-op films or you have to remove that and that's, you know, again, it's a feel thing, right? and Technical note with the screws. That's why we advocate you need to start proximal because that more that second more distal screw You need that bridge to be able to take this bone off So if your two screws are distal not going to be able to take Really any of that bone off and these patients will feel it short of that chubby patient You explain but they will absolutely feel that so you have to that is part of this technique You will replace a bump with another bump if you don't do that. Thanks Like a great talks by the way Just want to have a question about the soft tissue release. How do you decide? You know, who gets a soft tissue release do you go? before or after and the other thing is, you know, if you Listen to these lappy plastic folks or Lapidus Promoting folks for them every bunion they have they get a lapidus. So how do you decide, you know, whether I want to do your Minimally invasive thing was Lapidus minimally invasive Okay, does anybody want to take the lateral soft tissue? Conversation. I'm happy In my Done I think I've got to be close to 450 now I've had one varus and it was the one that I did a lateral A Lateral soft tissue approach on I mean a lateral release. You said about lateral release. Yeah I probably do it 10% of the time you never do it before Always do it after because you'll find that even when you think it's over tension Once you do your aching that often alleviates a lot of the tension on the lateral side So for me personally, it's rare. You'll get a different answer from every one of us again. Remember this is extra capsular So if you release your lateral soft tissue prior to your shift You've inherently lost some of the stability as you shift it So it's very different than the open Chevron or a scarf where you can't even push the head over unless you're doing some of that Release if that is not going to be what interferes with your shift I'll just reinforce what Becky said if you do it before then you're really gonna have difficulty when you're doing the shift and And get these malunions dorsal plan or malunion because you can't really control that head as well So I would strongly discourage against that, you know doing it prior and I just had a comment on the medial eminence as well I think like Holly pointed out it gives you a better lever to leave that medial eminence and I can count with one hand on the ones that I've had to go back and resect that medial eminence So you'd be surprised, you know at how many you can shift enough that you don't even have to worry about that And you had your your other question was Lapidus versus the Pika Mika MIS Chevron MIS So for a lot of release I've been all over the map I'd say for me I have a low threshold to do a lateral metatarsal sesamoid release, especially in elderly patients Usually that it's scarred in their sesamoids. You need to do some form of release to allow those to de-rotate I used to be more aggressive doing a you know, a doctor release on everyone twice about doing aggressive release, so I kind of agree. You know, the difference is, I just, especially if you're doing. of that, especially when there's a different option. You know, I've had horrible flat feed. Another pearl with the lateral soft tissue release, do that if you need to. And I do it if the joint still looks incongruent and my sesamoids still look relatively uncovered. Because an aching is not going to change that. But do it before you're aching. I mean, some of the achings are very stable, but we've all had some, especially in patients with okay bone. If you've already got your aching, you put your screw, and now you're doing your lateral soft tissue release, and you're holding that toe embarrassed, you're like, please hold this aching. Right? So do your lateral soft tissue release after the chevron, but before the aching. Hello. Hello. Great talk. Quick question I had in terms of my developing experience with MIS bunions as well is, and I think a bunch of you have already mentioned on your guys' talks, is the bunion with metatarsus adductus. At least in the handful of cases that I've done, during the case I've struggled with trying to decide how far to push it, because the adductus is really preventing the reduction to make your x-ray look really pretty. So I was wondering, since you've got this symposium, if you guys would comment on, if you guys have any experience on addressing the metatarsus adductus MIS at the same time. I know there's literally nothing out there right now about this specific topic, so I was just wondering if you guys have any expert opinions about it. I'll talk about this just because it's fresh in my mind. You can do, I think you can do it either a lapidus or a proximal or a lapidus fixation or a distal. I think it depends on the mobility of the TMT joint. But in terms of correcting the rest of the foot, there's actually very well-described techniques for proximal and distal metatarsal osteotomies to address this. And I literally just had a very, very severe case that I sent out to the group chat of people who I think are European and international, actually, not just European masters. And I had a multitude of answers. And I started to do a literature search, and you can see. And I think that you have to move the metatarsus, you really do. And these are going to be oblique osteotomies, and you can do them distally, which will give you a little less control, or do them proximally, which are a little more challenging. But if you don't address the position of the lesser metatarsus, you're not going to get a complete correction. And you can do the oblique or closing-marge osteotomies of the toes to shift them immediately, but you're still not going to get that joint shift. That being said, if you have an elderly patient with metatarsus adductus who doesn't need a full correction, then you can probably just address it by dealing with the first breath. Holly, with patients that have lateral-deviated lesser-toes metatarsus adductus, what order do you consider doing it? Is it MMO, and then your proximal phalanx osteotomy? How do you go about that? That's a great question, too. So I used to fix the bunion first, but I realized that when you fix the bunion first, and then you do the metatarsal osteotomies, that shifts everything laterally, and you've under-corrected your bunion. So you want to do your metatarsal osteotomies first. Even keep, don't do anything to 5, just do 2, 3, and 4. And this is pretty, honestly, this is pretty advanced. And I think that you have to see pictures of it. It's hard to just, you know, kind of pontificate about it now. I'm happy to talk to you about it offline, but you should really fix, do the lesser-metatarsal osteotomies first, then fix your bunion, and just save the toes for last. So to piggyback on, I think, the first question on patient selection, that's not the first one that you should be doing your first one on. I wanted to touch base on patient selection again for some of these, whether it's bunion surgery, whether it's a calcaneal osteotomy. And I want George to comment on this, because, well, I guess Ettore can as well, because you guys are hailing from Florida, so your patient population's older. I struggle with this. I get these 70-year-old patients coming in with a bunion deformity, not really any hallux rigidus, and they want a bunion correction. How do you determine, do they have sufficient bone strength, quality, to support the screw fixation of a mica? So my experience, it's rare that the bone quality is so bad that the screws are not going to hold. But in those cases, I actually augment with 2-millimeter K wires for six to eight weeks, and then take them out. And that, so far, has worked relatively well. Anybody else? Honestly, I do live in Florida, and I take care of a lot of elderly patients. And I think the advantage of the MIS is that you have not violated the soft tissue, especially in the mica. And I think that that helps you kind of keep it together, if you will. The only time I'd worry is when you're actually levering it over. So you do have to be careful. I have busted the lateral cortex, which is not a huge deal, because you can just do a cruciplasty on that side. And then you basically got to manually translate it in that situation. And I have a big PA that helps me do that. Question? Thanks for great talks. I'm just wondering, the MIS bunion correction is working for the severe rotational deformity. And if yes, can you let me know any tips for correction of the rotation? Because my concern is always, like, correction of the rotation. The rotational deformity. So, Oliver, you kind of spoke a little bit about that. And that's kind of why you went more to a transverse osteotomy, correct? Yes. I mean, that's certainly part of it. Just, I didn't touch on this in the talk, but we did talk about dorsal medial sensory nerve. And the other benefit of doing a transverse ostomy, and I'll leave that topic, is just you can go mid-axial. You don't have to start more dorsal like you would normally to angled plantar with a chevron osteotomy. So again, just gives you more space. But in terms of rotational correction, so a couple things. One is, you know, most oftentimes you're going to do it by just taking the hallux and de-rotating it, right? You have to be very careful, like you would, you know, with a lapidus or any other procedure where you're de-rotating, that you don't over-supinate the toe. Because patients hate that, where they feel like their toe is kind of now pushing the other way. Number one. Number two, you can put a K-wire, if you want, into the head and just use that to de-rotate the head itself. Because obviously when you're rotating the hallux, you're doing it through the hallux itself. And really you're trying to de-rotate the head more proximally. But you can use a K-wire at the same time. You know, again, you start to run out of hands and fingers to hold everything. But that's just one other option to help de-rotate it. But usually for me, it's most commonly manually de-rotating. I'm taking a look at the head to see, you know, if I over-rotate it, does it look neutral? And again, transverse osteotomy, as I mentioned, ad nauseum, I think makes this easier. It makes a lot more sense from a rotational correction. Who here is doing a chevron? Curious. But I have a very, very, very short plantar oblique limb. Yeah, me too. I'm kind of a closet transverse. Wannabe transverse osteotomy. Yeah. Oh, it's chevron. Yeah. It's still chevron. Yes? This is a comment more than a question. I don't argue or disagree with the fact that some of the people with a bunionectomy may need metatarsal osteotomies. But I think there's a danger there where you're treating an X-ray rather than the patient. I don't think most people need that additional surgery. And I'm not saying it's wrong. I just, you have to keep in mind the patient over the X-ray. So I would say, for me, I don't, the only DMMO I'm doing in my practice, so you're aware, is really a fifth for bunionect or fifth metatarsalgia. No fixation. That's one of the easiest, quickest procedures with a great outcome and low morbidity. I don't personally do DMMOs because I want that control of the head. And when you do one, obviously you do the second metatarsal, then you have to go across the cascade. So that's just me. I don't know what the rest of the group feels like. We actually don't have to do all of them. There you go. Maybe you can speak up. At least according to Barbara P. Well, I think we are at that point that we're done. Again, thank you. Thank you to all of my colleagues here who gave some great lectures. If any of you guys have any other questions that you want to come up and ask us, we're here and available for you. Thank you.

minimally invasive foot surgery

percutaneous hammer toe correction

robotic foot surgery

endoscopic tendon transfers

anatomy understanding

careful technique

successful outcomes

complication minimization

patient selection

bone quality

soft tissue releases

rotational deformities

patient management

surgical techniques

post-operative care