Good evening. On behalf of AOFAS, I want to welcome you to the Advanced Foot and Ankle Challenging Conditions Expert Teaching Course. Tonight takes off three days of strategies to tackle your toughest cases. Thank you to course chair, Dr. Peter Mangone, along with co-chairs, Dr. Errol Bailey and Kelly Hines, for putting together such a fantastic course. Before we get started, I want to share a few housekeeping items. All faculty will share their disclosures during their individual presentations, and you can also find them within the virtual platform under Speakers and Disclosures. This course offers a total of 14.5 AMA PRA Category 1 credits. Use the tile on the platform landing page to claim CME at the end of this course. The broadcasts are being recorded and will be available under on-demand recordings on the virtual platform within 24 hours of the broadcast. All on-demand recordings will be available on the platform until October 31, 2022, and then will be available on the PRC to view whenever you like. To send questions to the faculty, please click on the Q&A tab in your navigation bar. You are also welcome to use the chat to communicate with other attendees, but please be aware that everyone can read what you write in that area. If you experience technical difficulties, please try closing your browser and logging back in the same way you did the first time. If you would like to ask a question using your microphone, please click on the raised hand icon and a moderator will call on you and staff will unmute your microphone. Lastly, we want to thank our sponsors of this course, Stryker, Treece Medical Concepts, and Ardalan. You can learn more about these companies by visiting the exhibit hall icon on the platform landing page. With that, I will turn the program over to Dr. Peter Mangone to get started. Thank you. Thank you very much. I appreciate the opportunity to be here, and I want to thank, first of all, the AOFAS staff for all the hard work that they've put in to put this course together. They've toiled and herded cats and gotten us all here, so we appreciate their efforts, and I want to make sure that we say thank you to them. Just as a housekeeping item, I want to say thank you, first of all, to my co-chairs, Dr. Ariel Bailey and Dr. Kelly Hines. They've been instrumental in getting this course going and getting the faculty. I really appreciate their help during what have been some challenging times in the last months for myself, so I appreciate that and thank them if you get an opportunity during the meeting and or at other events. I also want to thank the faculty members that have volunteered their time and their expertise to be here and to help teach everyone who is attending. They are putting in many hours of effort to try to bring presentations that can give you helpful advice as to how to take care of these more complex foot and ankle problems. And then, of course, I want to thank the attendees, everybody who's here, those of you who are also taking time from your family to be here and learn and participate. We appreciate you being here, and that's the reason we're here is to try to educate. That's one of the founding principles of the AOFAS is education, and we want to continue to provide that education at every level. And then finally, again, reiterating our sponsors, Stryker, Treece, and Ardalan. We appreciate their sponsorship and do take some time if you can to visit their virtual booths, as well as, again, if you see them at the upcoming meeting in Quebec City, please thank them for their sponsorship. So we have a fantastic faculty. We're going to start off with some talks here on bunions, but final word is just to reiterate, if you have questions, please put them in the question function if you can. If you have to use the chat, you can. You can raise your hand if you'd like, and we could try to, if there's something that has to be said, we can certainly bring it up. And we will try to answer the questions as best we can. In some cases, we may answer the questions directly via the typing function. In other cases, they may be questions that we want to address either immediately after a talk or during the discussion, interactive case discussion. And there may be several questions that run on a similar theme. And if that's the case, we may join a couple of questions together to discuss those during the case discussion section. So please be patient if that question isn't necessarily answered right away. We do want to encourage questions. The whole purpose of this is to try to encourage questions from the audience and get this to be a learning experience for the attendees. And so we want to make sure we're meeting your goals and getting you the education you need. So please feel free to send those on. All right. And as a final note, we will have a lunch breakout session on Saturday. We'll have more information about that tomorrow and Saturday morning about how that will work. But we'll have Zoom breakout sessions where you can bring your own cases and have faculty be able to review those and give you advice as to methods and techniques that they might use or information that they might be able to glean that can help you with your individual cases. So without further delay, this session is on Haloxalgis. How do we get rid of that big bump? And we have a great faculty of Dr. Michael Campbell, Dr. Errol Bailey, and Dr. Rob Santrop who are here, who all have expertise in these fields. They all have kind of different methods to go about correcting this problem. And so we're going to start with Dr. Campbell, who's going to talk to us a little bit about mini open distal chevron, which he's been pioneered. Pete, thanks. Let me see if I can get this up and working here. All right. How's that? Can you guys see that screen okay? Okay, excellent. So first off, I appreciate the opportunity to be presenting. Quite an honor and looking forward to a great course. Disclosure should be up to date if you want to check them on the website. I don't think I have anything that directly involves this. My background, I've been in 11 years of private practice. I did residency at Geisinger in Penn State. Talking about bunions, I think it's important to kind of know what's been done before. The old saying, those who cannot remember the past are condemned to repeat it. Bunions are something that have been discussed for years, hundreds of years. 1881, Reverend talked about a subcapital closing wedge osteotomy. Around 1980, Austin and the chevron kind of came into vogue and were described formally. If you think about 1980 to now, and you look at that Casio computer watch versus an Apple watch, things have changed quite a bit. When I first came out, this was a case that I did, and I'm not that old. I'm 44. Classic chevron aching, two K-wires. God, my surgery center administrator would love if I went back to doing it this way. It cost 15 bucks in implants, but it was a great experience. You know, change is a good thing. The reality is growth is painful, change is painful, but nothing is as painful as staying stuck somewhere where you don't belong. Probably about seven years ago or so, I realized it was time to change how I did bunions, because I didn't really like doing them, and I didn't think they came out that well. The reality was that's kind of when it was really being harped upon, the rotational component of it. This is actually something Bob Santrock, who's speaking in a little while, and Jim Nunley put on a really nice course at the Greenbrier every year, and they asked me to come up back in, I think it was 2017. I went back and looked at some of these little isoplate cases that I had done back at that point in time with a distal chevron and de-rotation, and I presented some of those early results. I'm talking about bunion, obviously, what are we talking about? What are we addressing? Well, obviously, everyone knows intermetatarsal angle and how it's found this angle, but really what's come more into light is the pronation angle, and that's something that technology has given us a better ability to evaluate. Weight-bearing CT has really changed our ability to look at these deformities, and actually to the point where we almost had to go through and define how we were going to talk about these and speak about them. This is going to change the whole future of bunion surgery. It already has started, but this is critical. If you go back and you look at the classic open chevron bunionectomy, it was an open procedure, no rotational correction. The beauty of this procedure is the stability that the osteotomy creates. Actually, the original description of it was to not use any internal fixation because the osteotomy is stable. You simply push the toe over and impact it and let it be and let it stick. What's the problem? Well, 80% of bunions roughly have some type of frontal plane deformity. If you simply try to pull those sesamoids over and they're not in stuff, that may not be the answer. Some people came along and said, well, maybe there's a different way that we can do the chevron, create a take a wedge out to allow not only a translation, but also a little bit of rotatory correction. Certainly, this is something that can be done, but quite frankly, pretty technically challenging to take a small little wedge out. The other thing too is one of the beauties of the chevron osteotomy is the stability it creates. Really, quite frankly, what you're doing when you do this is you're creating a sloppy osteotomy. You're creating some play so you can rotate things around. Talking about the lack of rotational correction with chevron osteotomy, maybe it's who cares? Does it really matter? We said 87% of bunions have frontal plane deformity, but that means 13% don't. For years, this is the way it was done. The bump is gone. The toe is straight. For most patients, that's what they're looking for. I think if you go and you look at this scatter plot here of pronation angle on the y-axis and intermetatarsal angle on the x-axis, you can see there's not a direct, but there's some correlation between them. With a classic chevron, you're good at correcting the ones that don't have a lot of pronation. Now, in those select cases, that may be what you need to do, but the reality of it is there is, in a lot of bunions, probably 85%, 87% of rotational deformity. Here's a little spoiler alert for you guys if you haven't figured it out already. I only use my distal metatarsal osteotomies for a small subset of my bunions. I do a lot of lapidus. If someone's arthritic or if they have something neuromuscular or inflammatory, I do an MTP fusion. I'm actually a design surgeon for Dynabunion, so I absolutely love lapidus and I do it quite a bit. That being said, I think there is a place and there certainly is a place in my practice for this procedure. That being said, there's a trick and it's trying to figure out which patients to do it on. A couple of years ago, my nurse practitioner started with me and I was trying to explain to her who and when for bunions. I pulled out this little algorithm and looking at it, I called it my bunion algorithm. My nurse practitioner would probably refer to this as my grossly oversimplified, usually what I do in most patients, bunion algorithm. In this case, what we're going to be talking about is the left side of this column, a bunion deformity, a stable medial column. We'll talk a little bit about what my definition of that is. Mild to moderate deformity, this is not something that I do for massive bunions typically. In those cases, I typically do some type of distal osteotomy, chevron if it's not a significant rotational component, transverse if there is. Again, for this, for me, I like to do this on the moderate ones. I don't do it on the severe ones. I'm not as happy with the results personally. Without the rotational correction, you are in this zone of deformities that you can correct. If you add in the rotational correction, you can really open it up and treat far more patients. How does it work? Well, you're going to make a cut and you can do a little bit of a twist without that chevron, but obviously, the trade-off with that is a loss of stability. Now, we talked a little bit about, for an appropriate patient for this, you have to have what I call a stable medial column. Now, that's something that's often referred to in the literature and also something that's pretty controversial. Doty and Coughlin have a really neat little paper discussing really what is hypermobility of the first ray. It talks about the facts and fiction and stuff. What comes first, the chicken or the egg? Does the bunion cause the hypermobility? Does the hypermobility cause the bunion? No one really knows. For me, what I'm looking for, a lack of plantar gap in your dorsal subluxation on the first tarsometatarsal joint. I don't want a patient to have a severe flat foot deformity. If a patient has a transfer metatarsalgia lesion, that's probably a time where you want to go more proximal and stabilize the ray because it's probably not stable. A negative, what I call a shuck test or a Morton's manual exam of the first ray. A radiographically unstable first TMT joint. Here's a pretty extreme example, but this is something that's pretty obvious and I think most of us would agree here. You probably need to do something to that joint to address this deformity. What's the stable medial column? I'm going to have a little video here that hopefully can demonstrate to you guys. If you look here, this is my shuck test or my Morton's first ray test. On that right foot, that first one you can see quite a bit of motion, sort of what we used to call in physical therapy school before I was an orthopedic surgeon, an empty end feel and stuff like that. The other one has nice stability. For me, I would probably both have relatively moderate un-uniformities, nothing serious, but I would consider treating the one on the left foot with a distal procedure and with that instability, probably something more like a lapidus. So we're talking about this osteotomy over here, the distal converse metatarsal osteotomy on this left side of the column. Another indication or advantage of doing the distal osteotomy as opposed to going proximal is when you have a distal, an elevated distal metatarsal articular angle, you know, and this is something that, you know, what's a case of what's old is new again. You know, I learned about this in my training and then it was Papoudis. Oh, that's just a radiographic artifact. When you de-rotate the first metatarsal, that's not something that's real. Well, it does, you know, rotation of the first metatarsal does certainly significantly increase the size of this in appearance. But the reality is they did, this is a really neat little study where they went back and they did a CT study looking at bunion deformity versus control patients. And there is an elevated distal metatarsal articular angle on Hallux valgus as compared to controls. And that's something that this has a nice little ability to address. And if there's a significant one, maybe something is a relative indication to push me towards this. The technique for this, I do a small incision at the junction of the head and the neck. I try to stay out of the capsule, any bunion I can stay out of the capsule. I think the patient does better afterwards. Typically, there's no rotation. I'll do a chevron, but more commonly I do a transverse osteotomy so I can fine tune it. I typically create my osteotomy slightly proximal to distal. You always lose a little bit of bone with any cut, no matter if you use a saw or a bar. One of the things I like with this procedure is I typically do it with a micro-sagittal saw, which I think creates a little less bone loss than using a Shannon bar. I typically make the cut perpendicular to the long axis. So with this type of cut, obviously the old fashioned stick a screw or a K wire in is not going to provide adequate stability, especially if you're going to weight bear the patient immediately and industry recognize that and respond to it. There's multiple companies out there that make implants that try to address this. The first one that I used back in that study that I presented at the Greenbrier once upon a time was with the isoplate that was actually described as for being used with a chevron osteotomy. Some of the newer ones now talk about just using a transverse osteotomy. They're all sort of twists on the same page. In full disclosure, I typically use the one in the top left corner. So that's the one you're going to see the x-rays of. You know, for fixation, it's an intramedullary plate, which provides some stability. You keep the plate parallel with the first metatarsal. You perform your reduction. And the neat part about this, like I said, is you can, you can shift the head to close the IM. You can change the distal metatarsal articular angle. And you can also correct the rotational deformity and fixate. Other tricks, if necessary, distal soft tissue procedure can be done. You know, doing a distal osteotomy, I try to avoid a big exposure with this. I typically do a limited one using a beaver blade. You can reef the capsule. There's some, this, this implant that I use has the ability to tie down to the plate. You can always use it like a suture ankle anchor. And then you can always do an Aiken. I don't know. I'd love to hear the thoughts from the staff, but I'm a big Aiken fan. And nowadays I do these using an MIS bar and percutaneous screw fixation. One of the things that's tricky is this floating metatarsal head that's created, you know, the Chevron creates a nice stable osteotomy. The purpose of this is to create a relatively unstable osteotomy. So you can have lots of the ability to correct in multiple planes. And you know, they've, they've come up with devices to try to capture the head. No different than a lot of the MECA and PICA ones where they have the similar types of things to try to stabilize the head. Quick little case I'll show here, 43 year old active female bilateral symptomatic bunion, bunionette deformities you know, well within the criteria that I would consider acceptable deformity wise, a bump that's bothersome. I did a distal first metatarsal osteotomy and an MIS fifth metatarsal osteotomy and bunionette. And you can see this is here, her healed up small cosmetic incision by staying extra capsular really maintained nice motion at the joint with a relatively quick recovery weight bearing. I don't know about you guys, but anytime I see a talk and someone says always, or it always works and stuff, and it's the only solution, I never believed them. So I wanted to throw some complications in here. This isn't my case, but this was a nonunion that occurred. And you can see the hardware broke and pulled out. There's a loss of production. This one was my case. This was someone who had a loss of fixation with significant deformity. One of the things that's nice, you know, whenever I do a procedure, I always try to think what's my bailout. If something doesn't work, do I have a plan B? In this case, what I did was I went back and I revised that malunion with a little mini frag plate, which I twisted up, extended the incision slightly and stuff. The same treatment was done for that nonunion with some bone grafting. Post-op protocol, I let these patients weight bear. I typically put them in a post-op shoe and then transition to a cam boot. Actually, my patients I find walk faster and better in a cam boot and typically like it more. Six to eight weeks, six weeks if they're young and healthy, eight weeks if they're older or bone softer, transition to a carbon fiber foot plate. And by three months, I'm letting these patients go. So in summary, why do I use this technique? Well, a couple of different reasons. One, it's easy, it's reliable procedure, immediate weight bearing, and it really gives you power to correct the deformity in all planes. Again, though, I reserve it for the less severe deformities. I think it's a smaller procedure than lapidus and that's why it has a place in my arsenal for how I treat bunions. As much as I love doing lapidus, I think these heal faster and I think they hurt a little bit less. And certainly I think it has a more cosmetic incision. I think for most doctors who haven't done a lot of the minimally invasive bar use, this is a little bit less intimidating. We're all used to using sagittal saws and drills, so there's probably a little bit less of a learning curve. And if something goes south, you have a bailout option like I showed. But I really believe like most surgeries, the key to success is patient selection. Thanks, guys. I'll wrap it up here. Great, Michael. Thank you very much. Appreciate it, Dr. Campbell. Excellent talk on that minimally invasive approach to the distal chevron with the mini open technique. And it definitely can provide a bridge point for kind of lesser soft tissue dissection, but at the same time still getting a good correction. So next up, we'll have Dr. Bailey's going to talk to us. Just as a side note, Dr. Bailey was a faculty member for myself when I was a resident. So Errol and I go way back and we had kind of lost touch for a while just with practice and everything. And this, the minimally invasive stuff has kind of brought us back together. So it's been great to get back with Dr. Bailey. And he was a great teacher when I was a resident and he remains a great teacher now. And so I thought it'd be excellent to get him involved in these courses and help teach a little bit about what he's learned and his experience with the minimally invasive technique. So take it away, Errol. All right, let me get here. And thank you, Pete, I appreciate it. My topic today is Am I Espanol? And what I really wanted to do was give some brief history on how this all began, and talk about how well it actually works, and how actually it is not nonsense. Mica, pica, whatever you want to call it, it really does work. These are my disclosures. I wanted to have fun with this talk, so this is going to be a little different. I wanted to give you the historical perspective, some insights on evolution, and support all of this with pertinent and relevant literature, and again, show you that this is something that you should seriously take a look at. This all began in the early 1990s, in the podiatry world, actually, with Dr. Stephen Isham, who put out his first paper in 1991 with the Reverdend Isham Procedure for correction of hallux valgus. It looked something like this, no K-wires, it was an oblique dorsal to plantar proximal osteotomy. Burrs were used here for the first time, and sometimes he would add a basal osteotomy for extra IM correction. Now when you look at that, yes, using a burr, no fixation, it was quite, quite primitive, but it was the new frontier. This was new. It was the first generation, and sometimes the first generation isn't the best, but in this instance, it was not. It moved throughout the world. Isham met these gentlemen in Spain, and then they took the technology to Spain and produced numerous articles and publications about minimally invasive surgery. Again, this all started in the podiatric world. It then went from there to Australia and multiple other countries. It led to many papers over time, and the most significant one on the first generation was Bauer where he looked at 189 cases, and what you see here is that this was totally non-reproducible. AOFAS scores did improve, however, this simply did not work. There was a lot of stiffness, and there was a lot of loss of correction. Later, even as late as 2020, the Riverden-Isham-Aiken procedure was still being used. Here's a study out of Foot & Ankle two years ago where 80 were done with an intermedinary nail as fixation. This was done in France by Biz, 31% complication rate, significant loss of motion, and multiple recurrences, so it was abandoned. The critics were thumbs up, thumbs down. There was no consensus on this, but overall, it was not good, so there had to be a second generation. There had to be something different, so we came with the next generation, which was the second generation of minimally invasive bunion surgery. What landed? It was the Bosch and the Seri. The Bosch was this osteotomy here, was a transverse osteotomy, and it was fixed percutaneously with the K-wire, and a burr was used. With the Seri, which stands for simple and reproducible and inexpensive, an actual small saw was used, but how did those do? Bosch did a number of papers on this. His first was in 1990, and then again, he looked at his results in 2000, and basically, these patients had significant loss of motion. There was a 9% pen track infection. They simply didn't do well. Others and other countries tried this too and got similar results, so then it came. It actually got to America, and the first significant paper here was done by Dr. Meyerson, who we all love and respect, but he had terrible results. You can see here in the red where he said he cannot recommend this procedure for correction of helix valgus, and they are no longer performing this procedure at this institution. What did that do when a person as big as Mark Meyerson says we can't do that anymore? Well, his comments loomed bigger than the concept itself. The hair outran the horse, and basically, MIS crashed and burned in the United States. It was thought as to be primitive. No one was doing it. The Europeans were wondering, what the heck is going on? Is this going to get any better? Because they were still successfully doing some of this and having reasonable results, so if you go back and you look at Meyerson and Kodaka's study, you want to go, wait a minute, 13 patients by surgeons who had never done any MIS before? What's going on with that? The Europeans just kept working. In 2005, Magnin, and in 2013, Giannini published significant papers with lots of feet and got reasonably good results, so it didn't die. They even formed an international organization called GRECMIT, which is now MIFAS, the Mentally Invasive Foot and Ankle Society, created by three French surgeons, and their mission was to promote MIS surgery to the world. It continues to offer basic science courses and advanced courses, and I and myself and Peter and Rebecca Serrato and Steven Newfield and many others teach these courses now. This isn't dead yet, so beam me back down, Scotty. Maybe we need to revisit this place again. So there came a third generation of mentally invasive foot. That's what you're used to seeing now. Piera in 2013 compared the mica to the open chevron, and Lamb in 2014 compared the mica to the scarf and found better AOFS scores, less stiffness, less pain, less infection, faster recovery, earlier weight-bearing, and less narcotics. If you look at the center screen, you'll see the early third generation where the screws were actually mid-shaft and distal. What you're used to seeing now is where these screws are placed initially at the base of the first metatarsal near the TMT joint. This actually could be a fourth generation, but we still call it third. So when did it get here? In 2017, these folks to your left, that's Holly Johnson and Rebecca Serrato and Peter Mangone, our host, is in this room, and sitting is Joel Benoit, and I cannot remember if George Acevedo was in this room or not, but they brought this here. They opened up a huge can of worms at this AOFS meeting. They were in the hot seat, because no one here was doing that, and even when you look at these x-rays, you see that they are very odd-looking, and it's not something that you oftentimes want to show your patients. So when surgeons here saw this, they were not believers. However, this crew stayed with it, and their belief led to the launch of the third generation here in the United States. Currently, there are three US leaders in MIS bunion surgery, Stryker, Arthrex, and Novastep. They all have very nice targeting guides here that I've shown, which all make this procedure much easier to do. The learning curve earlier was more difficult, but now with these particular devices, the surgery has been made much more reproducible and much more simple. And this is what you're going to get. The osteotomy is made. Here's one of my patients, Priya. Here she is at three weeks, then later six weeks, 12 weeks, and 20 weeks. You can see what actually happens to this osteotomy with the correction of the bunion. So let's talk about some specific things that I know you all want to hear about as it comes to this particular procedure. What about large displacements? Here's an article out of Foot & Ankle where a significant number of patients were done with IM angles averaging up to 17 and almost 18 degrees. Now that's something that you would normally do a laparoscopy on, and it's probably something I would too do a laparoscopy on. But nonetheless, there are still some patients who are elderly who you want to walk right away and who you can't put in a boot or on a knee roller. And so this is something even in large IM angles that you can sometimes use. It was 86% satisfaction rate, but there was a 7.5% recurrence rate. So you can do this in extremely large IM angles, but this is probably a more appropriate place for the laparoscopy procedure. What about anatomic structures that you can damage? Well, everybody's worried about the burr cutting a tendon. That's incredibly odd. But what about that dorsal medial cutaneous nerve? Here was a study by Capel and Foot & Ankle that took 40 cadaver feet. And what they saw was that there was a learning curve here. In 20 of the untrained specimens, six times the dorsal medial cutaneous nerve was actually injured. But in surgeons who were adequately trained, this only happened once, which was about 5%. The lesson here is this can be done, but you have to be adequately trained. And the key is rotation of the burr, not translation of the burr. That's when you actually get anatomic structures. The issue of flat cuts versus true chevron cuts, Acevedo and others took 18 feet and did a biomechanical study looking at the transverse versus the chevron. We've all thought that the chevron was more biomechanically stable. This study found that this was not necessarily true, and testing showed that there was no significant difference. What about other anatomy? Where do I make my cut with the burr? It's an extra capsular cut, but where is that actually? Where does the capsule stop? Rebecca Serrato and Chen looked at this in June of 2020 in foot and ankle with 10 cadaver feet and measured the distance from the central metatarsal head to the origin of the capsule approximately. On the dorsal side, it was found to be 15.2 millimeters, and on the plantar side, 21 millimeters. If you're at least 20 to 21, 22 millimeters away, on average, you're going to be doing an extra capsular cut, and you're not sacrificing any of the arterial structures. Speaking of arterial structures, what's the blood supply anyway, and what about the issues with abastral necrosis? This is also very rare. You can see that here there is a dorsal lateral artery that comes in the inner space, and there are also medial arteries as well, and they all form a plantar lateral complex extra capsularly, and then the blood supply enters from that complex. So technically, if you're 21, 22 millimeters away, whether it's transverse or chevron cut, you should be okay. And studies that I list here have looked at that and shown that there's no increase in abastral necrosis with MIS bunion procedures. Myself, Gary Stewart, and one of our residents, Derek Rindler, are currently in the middle of a study where we're looking at the first metatarsal blood supply, and we're looking at chevron cuts versus transverse cuts to see if there actually is any increased risk to the vessels with any particular cut. We took 10 feet, two fellowship trained surgeons, did five transverse osteotomies and five chevron osteotomies, and found that our average cut when we eyeballed this was 23.9 millimeters from the center of the head. When we dissected all of the anatomy of the cadaver feet, all blood supply was intact, which would make you lead to the conclusion that there would be no increase in ABN. How do they do overall? There are numerous papers. Here's one from Newfield where he looked at his first 94 and had a 94% success rate, an incredibly low reoperation rate. Typically when you have to go back, it's because a screw has loosened or is backed out slightly, and sometimes you can get a mild skin burn and you may have to do a mini debridement, but otherwise these do extraordinarily well. What about hypermobility? Can you do this here? Well, this is something that is evolving. I kind of figured out how to do this on my own. I don't recommend this for everyone yet. There needs to be a system that comes out that helps the surgeon with this, and there will be one out soon. However, Renoir and Redfern have shown that you can do this, and their study in the clinics of North America where they looked at 70 feet, they had a 95% good to excellent result and only four non-unions. Bottom line, what's the truth here? High satisfaction rate with MIS bunions. They are higher in terms of cosmetic results. You can work on these right away. There's a faster post-operative recovery, shorter OR time once you figure out how to do it. The complication rate is lower. Why not? Maybe we are on to something here, but I have to admit, and the reason I'm presenting this way is because when I first saw this, I was not a believer. I was like most of us out there in the world who were doing bunions because only a small percentage of bunions now are still done with minimally invasive techniques. I saw this first in Mexico many years ago, and I simply was not a believer. There were wires flying everywhere, odd-looking healing bones, and I just said, this has to be nonsense. But then I learned something. With all great change and innovation, it tends to always come from a pool of nonsense. Something that may sound utterly ridiculous, there's always something there that makes sense. What we have to do is find that particular thing. Here are some examples that I know you can relate to. Can you imagine this guy's teachers when he was 13 and Paul Allen and Bill Gates did their first software program? If you told their teachers that, hey, this guy one day is going to own a company that's going to put something in everyone's house or desktop or desk and be one of the richest men in the world, we all would have said, and the teachers would have said, no way. That's nonsense. What about this guy? Imagine that phone call when he called home to tell his parents he was leaving Harvard undergrad and start his own computer company. Can you imagine what was said about that? That had to be nonsense too, but it wasn't. What about this guy who says he's going until he's 48 or 50? Is that nonsense? I don't think so. He may just be able to do that. You're wondering what my point is. Well, in medicine, it's the same way. Can you imagine this conversation when Professor Katagi went to his urology partners and said, I wonder if I could use that 7.3 sistascope and put it in a knee. They probably looked at him and thought he was crazy, but that was the beginning of arthroscopy as we know it today. Same is true here, Lord and Merat. That's a total ankle replacement. That's the first total ankle replacement, which was an inverted total hip prosthesis with a cemented cut in the talus. And now look at what we're doing. So was this nonsense? I don't think so. And the best of all was Charlie who took something like the total hip replacements, which had been abandoned totally and revived it and almost won a Nobel Peace Prize for it. And I want to quote Charlie. After he'd done all his work, he said the cart had been put before the horse. The artificial joint has been made and used, and now we're trying to find out how and why it fails. That is very similar to what happened with minimally invasive surgery. We've got this now. We figured this out. This works. This is not nonsense. Are we completely there yet? No. It's the stuff that we need to get better. Yes. And things are evolving. It's still controversial. There's still haters. They're always there. And my favorite therapist says, no matter how flat you make a pancake, it's still got two sides. So there are always going to be those who disagree. But what we're asking you to do, those of us in the MIS world, is to unleash your inner Superman. Take a good look at this. Don't be a skeptic. Join myself and others like Captain Kirk, and boldly go where no one has gone before. And in all fairness to Dr. Myerson, he is now the consulting editor of minimally invasive surgery in The Foot and Ankle, the first edition and the second. He came along too, and many of our thought leaders in the world now were fellows trained by Dr. Myerson. So kudos to him at the end of the day. Thank you. May your MIS journey live long and prosper. I also would like to let you guys know that soon to come, if you're interested in this, there's going to be a North American version of the minimally invasive foot and ankle society started by Pete there and George Acevedo, Rebecca Serrato, Holly, and Alistair. We all get along incredibly well. They're all from different companies, and it doesn't matter because everyone is about furthering MIS surgery in the United States. Thank you very much. Thank you very much, Errol. Excellent talk. It definitely characterizes the journey that's been ongoing. Speaking of a journey, I remember Michael Campbell alluded to the Greenbrier and being at a meeting. I remember Dr. Santrock asked me to be there and said, hey, can you talk on this arthroscopic brostrum thing? I got up and I spoke about my passion for lateral ligament reconstruction. Bob got up and he was like, I get energized because when Pete talks about that, this is my passion, is this three-dimensional correction of a bunion. I really have to give a lot of credit to him because at the time, we still were working in a two-dimensional world of x-rays and IM angles, and really, we're still in that same universe. really what Bob Santrog's done is opened up a whole new universe that really has changed the dynamic and what we all talk about when we talk about bunions and moving toward three-dimensional CT, weight-bearing CT, all those sorts of things. I think really a lot of the credit revolves around the work that he's done. And so we'll hear him talk today about the work on lapidus procedures and how it's fundamentally changed the bunion world. Thanks, Pete. Dr. Bailey, it's an honor to follow you. I will agree with almost nothing you said. Not ironically, I think you might know. I'm 100% supportive of MIS as a principle. What I have a problem with is cutting the metatarsal when it's a straight bone. And although the MIS progress is going to teach me a lot how to do bunion surgery through a small incision, I'm very grateful and will apply those principles as I evolve. I'm probably going to refrain from cutting a straight bone. So my topic is to try to convince you to consider that the TMT joint is the place to do bunion correction. And I'm making the case for the first TMT joint triplanar corrective orthodesis. I have disclosures here that are probably pretty relevant. As most of you know, where I work, where I developed with is with Treece Medical Concepts. My real driving message here is to think about bunions from a point of view of the etiology and pathogenesis. The last time this was written up in the literature for orthopedic surgeons was in 2011 in JBJS. And there is simply one line about frontal plane rotation. I believe we have just really very much ignored what a real bunion is. A traditional thought about bunion is really driven by the intermetatarsal angle. And so why would we have 130 different options to try to correct a bunion, including the new MIS osteotomies, when we don't have a way we're correcting the intermetatarsal angle. Every bunion from the time I was trained as a fellow to today has areas of deviation in P joint, which we focus on and call it Hallux valgus. And the TMT joint is always deviated as well. And now I've learned that those are pretty much triplanar deviations. Hallux valgus is a rotational deformity, whether we like to believe it or not, it's there at almost the majority. I'd say that the average is at least 87% in some studies, and it's an average in some studies as high as 22 degrees. That is what Mike pointed out earlier, it's a very compound problem. And if we leave behind that rotation, we're gonna leave behind a moment arm on that metatarsal and sesamoid complex, that's gonna push the metatarsal back into promisvarus, which will lead to Hallux valgus recurrence. And why does this happen? Well, there's differences in the morphology of the TMT joint. We've had this alluded to in the literature, but now I'm starting to do some additional studies where we look at the surfaces of the cuneiforms, and you can see here's two different cuneiforms have gigantically different geography, leading to probably different mechanical stability of that TMT joint. And I believe that this is what leads us to necessarily treat bunions at the TMT joint. And so this is the common thing we see by correcting all three planes at once, you can get that correction back aligned, looking more anatomically. Early weight bearing is a key as Mike and Dr. Bailey has said, which is very much the importance of why fixation needs to be part of the discussion. As we can see with those other two talks, early weight bearing is principle of the recovery. I agree, we have adopted a principle of biplanar planing, allowing for this quick and early callus formation. And we also indeed weight bear our patients in this scenario immediately as well, along pretty much the same timeframe that Dr. Campbell outlined. We are also moving our patients to a shoe as quickly as possible, and sometimes earlier than the six week mark. When we tested the biplanar plating, which is essentially functions like an internal external fixator, it was comparably to a standard anatomic locking plate designed for Lapidus, stronger, to an ultimate load and cyclic load. And then we made our second generation of plating, we improved upon our first generation plating quite a significant bit as well. Dialing in the right amount of stiffness, but keeping some flexibility is something that's key to allowing for early and rapid weight bearing. So how's it function in the real world? We see that our first generation, we were able to, with 13 month follow-up, see a 97% maintenance correction with this technique, 1.6% non-union rate. And just the last month, we were able to see our nearly two year follow-up published with 99% maintenance or correction on the second generation plates and a 1% non-union rate as well. So we're really dialing this in, getting consistent and reproducible results with a triplanar correction at the first TNT joint. And I really think we're addressing this from an anatomic standpoint more appropriately, even better, a more pathoanatomic point of view. And this is the type of results we get. So if we're comparing to MIS, we're all blessed to work as foot and ankle surgeons where scars about the foot and ankle disappear relatively quickly and easily. Now let's get back into this. The metatarsal is straight. The core is always the same at the TMT joint. And so why are we addressing this in different ways? All bunions have this core where this first TMT joint is deviated. It's deviated in three planes. It's metatarsal is a straight bone. It has a plantar curve, but it doesn't have a transverse plane curve. It's just deviated in three planes. And so when we make an osteotomy, we're actually going to create a new cora. And in a lot of cases, we have left the previous cora behind. Now throw in the fact that this is three-dimensional. And as I mentioned before, Kim or her study, she showed with a weight-bearing CT scan that there's rotation present in 87% of bunions and 22% average on some studies like Dr. Dayton's study. I think that's probably a little bit overestimated today. We're probably talking more around the 15 degrees on average today. But this has been present in the literature for a long time. Look back to 1956, where pronation was mentioned as part of the Hallux-Valgus deformity. And we have very important members of our society and contributors to our research who have mentioned it throughout our history, but we failed to act upon it until very recently. Rotation is the key. When you add in rotation, you explain things like Mike was trying to understand about the MAA. He even said, well, that's just pronation. I agree. It is just pronation. You're just looking at the plantar lateral condyle. If you actually talk to an embryologist, they would actually look at you a little bit cross-eyed saying, why do you think cartilage is going to move later in life? It doesn't do that. That's not how that works. So when you look at this 10X recurrence rate when there's incomplete sesamoid reduction, that meaning when they are still subluxated around towards the first web space, or with 12X recurrence risk when the lateral round sign or that what we can perceive as DMAA is not reduced. Those are both frontal plane rotation deformities. If we look at the tibial sesamoid position as a predictor, and you can say both of these have a high tibial sesamoid position of five and four, but when you actually look at it in the frontal view, you can see that they're actually tibial sesamoid position zero. So what is this? This is a rotational deformity. This is not a subluxation or something that would need capsular invocation. Rotation has a dramatic effect on alignment and therefore a dramatic effect on correction. And this is where I start to go into how I do my corrections because I'm moving everything back to where it once should have been and within line with the biomechanics of how the foot will function. The result of D rotation eliminates DMAA and this or PASA and tibial sesamoid position all at once. And when we look at this over and over again, we can see that the tibial sesamoid position when corrected with a triplanar correction, we can reduce that tibial sesamoid position and the DMAA to normal numbers. And so this is my argument that you don't need a head osteotomy to change those alignments. Now, if that's not enough, let's talk about how the morphology of the TMT joint is different. It's been sitting here in our literature for quite a long time. When Lapidus produced a review of his, in 1960 of his work since 1934, he compared this to the anatomy of the non-arboral and arboral monkeys. So when monkeys and primates started walking on the ground bipedal, he noticed that their foot changed to look like our foot and that the monkeys that lived in trees, they still used their foot as a hand. And so they looked more like what a bunion would look like. When you look at this from an anatomic standpoint, Latimer produced a study showing that the early homo sapien and the modern homo sapien had a change as well, where there are multiple facet, those bipedal animals opposed to the arboral animal, which had a much more ball and socket joint. And then Mason studied patients who had bunions and found that they were also prone to this. A unifacet, first cuneiform versus a trofacet in a normal patient. Doughty and Coughlin mentioned this in their study as well, that continuous joints, there is a relationship with the deformity. So again, another completely continuous joint, smooth joint is probably representative of the morphologic difference that may spur on how it's balanced development. So what if we compared, what if we assumed that that meant that this joint is unstable and we assume the association is about 80% of people that have bunion have some. I looked at this myself, symptomatic patients requesting bunion surgery. So they were already symptomatic with bunions. So we signed them up for TMT joint correction and harvested the joint and analyzed it and found that 82.3% of these patients had the unstable type of facet morphology. Now that's not enough. I need to keep looking at this because that's eyeballs. And so I still have harvested another anatomic set of 20 TMT joints. I had 10 surgeons look at the joints and then make an analysis. We're looking at these results, but we also scanned them with LIDAR and we're looking at differences between the TMT joints and based on their, and then comparing them to the radiographic assessment prior. So as I get closer to the results of this, I'll be reporting it to you to see if indeed this dataset proves out to be something interesting. Right now, anecdotally, I can see that patients that had metatarsus seductus look a little different morphologically. These will be painted with topographic markers eventually, and I'll be able to give you some sense of the differences between these types of facets. And they're still in the early analysis. So I would argue that bunion is essentially a midfoot instability. And when you see this, it's hard to unsee that if we would have just called this midfoot instability in 1870, when Huter coined the term, how it's found this, I think we would have went down a far different trajectory. So if you don't wanna believe that it's midfoot instability, you still only have three ways to correct a bunion. You can go distal to the TMT, proximal to the TMT, or find someplace else in the foot that starts all this deformity or instability. And it really is, in my opinion, the reason why we have a TMT joint. So God gave me something to do and allows me to correct bunions. But there are a lot of myths about correcting bunions at the TMT joint. When we look at the Labrador's procedure, again, we escape pathology at the MTP joint by its name, by the nomenclature, but it's really the TMT joints involved in every one of these. Now it may not be severe, it may not be rotated at the TMT every time, but there is an involvement at the TMT. Sacrificing of a normal joint is always what I'm arguing against. It's not normal. I believe that the vast majority, at least 80% in more than one study are showing that these joints are not normal, and essentially unstable, at least in the frontal plane. You know, there's a procedure is too difficult to reproduce has a high non-recurrence rate. Well, again, those days are gone. I mean, these surgeries are easy to reproduce and they don't have this long project of learning curve. This is a relatively easy, straightforward way to treat the binding deformity, and they apply to all binding deformities. Traditional osteotomies have better results. That's not true either. Those results are in the studies of 30 to 70% failure. Now I'm not talking about new MIS studies. Those are early yet. We'll have to see how those play out. But the recovery is also noted to be exceptionally onerous. Well, again, that's not true. We have the exact same recovery period. So let's look at non-union recurrence rates. Non-union rate, 10% reported by many authors. I could see it got down to 2%. Lock plating reported by Scranton was a big help. And then if you look at recurrence, it's the same. In 2018, it was associated with incomplete sesamoid reduction, therefore not rotated. You would get increased. Same with DMAA. You can see it over and over. There's reasons why you got a recurrence was actually never correcting the frontal plane. What about Paul Lapidus' era? What did he have? He spent, they spent a week in the hospital, of course. So surgery back then, very weird. But look at that. He would weight-bear his patients near immediately. It's because he had relatively semi-rigid fixation. He didn't have big rigid screws criss-crossing. And what we see today, we see in patients with an immediate weight-bearing protocol with a high success rate. We preserved the MTP joint. And if you look at this patient here who had one surgery done triplanar, all right, on the left, and one surgery done uniplanar, transfers plane only on the right. By leaving those sesamoids not articulating in the right spot, we destroyed the MTP joint. So by stabilizing in a triplanar fashion in the correct orientation, that MTP joint is preserved. You say, well, you can't go back to sport. Well, we surveyed the entire AOFAS and they told us, yes, you can. And actually there's nothing in the literature thus far that says that patients that have a TMT joint or an arthritis cannot return to full sport. And we have many patients who are collegiate and professional athletes doing everything from triathlon to softball catcher to high-end impact sports. Biplanar plating is a relatively new concept that I didn't invent it, but it is something that has an extremely high success rate. And it's basically using the AO principle that secondary bone healing comes on rapidly as callus formation, but not making it absolutely too rigid. If you make things absolutely too rigid, you're actually creating a higher scenario for non-union. If we wanted to weight bar our patients immediately, we had to have a way to do it with immediate weight bearing and that required a construct that was stable yet flexible. And that's what we got with this. And we see a very high union rate with this type of a fixation in paper after paper. And so it is well accepted. This was first, I first saw this article from Duke University in the 1990s, I believe. So again, 97.44% with progressive healing on seroradiographs. And ironically, the actually last couple percentage points may have never looked like they're healed, but none of those went on to any kind of non-union revisions. So Justin Ray was one of my residents who helped me put together this paper where we saw that our first results, which was 13.5 months, first generation hardware, and this is what we got. So clinically, these people do well. They actually have a boot walker on for six weeks and they return to sport at four months, but they're all walking immediately. In the protocols, it was multi-center, was an average of 10 days. My facility was immediate and some facilities was up to two weeks. So that's what we ended up with a consistent result showing correction can be maintained with an immediate weight bearing. You know, we get, I see the MIS pictures and I think you don't actually make the foot any more narrow, which is one of the aspects that I think bunion patients would like is a foot shoe wear to be more accessible to them. And osteotomies all make the foot wider. And we know from a lot of our MIS colleagues that cranking open the proximal fragment to stabilize the TMT joint is part of the process, which makes the foot wider. And if it needs stabilized, why not address it anyway at the TMT joint? But with this type of procedure, we can see almost a centimeter of foot reduction, which is an entire shoe width sizing reduction. And this is an extremely pleasing thing to patients to see that none of these patients have medium eminence resection by procedure. So this is the result we saw that this was a bony reduction of one centimeter and a soft tissue reduction of 0.7. Now I always get criticized that I'm doing a wedge resection. So we get shortened, right? Well, we get 2.4 to 3.06 millimeters of shortening with the resection that we perform. And in this case, we had no cases of metatarsalgia. We have to monitor this as part of our ongoing five-year study. And what we found is that so far, no cases metatarsalgia up to 208 patients in that study so far. And they are not allowed to have lesser toe surgery to be in that study. And our shortening of that small amount is probably just getting to the subchondral bone, which is described to be 3.1 to 7.5 millimeters in some other cases, but there's at least 2.5 millimeters of subchondral bone cartilage in that area. So we're getting to where the fusion needs to be anyhow. And I know some cases they just correct, but they correct and pulverize the bone till they get to the same place that I get to with the saw cut. So where do we end up? Triplanar correction is what we need. Etiology and putting the foot back to its binomechanical position of function is what we need. And it can be applied at the TMT joint or the MTP joint if there's arthritis or even metatarsus adductus if needed. And so it's applicable in every case and it doesn't destroy the reconstruction ladder as Scott Levin would say. It leaves and preserves your options as opposed to deforming bone that is not appropriate. So our algorithm like Mike has, a little bit more complicated, but you might see if you have arthritis, it goes down to the arthrodesis side, but we also are getting to the point where you saw on the previous slide, correcting the entire midfoot. So I hope that you might take away that the TMT joint is where the bunion is originating and where it should be corrected. Thank you. Great. Thank you very much. I appreciate that, Bob. Excellent talk. And like I said, it's been great work that you've done over the last eight to 10 years to expand our knowledge and really start to talk about how do we deal with the triplanar component of this deformity, which as you said, has been kind of mentioned in the past, but never really dealt with. So I appreciate that. All right. So we've got about 20 minutes or so before we'll start to transition. And so we've got a couple of case studies. I'll pull up my screen, but I also wanna just quickly, there's one question here about MIS and Dr. Bailey, one of the attendees asked if there are patients that you would not recommend MIS for fixation stability for the potential of late fracture, whether it be a high level athlete or some other person, is there a criteria that you use in terms of identifying, hey, is this a good patient for an MIS type procedure or is there an issue either with their activity level afterwards or their bone quality beforehand or something that makes you say, well, wait a second, I don't wanna do this procedure outside of an IM angle issue or things like that. The one area I've had some difficulty are elderly females and there's mid to late seventies with osteoporotic bone and large angles. That's probably where I would probably go to an MTP fusion or something like that where I can weight bear these people earlier. And which is why, and so what has happened is when you're reducing the metatarsal head and osteopenic bone, you can blow out the medial wall trying to get your reduction and also your screws may cut out. So elderly people with osteopenic bone is one area where I have significant concern. But in terms of young athletic people, no problems whatsoever. I'm not sure if that study has been done about how these do and athletes, but I haven't had an issue at all. Yeah, just personally, I've had patients return to running. I had one patient run a 5K at three months out from their MIS procedure and did fine. She was kind of about a 45 year old woman who was a big runner and did fine with that. But that was not necessarily with my blessing. That was one of those where she told me when she came back. But yeah, and I think one thing to also mention, we haven't touched on here in the advanced courses, there is a role for, I think Dr. Campbell mentioned it, there is a role for MTP fusion and Dr. Sandtrak kind of touched on it as well. There is still a role for MTP fusion in hallux valgus correction. Obviously you might not want to do it in a 25 year old, but certainly in my elderly patient who has osteoporotic bone, where I'm concerned about fixation of multiple different aspects. MTP fusion is a very effective method to get a hallux valgus correction. And for many patients in my neck of the woods, I live in a retirement zone of the world, they are, even though with success rates or bunions are better, the certainty, if you will, the predictability of an MTP fusion is a very desirable thing for some of my older patients upwards of 75, when they get past 75. So they don't want to have to have a possibility, even a 5% chance of a recurrence, they'd rather just have the high index of that. A question for all the panelists, would you consider doing bilateral, is that for MTP arthrodesis or TMT? I'm going to assume it's TMT. Would you consider doing bilateral arthrodesis, Dr. Santrock, in terms of your first TMT arthrodesis, do you do any bilaterals and let them go right away? I have done it, I don't favor it. I don't favor bilateral surgery in general. So that's probably a bias that starts there, but it's certainly mechanically good to hold up. In my opinion though, I want my patients pretty mobile pretty quickly and bilateral tends to put people down differently than a unilateral. And so my surgery deploys walking as part of the healing process. So I don't recommend it with the biplanar plating because I think it slows them down, therefore potentially slows down their recovery speed, in my opinion. Gotcha. And I think the follow-up on that, somebody was saying, it was actually, they were talking about the MTP joint. I'll just comment, I certainly do bilateral MTP fusions at times. I think like Dr. Santrock alluded, what my, it's not a linear issue in terms of immobility. As I tell patients the first three to four weeks after any bilateral foot procedure is a fairly intense recovery. And most of my patients that I do bilateral procedures on fusions, whether they be MTP joints or TMT joints or midfoot, whatever I happen to do, even if I just do bilateral forefoot procedures, they usually come back saying, boy, that was a little bit more than I thought it was gonna be. So I think you can do it, but I would caution because my experience is that one side never does quite as well as the other, cause that's the side they cheat on to kind of get around. All right. I'll pull up the cases for a second, but I wanna ask a couple of questions while we're pulling that up. Let me pull up my PowerPoint here, make sure I'm on the right slides here. But, all right. Hold on a second. I'll share my screen for the PowerPoint. All right. Everybody see that okay? I'll pull it up on this. There we go. So a couple of questions for Dr. Campbell. Do you find that you can routinely with that, you know, in a minimally invasive kind of extra capsular osteotomy, oftentimes we can rotate the sesamal, we can rotate the entire head and in times have to do a slight lateral release, but usually can de-rotate that head to get the sesamoids corrected. At least that's been my experience. Do you find that with this intra-articular, you know, osteotomy approach when you have to do it, are you able to correct the sesamoids without doing a lateral release most of the time or do you have to still do a lateral release and kind of reef the capsule? So I think there's two different types. There's the, you know, true sesamoid subluxation and then there's, you know, Kim describes this pseudo subluxation, where really what it is is you're seeing what looks like sesamoid subluxation from a pronated metatarsal and they're actually sitting in the sulci where they're supposed to be. For those ones, I would definitely stay extra capsular and just use the metatarsal head to put the sesamoids, you know, keep them where they belong. For the other ones, for the other ones, reefing the capsule is certainly an option and trying to, you know, pull them over. That I think has to be done in conjunction with some type of limited lateral release. You know, in my experience, there tends to be a pretty big age component with that. You know, the younger patients are more flexible and usually you can get away without doing that lateral release. But certainly I, you know, in my experience, what I try to do is stay out of the joint if possible. So I rotate the head first before I just dive in and start releasing things, unless I know it's a done deal, say, you know, 75 year old patient or something like that. Right. And on that same track, Dr. Santrock, so how often, I find that some of these more severe hallux valgus deformities with the very pronated, you know, toe, severe hallux valgus angle on an, you know, an AP type x-ray, at least I've found it extraordinarily difficult sometimes to actually get the full MTP joint back and corrected, right? I can get the first ray corrected with a lapidus derotational type osteotomy, but it's like the plantar structures are almost shortened because they've been in that valgus position and rotated position for so long. Are you routinely doing a lateral soft tissue release when you do your lapidus or are you, or is it how, what percentage of the time, or is it just, you just stretch it out with a little bit of time and effort? You there? Did we lose Dr. Santrock? Look, it looks like he's joining back. I know he's- Oh, okay. All right. Okay. All right. How about Dr. Bailey? Cause you were doing MIS at times. Do you find that you need to release the distal soft tissues when you do your lapidus corrections in those contracted ones? Yes. I do a lateral release on every lapidus that I'm doing, whether it's minimally invasive or open. I find that I just simply can't get the full correction that I want because of the lateral soft tissue contractures. So I'll go percutaneously under the EHL laterally, sweep through and see what I get. And if I don't like that, then I'll try to get in between the sesamoid and the plantar aspect of the first metatarsal and sweep down the shaft there a little bit. It's a little dangerous. I don't ever quite know what I'm getting when I do that, to be honest, but I have not had any problems. But I always, in fact, I do that first. That's the first thing I do is I'll do a lateral release and then I'll do my procedure. And Dr. Campbell, there's a question here about constitutional hyperlapsity. You mentioned that briefly in your talk. Is that a patient where you're gonna deal more with an MTP fusion or would you be, obviously you're gonna deal more with some sort of a bony type correction component, but you lean more toward doing an MTP fusion in a patient who has hyperligamentous laxity like Eilers-Danlewis or something like that to get the correction or do you just lay crepe and tell them, hey, this has a potential chance of coming back and if it comes back, then we'll do the fusion later? That's a good question. I always find that diseases like that tend to be a spectrum. And I think if someone is really ultra flexible, a lot of times that's a component that they're gonna have a flat foot deformity as well. So that would drive me towards wanting to address the first TMT joint to restore the arch stability. Potentially that's a patient who gets a double arthrodesis where you also fuse the great toe or if you do the lapidus, you certainly lay the crepe that there's a recurrence chance. To go and do the first metatarsophalangeal joint with a flat foot, I don't think that's a winning choice either. I switched back off my share screen for a second so I can see everybody and ask questions, sorry. Another question about, and I think, Rob, what are you doing as far as your weight-bearing CT? Obviously not everybody has a weight-bearing CT. Before you had weight-bearing CT, were you getting axial sesamoid views on everybody? Is that how you were measuring rotation? Or was it just something you were looking at intraoperatively? Yeah, we changed our protocol to do an axial sesamoid X-ray with all of our new patient foot complaints. Certainly anybody heading towards bunion surgery, we would have that as well. So that's a standard foreview now. Our foot X-rays are foreview and that's just part of our standard protocol. So that is, doesn't matter what their foot complaint is, we're gonna get that view and look at that axial rotation. Weight-bearing CT has been a wonderful adjuvant. I completely enjoy having a weight-bearing CT. I've learned so much from it. I have a protocol where I try to get a weight-bearing CT on every bunion patient that I can pre-op and certainly get them post-op. Getting post-op has not been a difficulty. As we know, there's literature there to support arthrodesis recovery analysis with weight-bearing CT, with any kind of CT. That's the studies done by, you know, Carol Jones and Mike Coughlin back on looking at the sub-tail joint. So I've had no problems getting weight-bearing CTs approved post-op. Pre-op, I do have to fight a little bit once in a while. And then it's also a little bit of the inconvenience of patients traveling very long distances because I can't get them pre-op, sometimes on the fly. So, but I use the, I do believe this is midfoot instability and I do believe this therefore deserves to be looked at and that's my justification in my documentation. But if you don't have a weight-bearing CT scan, I would highly encourage you to look at them and see if you can incorporate that in your practice. I believe it's where we're going in the future, Pete. Now we can get some of the Insta x-rays off of these things that are almost the same quality as our digital x-ray. It's not quite there, but it's getting very close. And I personally have, I have no relationship with CurveBeam, but that's the machine I've been using and have had, been pleased with. I've seen a couple others and they look nice. I think Dr. Campbell has it as well in his practice. I would echo those sentiments a hundred percent. Yeah, I have one in my practice. And what I would say is I think we're, you know, I've been in this business a while. I know Dr. Bailey and Dr. Santragon are all kind of, if you will, on the older end of the spectrum now. Mike's still pretty young, but basically when we, I liken this to the way the pelvis imaging has evolved, right, it's a three-dimensional imaging. When we first started, everybody, when I was a resident in 1993, everybody got, came in, had Judae views, inlet-outlet views, all that sort of stuff. And now nobody gets those, right? You come in, you get a pelvis CT, right? That's what you get because that's what you can see immediately, you can get the information you need in one fell swoop. And I think that that's where weight-bearing CT is gonna go, I think over the next 10 years, we won't be getting regular x-rays on a routine basis. I think the cost will come down. The actually, the radiation is actually less than five view, five views of the ankle, you know, two views of the ankle and three views of the foot. And then if you add a fourth view in there with the sesamoid view, you actually, the amount of radiation is actually less to do one of the weight-bearing CTs. So I think we'll find that that will take over because more and more of our life is revolving around three-dimensional corrections of these problems, whereas traditionally they've been viewed in a two-dimensional manner. And so I think it evolved that way. And a lot of the credit needs to go to Alexei Barg, who, you know, was leading the way with a lot of this research and we need to honor him by picking up that research and continuing on. Continue, yeah, exactly. There's a couple of individual questions about the role for a medial opening wedge, medial cuneiform osteotomy to address like a short first ray. I have no experience with that. I don't know much about that. Anybody on the panel have any experience with that concept? I do not, Pete. I don't have any concept. I mean, I guess it's, in Dr. Santrock's world, would be another extra-articular solution for an intra-articular, you know, CORA problem. And so I understand- I totally agree with CORA. I'll tell you, Pete, the thing about the short first ray issue and the shortening that really comes up, it's an interesting topic, right? With, at least through TMT arthrodesis, and also through the three-dimensional osteotomy, if you can get those sesamoids plantar and rotate the metatarsal sesamoid complex, I don't think shortening matters nearly as much because we're getting that sesamoid complex below the lesser metatarsal heads. And therefore, you could actually do an arthrodesis or an osteotomy with a short first ray, as long as you get it in a triplanarly correct position. I doubt you have the issue with metatarsalgia or shortening issues that you would see otherwise. And right back at you for a second, there's one question that came in about your algorithm on Bunyan's and Hallock's valgus correction. And it talked about one of your, one of the, I guess I didn't look at it too carefully, but one of the algorithmic components had an arthrodesis of both the MTP and TMT joint at the same time. How often do you do that? Do you do it in younger patients or is it mainly older patients? And is there any, the question is, are there any tips in terms of adjusting the fusion position or other tricks to help these patients do well with both locations being fused? Excellent questions. I would say that the great thing about the algorithm I use is that it's all anatomically based. So if you have anatomically a diseased MTP joint and you have a anatomically diseased or widened intermetatarsal angle, so make the foot normal, you address them both. So yes, if it's a young patient with an anatomically diseased MTP joint, I'm gonna do both. So how often do I do a double arthrodesis? It's not infrequent. I would say that it's, you know, 15%, 10 to 15% of my Bunyan load of which I'm probably 90% Bunyan's these days based on the draw of patients I get. So it's not insignificant. My algorithm is essentially that if I have disease at the MTP joint, but I have an intermetatarsal angle greater than 15 degrees, I'm gonna do a double. And that will, it greatly increases the shoe fit. It greatly increases the satisfaction. I don't believe that there's anything anatomically you have to do to adjust it. The TMT joint anatomically is not that hard to correct as far as the sagittal plane. If you just follow the distal surface of the cuneiform, it lines up to where the inclination needs to be. So that's usually never adjusted. And then the MTP joint, I just use the dorsal cortex of both the phalanx and the metatarsal as a zero degree angle. I wrote a paper about anatomic plates, about dorsal plating, and you can easily get off by plating too proximally. And then you end up dorsal flexing in your construct. So for me, I pin, once I get my joint prepped at the MTP joint, I pin it so that I have a zero angle of my two dorsal cortices, my phalanx and my metatarsal. I tend to still work from proximal to distal. It would not be unreasonable to prep and pin your MTP joint, then fuse your TMT joint. I know that there are some people that do it that way as well, but I'm a traditionalist. I go from most proximal to distal in all of my surgeries. And I'll say, I don't know, Mike and Arrow, any comments on that? Do you ever do double MTP and first TMT? No, I do not. I did have a question for Robert. I must not have looked at that algorithm too closely either. But my question was, in his algorithm, if he has an IM angle of let's say 14, is he still doing a laparoscopic procedure on that patient? Because I've always struggled with that particular aspect of sacrificing a joint when you don't have to for small IM angles. Yeah, Dr. Bailey, I'm a straight bone guy. I don't wanna make a straight bone crooked. So my heartburn comes in making the bone crooked. Your heartburn comes in taking out a joint. That's fair. The truth is, yes, I do laparoscopic because I believe the disease is at the TMT joint. And I believe that there's a better chance for me to get all three planes of correction done there without, I haven't perfected a way to do it smoothly without a lot of difficulty at the mid shaft of the osteotomy where the core does not exist. But also I would argue, and my argument, and it is an argument, it's not a fact, is that I don't believe that joint's normal. We have to start, we have to as a group of people, a group of scientists, understand why we get bunions. And I don't think we do. And right now I'm hooked on the idea that the TMT joint is pathologically different than the normal anatomy. And I'm trying to figure that out. I by no means have definitive information yet, but I'm constantly exploring it. And if anybody's got a better theory, let's go down it. We need to, once we find out the etiology and the pathogenesis, I think we'll have a little better understanding. And I believe it's gonna lead to the TMT joint. So that's my belief right now. Dr. Campbell. Okay, so for me, double arthrodesis is pretty darn rare. I honestly, I don't think there's a lot of morbidity infusing the first tarsal joint. I think actually, especially like my young female athletes, I think it's a great procedure that actually gives them better stability. But I live in Virginia Beach. I have a huge patient population that likes to go to the beach and wear flip flops. And it's a really hard sell to do a first metatarsal phalangeal joint fusion. So you guys hold your nose when I say this, but I actually will do, if I need to do something at the joint with an arthritic first metatarsal phalangeal joint, but a more severe bunion deformity and the TMT has to be addressed, and I want a spare motion, I'll actually do something like a CAR Tiva, or some type of interpositional arthroplasty to try to maintain some motion there. But there are definitely cases where you do it. When I do it, I go from proximal to distal. I think it just makes more sense. I wouldn't know where to set the toe fusion if I hadn't done the first TMT yet. And one question, while we've got about two minutes left, I'm just gonna say, so I do a ton of MTP fusions, just for like my patient population. And I will say that, except for one patient in my 23 year career, once I correct the IM angle and get the sesamoids underneath the, get the sesamoid sling underneath the metatarsal head and put the plate on, I don't have an issue with the first TMT joint going out of place, right? The MTP joint solves, once I get a line, tensions on the toes release correctly, then the TMT joint seems to stay there. I don't know what that means, but that's been my experience. Last question for Dr. Shinch, you were having your connection problems for a second, and I asked, how often are you doing a lateral release with your lapoplasties? Almost always. Okay. It's a rare time that I will not do one. I reserve the right to say, I will not do one in a very young patient who does not have sesamoid subluxation. The crista is stable and the sesamoids are on either side of crista really nicely and it's a pure rotational deformity in that sense without subluxation. And they'd have to be very young and flexible. That I come across that rare, but I'm a traditional bunion surgeon. The vast majority of our patients are 40 to 60. You know, I don't see a lot of sub 20 year olds, although they exist. And that's the patient I would reserve to not do it if I didn't. Like Dr. Bailey, I do a incision just lateral to EHL. I stay out of the capsule, but I make a little capsule out of me to get to the lateral collateral ligament. And then I transect the accessory suspensory ligament of the fibular sesamoid. I also go a little bit past the sesamoids and get that complex of tissue that Dr. Bailey was talking about taking the knife up the shaft a little bit. That it's described in Serafian's textbook as a confluence of tissue where the inner transverse ligament comes over and confluences around the FHB. I think you're below the vascularity that Dr. Bailey describes. I think it's pretty safe. I opened up about 30 of these in a lab and we found that we were pretty safe zone, Dr. Bailey. So I think you can do that technique pretty safe. All right. Well, wonderful. We are at our time limit and that was a fantastic. We didn't even get to our cases. What a fantastic discussion. Great questions from the audience.

bunions

treatment

deviations

metatarsal

surgical techniques

lapidus osteotomy

minimally invasive surgery

weight-bearing CT scans

assessment

panelists

recovery protocols

research