And we will be back tomorrow at 4 p.m. Central for another couple of sessions, and then Saturday, but 4 p.m. Central tomorrow. But I'm gonna turn it over to Dr. Bailey. He's gonna be the moderator for this next session, which is on lesser toes. Always a frustrating experience in my regard. So I look forward to learning something in this panel. So take it away, Errol. Okay, thank you, Pete. Can everyone see me there? Yes, sir. We're good. Our next session is on that second toe. And I don't know about you, but it's one of the most dreaded things that I do in foot and ankle surgery. I can get the big bunion correction right, and everything looks lovely on x-ray, and it's that darn second toe that the patient is complaining about. So today we have an incredible panel. We have Holly Johnson, we have Paul Toulousan, and Christopher Miller, who are going to share their thoughts on second toe problems. So Holly's first with how the MIS lesser toe correction has been a game changer. I've actually seen her do this in labs, and it's pretty incredible, something that we should all take a good look at, particularly MIS surgeons. So Holly, take it away. Great, thanks, Errol, and thanks everyone for the invitation. I always like talking about lesser toes because it's sort of a time for me to air a lot of dirty laundry with MIS and really everything in general. Hang on, I'm just gonna bring this down for a sec. Okay, here are my disclosures. And so I've shown this slide before, but I think of hammer toes as a mystery of life. Like when you lose a sock in the dryer, you never quite figure it out, or accordion traffic. What on earth is going on here? How did the body evolve such that the feet sometimes look like this? I can't think of any logical reason at all, but nonetheless, every time I think I've seen the worst hammer toe in my life, another typically 80-year-old woman comes into the office with a foot looking something like this. You know, the etiologies are multifactorial. I tell people I don't really understand how and why they occur and what the genetics push the body to make these crazy deformities. But nonetheless, they can occur in every way, shape, or form, as we all know. And we've all seen patients desperately trying to control deformity with various taping, shoe wear changes, and everything else. But they get to the point where things aren't working out and they come to see us. Well, I hate hammer toe surgery. I still hate it, even though I think that I have a couple of ways that make it a little bit easier, but I still hate it. And, you know, it's unpredictable. There's a high recurrence rate, even with the MIS approach. Patients have completely unrealistic expectations. And I think I always try to manage this as best I can and try to give them, tell them the worst it can possibly be. And there tends to be low patient satisfaction as a result. And then that causes low surgeon satisfaction. So there's a reason why we're all, we all despise hammer toes. There's a million things we can do. We can release and lengthen tendons, capsules, ligaments. We can transfer tendons, the dreaded plantar plate repair that doesn't work. We can do phalanx osteotomies, metatarsals, osteotomies, all of these things. For me, the surgical choice is based on the deformity. And the things I look at are whether this is a rigid or flexible deformity, which joints are involved, and then what I'm comfortable with. And often, admittedly, that depends on what my last complication was, for good or bad. So, you know, when we compare open versus percutaneous, you know, there are some advantages to open. I think it's technically easier, certainly at the beginning. There are more options for tendon transfers, in tissue, different tissue repair options, and certainly a more anatomic correction, in my opinion. However, it usually requires some sort of fixation. In my hands, I saw many more wound complications and stiffness is not only common, it's almost ubiquitous. So with the percutaneous, there are less wound complications, if any, less pain, less stiffness, and it just takes less time. It's technically difficult, though. I think the learning curve is steep and requires a lot more postoperative care. I'm often having patients come in every two weeks for different taping and strapping mechanisms. And if you have a patient who's non-compliant, this can be an issue. However, I will say the percutaneous approaches have been really life-altering. I always want to acknowledge my mentors, Joelle and David, for getting me into this. And then Barbara P. Clay is the most unbelievable hammer-toe surgeon on the planet. And I'm constantly reaching out to her for help and advice. This slide was given to me by David Redfern, and these are all the things you can do percutaneously to the lesser toe. I'm not gonna go through them all, but I'll go through some of them. This is another MEFA slide. So the European, sort of outside of the U.S., Minimally Invasive Foot and Ankle Society, who has this diagram. I'm not a big diagram person, but if you have the time, go back and look at this slide and you can go through it. For me, I like more diagrams that show the toes themselves. So I'll go through those. So for simple, mild, flexible deformity, you can treat these pretty easily. You cut the extensors at the hood so they don't retract that much, and then you study them down postoperatively. And sometimes this works really, really well. This is a nice example where I was doing a percutaneous lapidus, and I realized at the end of the case that that second toe was over and I knew the patient wouldn't be happy. So I just did a little tenotomy and it popped right back into place and the patient was really happy and it was this tiny incision. So for, hold on one sec, I'm trying to get rid of my, no, it's not gonna work, sorry. So for flexible deformities, you can release the extensor tendon, release the FDV and the plantar plate, and do these nice little plantar closing osteotomies of the proximal phalanx and closing osteotomies dorsally of the middle phalanx, and you can correct the deformities pretty nicely this way. I find that this release through the PIP joint is actually a little more difficult, and I think if you haven't done it before, try it in the lab. You use a beaver blade and sort of slide underneath the base of the middle phalanx. You really have to kind of saw off that plantar plate and FDB, but it does work quite well. And you need to make sure you keep the long flexor, otherwise you're gonna end up with a floppy toe. And this is an example, I think if these are gonna work, let's see. Yeah, where are you going? And this is an example of the, you know what, actually, it's gonna be better. It'll be better on the next slide. I'll show you a better video of cutting the osteotomy in this slide. So if you have deformities in this plane, you can do these nice closing wedge osteotomies, and you can do these either dorsally or plantarly. You'll see an example below. And then kind of green stick the toe down, and I think that these work pretty well. This is what I was gonna show you in the last video. You place your, you identify the starting point by finding the metatarsal head, and then you make a small incision just distal to the metatarsal head. You put your burr and cut it, and then here you'll see me kind of manipulating the toe, and I green stick it, and really you get this nice click, and the toe kind of pops into place. Generally, you can kind of tape and stare it down. Sometimes I use pins. This is another example of it here, where you can see those little cuts, and you can kind of impale the phalanx into the base, and it generally stays in place pretty well. This is probably the most life-altering osteotomy I discovered for the crossover toe, and I use this actually for much more than I use that sort of closing wedge osteotomy that I just showed. With these oblique osteotomies, you do these before you do any major tendon releases, and you'll find that sometimes you don't even need to release the extensor. You make these oblique cuts, and the toe shortens and then moves in the direction of the cut, so if you have a medial crossover toe, the toe will move laterally, and it's very effective. The shortening takes a lot of the tension off and helps reduce that deformity, and you can see here, this was a major deformity that really overlapped afterwards. This is an example of it here, and I think you'll see the toe kind of shorten. I cut it, and then I do a little manipulation, and it really shortens up nicely. Make sure you irrigate. For the purposes of the video, I didn't irrigate. You always want to irrigate when you do any osteotomies. This is a nice example of a patient who had bilateral crossover toes, and I did these oblique osteotomies. She didn't even heal completely on the left side. She really is a stable nonunion, but is extremely happy, and I've seen her at a year-and-a-half post-op, and she still looks great. This is another example where I used the technique not for a crossover toe, but for this woman who had had multiple prior surgeries, had really seen the best in our field, and her biggest complaint was really at this point just those second and third toes, and you can see I cut the bones, and the toes sort of floated, and she's feeling great and looks great, and I had two-year follow-up. I think two-year follow-up on her, and she's still doing really well. For rigid deformities, I'm still fusing the PIP joint. I just think it's the most reliable treatment in my hand. Sometimes I'll use the burr to do it, and in some cases where it's really severe, and I want to shorten more than a few millimeters, in those cases, I'll actually still open it, use a saw, really try to shorten it and compress the two ends, and then use either K-wires or a screw to close it down, but I think if you use the burr, it's very hard to shorten a great deal, so if it's a long second toe, I would recommend doing just a little mini open PIP. There are a lot of different ways to hold a reduction. These are just some different suture techniques that I've used. I like this wet dressing that's often described. I learned this from the European guys, and I do this sort of moist dressing on pretty much every forefoot procedure, even if it's an MTP fusion, I'm using this moist dressing, and when it dries, it becomes sort of like paper mache and really holds everything in place nicely, and the patients come back and they have minimal swelling, but there are all these little suture techniques that you can use. I still do use pins, and actually, I've started using K-wires again more and more as it's just so time-consuming to have patients come back to the office for different strapping techniques, so if I see patients who often live two, three, four hours away, for them to come in, it's really difficult, so I'll use K-wires. I wanna show you a few cases that didn't go well. This is a morbidly obese patient where I tried to get out of surgery easy and just did this oblique osteotomy, and initially, it looked really good, and then she came back, and you can see what happened here, and this is what Bob Santrock would probably say happens to the MIS bunions, but I cut the bone, and I created, I straightened the bone here, but I didn't address the issue at the joint, and because of that, the toe just slipped right back into place, and I had done her other foot, and I opened this one, and she was quite happy with it, so I had to go back, and I did an open-wire osteotomy and restored the joint line, and then she was much happier, and it worked out quite well. By the way, she's lost 100 pounds since these surgeries. This is a newer technique that I'm now using where I'm really trying to address that MTP joint, particularly in younger patients. You know, in an elderly patient, I'm just trying to get the toe out of the way, but if I have someone who's gonna be wearing shoes and is active, what I do is I cut the toe, I pin across it, I do a release of the MTP joint, I reduce the MTP joint, pin it. I usually use two pins, and then I do an oblique cut, and generally speaking, these oblique cuts heal better if you cut two and three at the same time. The idea that you have to cut two, three, and four is false, you don't need to, but cutting two and three definitely helps, but this case ended up really nicely, and this oblique osteotomy helps sort of correct the deformity as well. This is another case where it's a similar type of technique, and you can see this guy's pins came out, I think, before I saw him for his first post-op visit, and he kind of collapsed at the third MTP joint, but he actually still did quite well and was really happy with no pain. I haven't seen him since back, because he's been doing well. This is a case where I couldn't manual, I couldn't reduce the second MTP joint percutaneously, so I had to open it, and if you can't reduce it, and this was a younger, like a 65-year-old active guy, I opened it up, I did my open metatarsal shortening osteotomies, and the result, I think, was really fantastic, as you see on the right side, and he's doing great. This is another case where I did that, the sort of double oblique cuts, and she's doing great. I'm gonna, if I have time, yeah, quickly, I'm gonna go through metatarsus adductus. I know Chris Miller's addressing this tomorrow. I didn't realize this when I put the slides in, so I'll go through this quickly, Chris. This is how I used to do it, where I used to just sort of fix the IM angle and then cut the toes and do these oblique osteotomies, but I know that these recur, and when you don't address the MTP deformity, the toes are gonna go back, and this is gonna recur. This was an early post-op, but this patient is going to recur. It's not a reliable way to treat metatarsus adductus, so now what I do is I do an oblique osteotomy. I address the toe deformities first, so I do that sort of reverse oblique, so I do the oblique osteotomy of the phalanx, reduce and pin the MTP joint, and then I do the metatarsal osteotomies under the pins, and so what happens is this causes the MTP joints to be reduced and the lesser toes to straighten out, and it increases the IM angle, and then I do my percutaneous lapidus, and the x-rays look a little goofy, and if Bob is still on this, I'm sure he's grimacing, but the results have been unbelievably fantastic, so it looks kind of crazy afterwards, but this is an example. On the left side was the first one I had done, and you can see she had a little bit of recurrence at the osteotomy sites. I didn't pin her across the MTP joints initially, and I think that's why that happened, and I pinned this other side, but you can see that range of motion. You can't get that with open metatarsal shortenings. I mean, the pain relief and the ability, this woman's back in shoes at three months, and I just haven't been able to get that with any open approach. So in general postoperative care, most people do immediate weight-bearing and a hard-sole shoe. I will say for my older patients, I'm putting them in boots, and when I say older, I'm using, I hate to say older is 60, but really it's based on the osteopenia, and I'm putting them in a short boot, using taping techniques or dressing changes or whatever I can do. This sort of orthoplast stuff, this is Barbara P. Clay's slide, and I'm starting to use this stuff, and it's been really helpful. The literature is really limited. I don't think it's that useful, except in this top paper, they did note a higher complication rate when you do tenotomies. I find that you really have to combine the bony and the soft tissue procedures, and you have to make sure your NTP joints are reduced. So my limitations are, as I said before, the rigid PIP joint. If I can't reduce the NTP joint, I open it and do an open shortening. And just be careful with your tendon releases, because you'll either get a floppy toe or you can create a worsening hammer toe if you're not balanced. Anything that happens with an open hammer toe can happen with a percutaneous hammer toe. I've seen every complication, non-union, over-under correction, recurrence, ongoing swelling. Stiffness, however, is quite rare. These are the complications I've avoided. I used to say no infections. I did have one infection that had to be treated with antibiotics. It was a pin site infection about two months ago. She ended up doing fine. But percutaneous crossover toe surgery has been life-altering, as has my new metatarsus adductus treatment. So again, another tool for your toolbox. Major advantages in many scenarios. Don't be afraid to combine the techniques. You can do an open lapidus and you can do percutaneous lesser toe stuff. We need better studies to compare. And one last thing I'll say, virtually none of my patients take opioids across the board. None of my minimally invasive surgery patients take opioids. And I think that in and of itself has been life-altering. Thank you. Thank you. Thank you, Holly. That was fantastic. Every time I hear that, I absolutely love it because I can't stand plant or plate repairs. And I'm looking for any way to try to avoid that. And with that comment, I will lead into Paul's talk, who's going to talk about that extensively, that darn second crossover toe and how to approach it. Paul, are you there? I'm here. Thank you very much for the opportunity. And here's my disclosures. So I think, you know, the thing that separates me from a lot of other people, I think, is that I love plant or plate repairs and I like forefoot deformity a lot. So jumping into it. So, you know, with the crossover toes, it's, we got to think about what the problem is, you know, and, you know, so with the crossover toe, why is the toe, the toe is cocked up or floating. So that's where the plant or plate isn't working. And for the splaying of the toe or the, you know, medial or lateral deviation, that's a collateral ligament problem. And then when you have the two in combination, that's when you get your crossover toes. Just to dive into what the plant or plate is. So it's this fibrocartilage, sort of has the consistency of the meniscus in the knee. And it originates from the metatarsal and also from the plantar fascia. And then it inserts into the base of the proximal phalanx on the plantar side. Looking at the origin of it on the metatarsal, so it's typically been described in the literature as being this loose, like areolar tissue of minimal significance, more or less. But, you know, in doing a fair amount of dissections, like this little pedicle is pretty stout. And I think it's underappreciated. And then looking at the collateral ligaments, so on the right side is the phalanx, on the left side is the metatarsal head. So the collateral ligaments are on the medial and lateral sides of the MTP joint. There's actually two bands of it. There's the proper collateral ligament and the accessory collateral ligament, but we'll just call them collateral ligaments here. And those resist medial and lateral deviation. And so, you know, Dr. Johnson was mentioning, like, you know, why do these happen? So I think the root cause of a hammer toe is a plantar plate tear, or at least plantar plate insufficiency. So what happens is when the plantar plate tears or stretches, the toe becomes dorsiflexed at the MTP joint. And when that happens, the intrinsic tendons, they're displaced dorsal to the center of rotation of the MTP joint. And so the intrinsic tendons become dorsiflexors and perpetuate this deformity. Over time, or as this happens, the FDL tendon becomes tight, and that's what causes flexion at the IP joints. And if it's, it starts out as a flexible deformity, but then over time, the capsules become tight and it becomes a fixed contractor. And so what happens to the plantar plate? How does that become a problem? So MTP synovitis is thought to cause some attenuation of the plantar plate, but also one of the risk factors is a long second metatarsal. Acute trauma can cause this. There are some papers that describe steroid injections as leading to weakness of the plantar plate. Hallux valgus, for sure, is probably the most common reason that we'll see crossover toes and plantar plate tears. And as far as the gastroc contractor, so, you know, when we think about metatarsalgia in relation to a tight gastroc, we think about forefoot overload. But when I think about this as plantar plate tears, if you have a tight gastroc, when you are going to toe off in the gait cycle, not only are you loading the forefoot, but you're also tensioning the plantar plate. And so I think over time, people with tight gastrocs will stretch their plantar plates out. Clinically, when I see people with plantar plate tears, so, you know, they may have, sometimes it's something just pain at the MTP joint. They could have some subluxation. The paper pullout tests, which I don't typically do, but that's described as being one of the physical exam tests to do. The most sensitive thing for me is a drawer test. And it's a lot like doing a drawer test in a knee. This is a normal side on a patient. And so, and this is the abnormal side. So there's a lot more dorsal translation of the toe at the MTP joint on this right side here. Imaging for me doesn't do a whole lot. I mean, you always get x-rays to make sure there's nothing crazy happening, but you obviously can't see a plantar plate there. You'll see on the right side here, the second toe, which is kind of cocked up here. So this is almost purely a plantar plate tear. I don't typically get MRIs, but I used to. And, you know, the plantar plate, it's pretty hard to see. Radiologists almost never call plantar plate tear. But if you see, and this would be an abnormal one where, you know, that the typical thick black line you see in a normal ligament isn't there. And then sometimes you can see some like hypertrophic synovitis within the joint as well. In classifying these. So I know, I've talked to Dr. Nair and Dr. Coughlin pretty extensively about this type of stuff. And, you know, in my experience, maybe it's just because my indications are kind of loose with addressing plantar plate tears. But for the most part, I see these grade zero tears, which is mostly a stretched out plantar plate. And I'm pretty thorough in examining. I don't put a scope into the joint. I kind of want to, but I'll probe around the plantar plate to really try to find the tear. And a lot of times I can't find a discrete tear. I think the grade ones and twos, I don't see very often where it's, where you get like a tear off of the phalanx. And then I probably, the second most common thing I'll see are the grade fours, which are like, just there's no plantar plate there at all, or it's really torn up. And those are the big dislocations. So the non-surgical treatment, we've kind of touched on it before. So if it's something, you know, calf stretching can be helpful, mostly for the metatarsalgia aspect, bigger shoes, strapping the toe down, really the principle of this is you're trying to stabilize the MTP joint. And going into like, I mean, I've always been fascinated with the plantar plate. So, you know, me and some residents and other people in the lab have really nerded out about this. So one of our questions was what's the blood supply of the plantar plate? And it hadn't really been described. And we had some people in our, some scientists in our group who had access to these micro CTs. So we looked at the blood supply of the plantar plate and the plantar plate blood supply comes from the phalanx to probably supply the distal portion of the plantar plate. And then proximally there's two tributaries. One comes from that pedicle coming from the metatarsal neck. And then the other portion of the blood supply proximally comes from the plantar fascia. And I'm going to talk about that importance a little bit later. But the blood supply of the plantar plate, it's kind of like the meniscus where there's kind of a red, red zone and a white, white zone and that type of a thing. So jumping into the surgical treatment, because that's the title of this talk. So various things have been described. So, you know, simple synovectomies, syndactylization, which I've never done, but I would love to, cause it just kind of seems cool to do. Collateral ligament reconstructions, tenotomies, MTP joint fusions, tendon transfers, metatarsal shortening osteotomies. And in most of the literature, the residual deformity is, is like 25 to 40%. So it's still, it's very high. And I think that's why everybody hates doing, you know, plantar plate stuff. And repairing plantar plates. So there's been a couple of things described. So there's the plantar approach, and then there's the dorsal approach. I don't really know anyone who does a plantar approach. And I think most of us dislike incisions on the plantar surface of the foot. But, but the nice thing, I think the advantage with doing a plantar approach is that you have a direct visualization of the plantar plate. And in this paper described here, they did a, basically a pants over vest type imbrication of the plantar plate. But, you know, what if you have to address multiple toes? Are you going to make multiple incisions? I think it kind of gets a little complicated cutting on the bottom of the foot. But I'm a big fan of the dorsal approach. And so in this paper by Dr. Watson, almost 10 years ago, so this was probably the first paper that described the plantar plate repair from the dorsal approach. And this has sort of been the traditional plantar plate approach, I think that people talk about. And I think in over the years, you know, the techniques evolved a little bit, but going through like your textbook plantar plate approach is a dorsal incision, followed by placing a McGlamory elevator to release that metatarsal attachment of the plantar plate. And the biggest thing with this plantar plate thing is it's hard to see, you're working through a really tight space. So one of the hardest things to do is just visualize all the things you need to see in order to pass the stitch. So this paper describes placing a McGlamory elevator to release the metatarsal attachment, they do a plantar condylectomy so that the plantar plate can sort of reattach to the metatarsal approximately. And it can also help with some metatarsalgia, like the feeling of walking on a marble. And, oh, this is just demonstrating like what that McGlamory does, you're stripping off that metatarsal attachment. An interesting study by Jastapher and Coughlin, so they were distracting the MTP joint of the lesser toes, and they just, they section different things. So they started by cutting the capsule, seeing how much you could distract, and then you cut the collaterals and see how much you can distract. And so when you get to putting the McGlamory elevator in after you release the collateral ligaments, so you gain 1.6 millimeters of visualization and everything combined up until putting the McGlamory in. So now you have four millimeters of visualization. And so that's followed, that's usually followed, well, I'll get into that in a second. So you'd put in the McGlamory, now you can see some stuff. To see even more, a metatarsal, like a while osteotomy is used, and that gives you very, very good access into the MTP joint to pass a stitch. The next part of this surgery is to cut the plantar plate off of the phalanx. Either you complete the tear, or in the case of like a grade zero tear, or a grade zero where there is no tear, you cut the plantar plate off of the phalanx, and then whatever, and that gives you an extra 1.2 millimeters of visualization. But after you cut the plantar plate, now you, whatever you use to pass the stitches. So, you know, there's suture passers that were sort of adopted from shoulder surgery. There's various needles that are around, but whatever it takes, you're trying to put a stitch through the plantar plate. After you put the stitch through the plantar plate, then you drill a couple bone tunnels, in this case into the phalanx, and then you're passing the stitches from plantar to dorsal in the phalanx. And then you have to fix your while osteotomy, tie everything together, and that's what it is. I bet that's how I started doing these, because that's how I just learned how to do them. And here's one of my patients, pretty good result. Looks like there's an improvement in the position of the toe, still floating. And then in Nary and Coughlin's paper here, in their pool data, they still had a good amount of residual floating toes. And, you know, why are the toes still floating? Well, maybe we're killing the plantar plate with this traditional approach to repairing the plantar plates. As you've seen, it's very aggressive in order to get yourself down to the plantar plate. So you're sticking a McGlamory in, so that could be killing the blood supply back here. You're cutting the phalanx, you're cutting the plantar plate off of the phalanx, so you could be sacrificing blood supply here. And so, you know, you're essentially using allograft, is the way I think about this. And so, you know, if you think about, like, my kid trying to charge his iPad, I think that traditional plantar plate repairs is sort of like when my kid needs to charge his iPad, but he won't move closer to the wall. So he's, like, yanking on the cord, pulls it out of the wall and plugs in his iPad and is surprised that it doesn't charge. So, you know, and the work that's been done here before, I mean, I think it's all been great, but I think that, you know, there's definitely room for improvement. The other thing is, you know, do we have to stick a McGlamory in there? Do we have to strip the plantar plate off of the metatarsal? And so, you know, based on what we've learned with the blood supply, I kind of think maybe we don't do it. And I say that as a question, not as a statement. But even if you are going to strip the plantar plate off of the metatarsal, maybe we should be repairing it to the metatarsal to make sure we keep that ligament tight. The way that I've evolved into doing plantar plate repairs, so here's just the drawer test again, but the way I've done it is to try to minimize all that soft tissue stripping and minimize and try to eliminate doing a while osteotomy unless you have a long second metatarsal. So, I will make that incision, I'll do a plantar condylectomy, and I do a proximal repair typically. And so, I'm repairing the plantar plate to the metatarsal. The way I pass a stitch is I use a Keith needle, I pass it from dorsal to plantar, and I'll actually pass that Keith needle through the plantar skin. And then I'll grab the needle outside of the skin on the plantar surface of the foot. And then I will slowly pull that needle until the head of the needle and the suture is only through the plantar plate. This little piece of yarn here, that represents the flexor tendon. So, I'm sort of pulling the needle through the plantar plate, using it to kind of blindly sweep the FDL tendon. I'm probably catching the tendon in some cases. And then holding the needle outside of the skin on the plantar surface of the foot, I'm then going to pop up the needle through the plantar plate. And that's how I pass the stitch. I've been doing this for probably four or five years. And we presented these results at the winter meeting and it's in process to be published. But in the proximal plantar plate repairs that I've done in low grade plantar plate tears, we've gotten people's promise scores to go from like 39 for their physical function. We've gotten them from 39, which is not a good score to 52. And 52 basically represents people who can do all of their ADLs, plus some strenuous activity. It's essentially normal. So, that addresses the floating toe aspect of a crossover toe, but getting into the collateral ligament reconstruction. So, people have talked about, if you're going to do a plantar plate repair, just drill your bone tunnels eccentrically, and that might be able to correct some of your frontal plane deformity. Tendon transfers are definitely talked about in collateral ligament reconstructions. Myerson's paper of 64 feet, they did the flexor to extensor transfers, and they still had like 37% residual dorsiflexion or floating toes, and they had 27% with residual medial deviation, and 34% are really unhappy with the outcome. So, maybe we could do better. For the minimally invasive folks, I've never done this, but this is a paper I stumbled across, and they did this arthroscopically. They did a scope of the second MTP joint. They did a lumbrical release, and then they passed a stitch through the plantar plate sort of percutaneously, and then they took that stitch and put it through the extensor tendon. So, they're basically tying the extensor tendon to the plantar plate and using that change of vector to straighten out the toes. They didn't really talk about how the toe functioned afterwards, and it was a very small series, but this was a pretty interesting idea. I'm a big fan of just anatomic, you know, fixing things anatomically, and so I think that doing an anatomic collateral ligament reconstruction is what I prefer to do, and this paper talked about doing that. They did, I wouldn't exactly call this anatomic reconstruction because they drilled the two bone tunnels that you would do in a proximal phalanx. They passed stitches through the plantar plate but also through the collateral ligaments, and then all of those sutures were passed through the same bone tunnels, but how do I do it? So, this is a patient that I have and with a not quite a crossover toe, but it was definitely deviating medially and had a previous bunding operation, so that was probably the source, you know, of where her crossover toe came from, and what I typically will do here is I'll do a couple of bone tunnels through the metatarsal transversely, and then I'll take a stitch, and I'll pass it through these bone tunnels, and then I'll put those stitches through the collateral ligament, kind of like you do for, like, a rotator cuff repair or a brostrom or something like that. Basically, it's just a mattress stitch, so here's a bone tunnel going transversely through the metatarsal. I use a suture passer to pass the sutures, and then to this point, you know, basically I've done that, so the sutures are not, they're through the bone, but they're not through the ligament, and then I'll use a free needle, and I will take those sutures, I will pass them through the collateral ligament, and imbricate the ligament, and then tie the sutures, and this is about a year later, so she's been able to maintain her correction, and just here's another view of it, and here are post-op x-rays from about a year later, so in conclusion, so the, I think the plantar plate incompetence, that leads to dorsal instability, collateral ligament incompetence leads to medial or lateral deviation, the MTP instability, it's painful, people get metatarsalgia, synovitis, and hammer toes. A lot of people, I think most surgeons will just, are still doing metatarsal osteo, like, while osteotomies and hitting the toe, but I wouldn't say those are really anatomic treatments, nor do people necessarily have, like, normal functioning toes afterwards, and so I think that repairing the plantar plate and the collateral ligaments, it's anatomic, and I think it addresses the root cause. Thank you. Thank you, thank you, Paul, that was, that was excellent, incredibly detailed, and very nice, very nice job, and we'll hold all questions until Christopher finishes. We now have Chris Miller up, and he's going to talk about the role of metatarsal head resection and metatarsal osteotomy, MIS, and OPEN. Okay, thank you guys so much for having me, and for the other panelists, and just great talks tonight, it's hard to be the last person to go, but I'm going to talk about OPEN and MIS metatarsal osteotomies here, so I'm up in Boston, and these are my disclosures here from a sort of financial standpoint, but I think my biggest disclosure just for this talk is that I consider myself an MIS guy, much like Dr. Bailey, and Dr. Johnson, and Dr. Johnson certainly taught us all a lot about this stuff, so keep that in mind as I, as I go through here. So, you know, I like to start my talks with, you know, a little, little case to get everybody thinking, so, you know, these are two women that came to see me, bunions, lesser hammer, lesser toe deformities, metatarsalgia, and I think anybody on the panel here or in the audience looking at this is going to say, look, we're going to have to fix the bunion, we have to do something for the metatarsals, and I think many of us would also agree that we need to do some sort of shortening osteotomies for the, for the lesser mets, maybe not Dr. Johnson with her, with her new magic second toe surgery, but for those of us less skilled, we'll need to do something with the metatarsals as well. So I'm going to come back to this at the end, but I did treat one of these with an all MIS approach and one of these with the open approach for the lesser toes. So the goals here, I'm going to go over some of the anatomy, Paul's talked about some of it already, and then we're going to talk about some of the osteotomies that you can do, both MIS and open, and then share kind of one of the algorithms that I found has been very helpful in terms of thinking about doing this from an MIS approach. So lesser toe anatomy, and I think when you're talking about metatarsals, we end up spending a lot of time talking about the MTP joints, and it's because there's a lot of, you know, very complex anatomy that is very frustrating for us to deal with. I think one thing that we have over our hand, colleagues, is that at least we can kind of treat it a little roughly because they don't need quite as much dexterity as we do in the hand, but we have our static stabilizers, our static stabilizers, which Paul showed us how to fix. We have our various intrinsic and extrinsic muscles here, and you can see the complexity up here on the anatomic dissection out of Barcelona. And they all have their important roles. We certainly have a nice talk about the plantar plate, but all of these are going to come into play, and we have to think about how it's going to affect our patient's anatomy and function. So our extrinsic muscles are going to be dorsiflexing at the MTP joint and then plantar flexing through attaching distally, and they're really counteracted by our intrinsic muscles, so these are going to provide counterbalance to those stronger extrinsic functions, but it's really as you get out of balance here that we start having problems, and this comes with the lesser toe deformities. Again, you can see the complexity on this diagram here. So the times this becomes relevant now is that we have, with dorsiflexion and deformity, you start having alterations, and Paul did a nice job showing some of this, but the interossei will start translating above the center axis of rotation of the MTP joint, become dorsiflexors. The lumbricals become much less efficient because they're now stretched at 90 degrees under the transverse ligament, and now all this, they can't do their job of extending our PIP and DIP toes, joints, and I often sort of think of this analogous to an intrinsic minus type hand position or a boutonniere type deformity. So what do the lesser metatarsals do? They spread out the gait across the forefoot. They provide a pulley function for the windlass mechanism, so as you go into the third rocker of gait, you come up onto your toes, plantar flexors, excuse me, plantar fascia becomes tight, and now you have a stiff midfoot that you can roll off of, but we know that if you don't have that parabolic arc in the forefoot, or if one is significantly longer, or if we have deformity of the toes, you now start having metatarsal overload, and now we have to do something to address that. So you can't talk about metatarsal osteotomies and not talk about the while, and we could talk for, you know, an hour or more on just this osteotomy because so much has been written about it, and by far the most common thing that people are going to be doing for this, and it has a lot going for it. It's technically simple, you can teach, use how we all learned in residency and fellowship probably, you know, you can control exactly how much shortening you want, almost down to the millimeter by just pushing it back. And because it's plantar to the rest of the metatarsal, you have some immediate stability to weight bearing, and then you can fix it with a screw to hold it in place. It's versatile. So you can shorten, you can elevate. If you have some coronoplane malalignments, you can sort of rotate where the sort of toe is gonna be positioned and pointing by changing the alignment of the articular segment there. And as we know, you can also access the plantar plate if you're crazy enough to do that type of surgery. So a classic example here, this is from one of my former fellows, Dr. Mikulski in LA, but he fixed a bunion, did an aching, and then he straightened out the hammer toes. And you can see the shortening that he achieved with his open while osteotomies there. So probably one of the more common indications for this. And why does it work? So as you have chronic deformity, whether it's dislocation or just subluxed dorsally at the MTP joint, your ligaments, your collaterals, your muscles, they become tight and shortened. So if you try to bring this down without shortening, or maybe stabilizing and repairing those ligaments in the proper position and under proper tension, it's just gonna slip back up and have recurrence of the deformity. So part of the idea of the while is that we'll shorten the metatarsal head enough so that now we can just bring the toe back down to proper position and then fix it in the right spot. And then hopefully this will then restore our ligamental balance. So again, we can standardize the shortening we do. We have flexibility if we wanna shorten plus take sort of a wedge of bone out. So this is a common modification, which is so-called macera osteotomy, where you will make two cuts parallel to each other so that you take out this segment of bone. And now you have the shortening plus some elevation and still have the advantage of being able to put the screw in the proper position. And again, angular plane corrections as well. So without going into an enormous amount of detail on osteotomy that we all know and either love or hate to our own degree, many of the patients will do quite well with 85% satisfaction, some of the studies I was looking at for this. But we also know that they come with their own set of complications. So floating toe by far the most common, upwards of 36, 40% in many of the studies. In my experience, I've seen a lot of them reduce over time. A lot of theories on why. One of the ones I like is that by shortening that, we may detension the attachments of the plantar fascia and that may kind of tighten up and then help bring the toe down over time. Or just increase scarring plantarly. But interestingly, if you fuse the PIP, they had a higher incidence of floating toe. And I think that kind of makes sense. If you're already prone to a little bit of elevation and then you further fuse the PIP joint, you lose whatever accommodation you might have at that site. So if you're a fuser or a resector, that may influence you a little bit. There's also recurrence. You can have either recurrence of the metatarsalgia or the deformity that we're trying to treat here. Transfer lesions to other toes and rarely delayed unions in this one study. So given that, and probably because we see so many wild osteotomies and are often then frustrated trying to fix some of these conditions, people have also tried to work on mid-diaphysial osteotomy. So it's trying to shorten and correct the deformity without having to get into the MTP joint and disrupt all of that beautiful anatomy that we saw in the earlier slides. So described, and I'll be forthright, I haven't done these right here, but they're described as sort of the step cut osteotomies, which sound quite demanding and difficult to do and probably don't allow good coronoplane realignment if needed. More classics are sliding oblique osteotomy, which you can then wire back together. And then the segmental osteotomy. So I did learn how to do this from one of my mentors, Dr. Eric Blumen. Very critical here that you're gonna fix it rigidly. So some of the studies looking at rigid fixation, so 98% healing with a plate. If you don't fix it, almost reciprocally non-united. So this was one of Dr. Blumen's cases here where he had about a centimeter shortening through the mid-diaphysis. And what he found and what he describes and what I saw in my fellowship is that if you need a lot of shortening because of a long second ray and they don't have a lot of other toe deformity that you have to deal with, this is a great option to get significant deformity without destabilizing all of those collateral ligaments, the plantar plate, and everything else that we see that might then lead to a floating toe. And high unions, although much like with our metacarpal and metatarsal fractures, they do take a while to heal radiographically. And even these have complications, right? So if you're creating the osteotomy more proximally, now you're gonna have a much longer lever arm where if you're not perfect with your sagittal plane alignment, you can really start disrupting the amount of your sagittal cascade. And so transfer metatarsalgia, transfer lesions were fairly common. Wound dehiscence and stiffness because of scarring in the midfoot was more common. And it makes sense. You're going to need a much larger dissection for these types of osteotomies than for something that's limited to the toes. And then non-unions in various cases, particularly if you don't fix those segmental ones. And plus they're a pain. I mean, I don't do very many of these because they're frustrating cases. And if you're doing a bunion and you have to do a shortening and you're making large incisions across the foot, why would you want to do all of this if there's something that you could do to avoid it? And I think that's partly why the while is otherwise so popular. But now we come to my disclosure here. I would much rather do this as an MIS procedure if and when possible. And so we're going to talk about a couple of versions of the MIS surgeries here. And so the workhorse in the MIS world is the so-called DMMO or distal metatarsal metaphyseal osteotomy. This is sort of the MIS version of the while, and you can see kind of a similar trajectory of the cut there. What's nice is that in an ideal world, this is an extra articular osteotomy. And so you shouldn't, or lower chances of developing an iatrogenic floating toe, but certainly harder to teach and harder to learn because now you're doing a lot of this by feel without actually seeing the bone. You're relying on the gesture of your hand with the bur and the x-rays that you have intraoperatively. But it allows passive shortening and elevation of the toes and you don't have to fix it. So the idea is that with weight bearing and over time, this will shorten and elevate and kind of find this new home and then heal in place. And it does heal reliably. Now, being on a panel with Holly is always dangerous because she'll say that you don't need to do all three of the osteotomies. And I totally believe that that's true. The classical teaching for the DMMO is that you should do at least two. If you're going to do one, then you should do two, three, and four. The theory being that they're connected by the transverse metatarsal ligament. If you just do one, then that ligament may, of course, stent that out into place. I think if you need to get a significant amount of shortening, then you certainly need to do all three. But as Dr. Johnson was showing, if you just need a little bit and a little bit of elevation, then doing one is probably enough for many of the cases. My personal bias is that I still do all three of them, at least, sometimes all four for my cases. The one exception would be for the DMMO for bunny net because the ligaments only on the medial side, you can get away with just doing that one. So why does it shorten? And you have to now think about the muscles and the intrinsic muscles of the foot. So you have this pull of the extensor brevis that's going to be pulling us approximately and lateralizing a little bit. And this can induce a little bit of a vector. So when you do this, if you do a traditional DMMO, sometimes you can notice that you'll get some lateralization even if you don't do the bunny correction. I think part of this is because those passive muscle pulls will pull you in that direction. The next slide I'll show a little bit about maybe exploiting that vector. But then the elevation comes just from the weight bearing. And when you're doing MIS, one of the big benefits for me and my patients is that I usually will let them weight bear almost immediately after surgery or after the block wears off. So when you think about your options for the DMMO, the classic one is just going to be in figure A here. And the burr is going to come through perpendicular to the long axis of the metatarsal. However, as you get more experienced and feel more comfortable, you can now start angling the burr in different directions. And this is a so-called distal oblique metatarsal osteotomy or DOMO osteotomy, because they love acronyms. But you can use this to then control your shortening in the direction of shortening that you're going to achieve. So if we think about this figure again, if I angle my cuts this way with that vector of pull, I may get more shortening and more lateralization. Or if I'm doing the fifth, I may get a little bit more shortening along that vector if I angle my thing medial. Conversely, if I wanted to shift more medially or maybe prevent some of the shortening that I don't want to achieve, I can make my cuts in this direction, maybe provide a little blocking force to prevent it from moving and lateralizing for me. So what are the outcomes for this? And there's not a ton out there. These are some of the more recent studies I found, but this was a study of 31 feet treated with MIS DMMO. And you can see they had a significant decrease in plantar pressure under the second and third heads. They had increase in the AOFES score, improvements in FAOS and BAS scores, and a mean shortening of about 6.6 millimeters when they marked it out. So despite having a sort of unfixed, uncontrolled osteotomy, all the soft tissues are still there. So it's not going to go that far, but you can get about six millimeters of shortening as well as improvements in your plantar peak pressure. This was a study of diabetic ulcers, and they use the same technique to cut the metatarsal necks. And all 30 of the feet healed. It took about eight weeks, and this was from Dr. Biz and his team in France and Spain. So this I think is a really great application and something that's been a real game changer in my world where I do see some of these plantar wounds in diabetics. And then I'll throw this one in on bunionettes. So this was a case of 74 cases with bunionettes, and you can see following an isolated DMMO of the fifth, they had improvements in the radiographic parameters for both the 4-5 IMA and the fifth metatarsal phalangeal angle and significant improvements in the AOFAS and pain scores and pretty universal, good to excellent patient satisfaction. And the healing was over about eight weeks. And this is just figures from their study, but this matches kind of the progression of healing that I tend to see in my own practice as well. So I told you I was going to talk a little bit about this decision tree here, and I encourage anybody who's interested in percutaneous lesser toe surgery to read this article that I have in the top right. A lot of these pictures are borrowed from that. I had to read this article about 10 times before it started to make sense. And I actually traveled over to Barcelona to work with some of these guys and learn from them because some of this stuff is really complex when you're trying to pick it up from the text, but I'll draw your attention. So this was his sort of thought on how to deal with a hammer toe. And if you have a rigid deformity with a subluxed but not dislocated MTP joint, this is where Dr. Redfern and Joel Vernoir would start talking about doing the DMMOs. And this will allow the shortening of the metatarsal head, take some of the tension off so that you can then let that toe sit in the proper position. But even these guys, you're sort of kings of the MIS techniques, still find a good role for open surgery, particularly if you have a rigid dislocation of the MTP joints. So this is a patient that actually just came to see me this week, and he has very rigid arthritic second and third metatarsal head. So for me, I know I'm not talking a whole lot about metatarsal head resection, but this would be somebody I might consider for that, where he has the dislocation and significant arthritic pain at that site. And so I'll have to figure out what to do with him, but I'm probably not going to treat him with an MIS approach. So coming back to the beginning, this was our first case with a crossover second hammer toe and a significant bunion. And early in my practice, if this person came into my office, I would groan, because I would not want to spend a lot of time with this. And I corrected all this with an MIS approach, and the whole thing took about an hour and 15 minutes. So we did a sort of traditional MECA type bunion, DMMOs, and then a hammer toe correction. And you can see the outcome here. And I use this little oblique osteotomy here that Dr. Johnson was telling us about as well. Looking at this now, if I were to do this more recently, I might also do an oblique osteotomy at the second metatarsal neck to help shorten a little bit more than I did here, but she was quite happy. And this is about six months out at that site. And this was my second one. So this had some lesser toe crowding, and her pain was more isolated to the second, and then she had some plantar plate instability. And so I started with the MIS bunion correction, but then I opened to do a more traditional while osteotomy of the second to realign the second toe. And then using my good friend, Dr. Fluesen's technique, I fixed his third as well. And so it's a real pleasure to be on the panel with both of them. This was her final outcome as well, and she was quite pleased. And, oh, I included a bunionette for the last minute. So she had a bunion and bunionette, and I just wanted to show you how that looks afterwards. So this was an all MIS approach as well. You can see how the fifth toe straightens out and becomes much less prominent for her. So in summary, shortening of the metatarsals is frequently required. You have a lot of options that you can use, but the goal is to change the biomechanics of the forefoot to take pressure off the metatarsal heads and change the dynamics around the MTP joint to address the lesser toe deformities. The while is certainly the workhorse here, does have significant complications, which are probably magnified by the amount of times people are performing whiles. There are other options for you, but they're technically challenging, maybe slow to heal and require more dissection and are not as familiar to surgeons. And then we have the MIS osteotomies, which for me has been a game changing in my practice, but it does also require specialized training. There's a learning curve, but once you get there, you can use a lot of these techniques to then achieve various corrections in a real sort of customized to the patient and even sort of customized on a toe by toe, joint by joint basis, but maybe limited in really severe deformity cases. So final thoughts, they both have a role open to MIS, strong proponents of both. I loved having the advantages of MIS and criticizing the open and vice versa for people who do not like MIS, but I think it's probably unfair to really criticize each other's too much. And there's certainly roles for both as long as you have experience with it. So regardless of your approach, you need a plan to address these issues and get comfortable with the various options. Thank you. Thank you very much. That was fantastic as well. My lean to is towards MIS. However, I agree that wholeheartedly, there are a variety of ways to approach these. I have done plantar approaches to the plantar plate and I find that to be very simple because that's where the problem is and you can see it and you can resect as much as you need to bring the toe to the position that you want and pin it. And I've found them to do quite well with very low recurrence. The issue has been plantar scarring, which I think we're taught to never do that, but I think it's a little overrated in terms of the complications. I just have not seen the complications that I thought that I would see from that. So I just want to throw that in there. We do have one question and this is probably directed towards Paul. Are you there? I'm here. Paul, the question is, what's your solution when you have a plantar plate that's so torn that it's irreparable and you have subluxation? What are your options at that point? Yeah, I mean, I think at that point, I mean, I certainly, what I do and I've tried a lot of things and I think that if someone comes in with a really big rigid crossover toe, which equates to basically an irreparable plantar plate, that's when I do a metatarsal shortening osteotomy and put a pin in it because it does work or it gets the toe straight. The toe is very stiff and it doesn't move very well, but it didn't before when they had this big rigid hammer toe thing. So in cases like that, I still think I go to a while osteotomy and pin the toe. Although hearing a lot of the MIS stuff, I'm certainly kind of interested in potentially doing some of that. Okay, thank you. Hey, Carol, I'm gonna step in and just say that, again, I think it's an underrated procedure and I know Chris didn't talk about it too much, but I actually, again, in my population, over 70, 75 years old in a patient with a rigidly dislocated second MTP joint, I oftentimes will do a second metatarsal head resection. And what I do is I will actually repair the plantar plate when I do it. And so I take the second metatarsal head out, I put an interpositional arthroplasty in, and then I repair the plantar plate and that will decrease that tendency for that second toe to float, gives it some stability, it maintains some length because you've got an interpositional arthroplasty in there, can't get paid for the interpositional, it's basically a metatarsal head resection. But my patients have been very happy with that procedure and been able to correct significant deformity with the, and again, these are patients with chronically dislocated, they don't get the stiffness that you get with the while. Yeah, Pete, I've done that a couple of times, maybe you taught me about it, I don't know, but you gave me a pretty broad topic to cover here and I made some executive decisions to limit on that, but. Oh, you're good, no problem, I just wanted to throw it in there on that specific topic, that's all. For sure. Holly, are you there? I am. In what instances are you doing plantar plate repairs since you're a master at the arthroplasty? You know, it's funny, Paul, it was great to see your talk. When Arthrex came out with their plantar plate, you know, correction device way back when, I don't know, five years ago or something like that. I really like went all in and I did a decent amount of them and I just never got good results. All the patients were stiff and maybe I was doing it, clearly I wasn't doing it right. I just never really saw good results. And then I also have seen a number of patients fixed by other people who come to me with the base of the proximal phalanx broken, with severely arthritic MTP joints. And actually the last one I did, the woman got arthritic. And so that really just kind of closed the coffin door on it for me. So I really, I virtually never. Now, if it's an acute, to me, a degenerative plantar plate tear, like I showed all those hammer toes, to me, that's not, in my opinion, I don't see that as something to repair. If I have an athlete come in and they've had a plantar plate injury to their second MTP, I go in and I fix the plantar plate. And I, sometimes I do it with an osteotomy and sometimes I don't. I see that acute injury, I will fix it. But otherwise I really don't. And again, maybe I just don't know how to do it well. Okay. Paul, I know what your answer is to that. Chris, when do you do your plantar plate repairs? As rarely as possible. But I did show in my one case, somebody who I did. And I think it's somebody who is very unstable on that toe, lockman test of the toe, so to speak. But I have primarily gone to trying to fix it with the MIS techniques. And sometimes, you know, if in that patient who has just a little bit of elevation, you know, I'll treat them by lengthening their MTP joints and releasing some of the extensor tendons and then doing a little plantar flexion osteotomy that Dr. Johnson showed. And I've been very pleased with that and their pain goes away as well. So I will say that since learning from Paul how to do it, I will only do plantar plates the way he showed me how. And I should also say that he was one of my co-residents and resident at Yale. So I've known him for an unfortunately long time. Excellent. To address the stiffness. So definitely that's a problem or it was definitely a big problem earlier in my career or earlier when I was doing these things. And my wife is a hand therapist, you know? So one of the, you know, hand surgeons that do soft tissue stuff like this, I mean, their patients are in hand therapy like almost right away to get things moving. So I started getting people into physical therapy after like two weeks to mostly work on flexion exercises. And I think that, you know, I think one of the things in all the literature, like all of these surgeries result in a floating toe, not just while osteotomy. So I think a lot of the big thought is that, you know, you get the floating toe because you're messing with the center of rotation of the metatarsal head, but floating toes are so common in every other procedure. And I think the common thing is scar tissue around the EDL. And so by getting people moving right away, I think that I've minimized how much scarring I get. Can I just respond to that for one sec, just about the floating toe? I have seen, I've even seen floating toes in percutaneous osteotomies, and that there's no scarring to the extensors. So I agree that when you do it open and you have these big open approaches, that's the case, but I can tell you that I've also seen it with distal metatarsal osteotomies. And I've seen people come back with pretty significant clawing. And that's why I caution people with the DMMOs. You have to be very, very careful with your indications because you wouldn't do a wild osteotomy on everybody with, you know, with metatarsalgia. Similarly, you shouldn't do a percutaneous osteotomy either, but that's one of the reasons why. So I can see that as part of it, but there's something else that we're all missing. I agree. My next question is for both Holly and Chris. What do you guys do, for those who don't do a lot of minimally invasive surgery, those X-rays look absolutely crazy. They look like non-unions, the bones are going in multiple directions. So how do you ease their concerns about radiographic findings? And two, do you show X-rays to your patients because they certainly won't understand what you're doing? Well, you know, sorry, Chris, I don't want to get ahead of you. You know, it's funny with, you just tell them that's how it's supposed to be. And I find that when I have a lot of confidence showing the X-rays and I show them that looks great and everything else, they kind of, they're fine with it. If I had, there's two instances where it gets dangerous. One is if they get X-rays from the outside and they get a radiologist who hasn't seen it before, that's dangerous. So I taught my radiologist at HSS, they know what to look for and they know how to comment on it. Outside radiologists can say some pretty scary things. The other thing I found is that this is a perfect example. I have a patient in, she's outside of Orlando and I did a, she had second metatarsalgia, she had a plantar plate. You know, what, Paul, you would have done an open procedure on. I did a percutaneous shortening and all of her metatarsalgia went away but she has a delayed union at the metatarsal. And her husband's an orthopedic PA and she's gotten multiple X-rays and you see this abundant bone and she still has a little bit of pain dorsally but all of her plantar pain is gone. I know if she goes to any local foot and ankle orthopedist or podiatrist, they're gonna open it up and they're gonna plate it and everything else for really, she needs more time and she needs a little reassurance and maybe a little score to BMAC or something. So if anyone is doing MIS around Orlando, please let me know because she needs to see one of my colleagues down there. Yeah, I agree. I think the patients care what their foot looks like. That's, you know, they're looking at their toes and if their toes are straight, they don't necessarily care and are not painful. They don't care what the X-rays look like. I think that we care what the X-rays look like a lot more than they do. I'll also say that as I've done this more, I spend a lot more time talking to patients about the downsides of MIS surgery because I think I got into a little bit of trouble early on kind of saying, you know, the recovery is gonna be easier. There's gonna be less pain. You're not gonna need any or very little opiate medications. And I think what the patients were hearing is I'm gonna be perfect. I'm gonna have no complications. I'm gonna have perfect motion. I'm gonna be normal again and I'm gonna have no recovery. And then I'm seeing them and they're having some swelling that persists. I'm not letting them run at two weeks. And so I spend a lot more time with them, you know, talking about, you know, the good and the bad, but a lot more about like, you know, the recovery. And I think that's good. But some, cause some people sort of think like, oh, it's magic surgery, it's gonna be easy. And I think that's something that I've grown over the last couple of years to understand more. I'm in agreement. I rarely, for the panel, I rarely do plantar plate repairs because I just, unlike Paul, I just can't get them to work for me. And I find for the early grade ones, I can easily do a percutaneous dorsal capsule release or leave the extensor tendons intact. And I will do a proximal phalanx base closing wedge osteotomy. And I'm amazed at how well that will reduce the toe. And if there's some varus or valgus to it, then I control that with the osteotomy as well. And then my last step is if it's still up a little bit, then I'll do a mini open extensor tendon, a little Z lengthening, and just let that float. And that typically does it. And I will pin it, however, and a little bit of plantar flexion. And I've been able to get that to work for me. Pete, are you there? Did Pete step away? No, I'm here. Sorry, I just- I'm wondering in the final 12 minutes, these speakers showed great cases. I'm wondering if the audience may wanna see some MIS bunion cases or something. I'm wondering what your thoughts were about that, because I do have a case or two I could share to get the experts' opinions on toes, but I don't know if we've beaten that subject up too much. What do you think? I think I'd just continue on the trend. I could show the bunion cases, but I think if you've got one or two cases just to show them, I think that'd be good. I think- Okay, I have a couple of those. There's a couple of questions that people had here about any experience with this TinoTac device. I've not had that. And I think there's a related question to that with, has anyone had experience just tinnadising the FDL to the base of the phalanx? Essentially doing a tendon transfer, it's sort of a streamlined, if you will, flexor to extensor transfer by taking the FDL instead of splitting it and wrapping it around and tying it on top, you're basically just tinnadising it into the phalanx, which is kind of a thing. Anybody had any experience with that? Somebody wanted to add a question about that. I've used that TinoTac thing in labs and it's basically a screw that you screw it into the planter surface of the base of the proximal phalanx and it catches the flexor tendon. So it's essentially a flexor tendon transfer to the base of the proximal phalanx. I mean, for me, I look at that and I think of it as a workaround. Just like Dr. Bailey was kind of mentioning, planar plate repairs in the traditional sense are really, really hard. When I started doing them and I was using the Arthrex kit, I mean, it was taking me 40 minutes per toe. As things have evolved, I mean, I get the stitches in and it basically takes me maybe 10, 15 minutes a toe now. And so, I don't know that there's a lot of debate in saying, what's the root cause? It's a planar plate tear, but I think a lot of controversy comes into what do you do about it? And so, what do you do about it? There's all these tendon transfers and workarounds as far as I'm concerned. But if you think about the rotator cuff, like you fix the lesion or you repair the lesion. And so that's been my thing. It's just difficult to do. I've sort of devoted my career to just making that surgery easier so that anybody can do it and do it efficiently, cheap, and have good results is what I'm striving for. Yeah, I agree. I think I've been actually similar doing it since about 2002. I've got my sort of semi-on repair on that regard and very similar. I think all of those procedures, if you think about it, basically, they just do the same thing. If you think about it, basically, they just are recentering the plantar plate, right? When you take the FDL, which is basically right underneath the center of the plantar plate, when you move it back underneath the center of the phalanx and you tie it in, you're basically just repairing that in a different method. So I would agree with you. I think I really love your... I've been doing it for about 10 years. I've been doing that plantar condylectomy trick as well, rather than a wild line osteotomy. I think that works fantastic to be able to gain access to the plantar plate. And I think that's something that I would definitely emphasize to people. It's a nice little thing. You don't have to take much off. And like Paul showed, really gives you, you can actually get better exposure of the plantar plate, see what you're doing, as opposed to trying to do an osteotomy, push it backward, and all the work that goes along with that entire process. We do... Errol, why don't we just... I've got a few cases. Why don't we just run through one case? Because we do have to spend about five minutes at the end, just kind of doing housekeeping items. So if you want to spend maybe one case, and then we can go from there. All right, let's see what the panel thinks on this here. Let's see. 60 year old, second toe pain. I'll stop there. You see what surgeries the patient has had prior. Second hammer toe, second met shortening, distal chevron. And now our problem is, she loves to wear shoes still, and she has pain and some metatarsalgia, and her second toe hits the top of her shoes, and it's really causing her a problem. Want to go down the line? Open for suggestions. Errol, where does she... Which metatarsal hurts? The second hurts or the third hurts? The second hurts and the second toe hurts. She actually does not have any great toe pain. It's all second toe and second plantar metatarsalgia. I'll keep it to a one-liner. I would do one, just the procedure. I would remove the screw in the first metatarsal, do a percutaneous chevron aching. And my guess is that would probably allow the second toe to come down and then revise the PIP fusion and probably not touch the lesser metatarsals unless they were super prominent. Others? I'll chime in. I think I was debating doing the full bunion. Looking at it, and I'd probably measure it out, but I think the joint doesn't look super off, and I'd probably try to get away with just doing kind of an aggressive aching to move the toe out of the way and maybe not cut the metatarsal neck. And then I'd do a fusion of the PIP joint for the second and then do a dorsal release at the MTP joint. I think if you, I think with that toe up, I wouldn't reshorten the metatarsals, but I think with the toe up that just pulls and it's gonna expose the metatarsal head on the bottom. So if we can get that down, I think she'll have less pain. So I would do an aching revision PIP fusion and MTP release. Paul? So I think here I would approach it a little differently. I think the big toe is really in the way. If you block out all the bones except for the first MTP joint, it looks kind of okay, but I would probably actually do an open closing wedge chevron with an aching because I think the hallux is really deviated there, but I think that should straighten out the first ray. And then I would take out that, I'd probably take out the screw and see what the plantar plate looks like. I'd probably end up doing a plantar plate repair and a plantar condylectomy. The plantar condylectomy helps with the metatarsalgia and then also the plantar plate repair would straighten out the toe, the second toe and also drag, bring the fat pad back to the metatarsal head. I think this is the beauty of the second toe. We have three experts and three entirely different opinions. And I think that's wonderful actually in a way for the participants because we just don't have this figured out. I ended up doing a big MIS aching and I did a capsular releases dorsal. And then I actually went to the base of the proximal phalanx and even though the patient already had a previous hammer toe, I osteotomized it there and shortened it down and plantar flexed it and just open pin the third. And this is my intraoperative films with the aching and I promise you, I don't have the final, I let her leave the office without getting the final. However, when I pin these, the toes stayed in this position before I pinned them. I was just uncomfortable not pinning them. So I pinned them and she went on to do quite well. So I didn't do a plantar plate repair. This was all osteotomies, essentially MIS. And the other thing I wanna show is I had another lady that was quite similar where someone had done a hemiarthroplasty. But in this instance, the second toe was plantar but she had no great toe pain. She had no bunion pain. The joint was stiff as you read about, but it was all about the position of the toe, wearing shoes. And she had second metatarsalgia. So, and to just move things along, I did another big ache and moved the toe over and then you're gonna see this screw in an odd place. Lately, I've been playing with trying to do parallel oblique metatarsal neck cuts resecting about a three millimeter wedge and then open and then just reducing it and holding it with a screw to try to prevent floating toes. And as you can see her, that toe sits down nicely. So it's something about, you know, I've never liked the wild myself because of what it does to the lumbricals and interossei. This tends to not do that with the parallel cuts and this worked out very nicely. Any comments before we go back to Pete? Yeah. Nice work. Yeah, it looks great. Yeah. All right. Great, great job. Elena is, you can go ahead, I guess stop the sharing for a second Errol and then we'll go back to sort of the full view. Appreciate that. Yeah, appreciate everybody. Elena has put in the chat section, how you can get CME. It's not every day, it's only a one-time claim. So if you're gonna be here for the next several days, wait till the end and then claim your CME there, but you do have that at the PRC and how to claim your CME for the course. I wanna thank all the faculty that's here today. I wanna thank everybody, the attendees who are participants and I appreciate all the questions, outstanding questions. We had great discussions, great talks and I hope you have all learned a lot. I know I have, continue to learn more and more when I hear these talks. So we have great specialists and wanna once again, thank our sponsors. Can't go on without having them play an integral role in our education programming. And that includes in this case, Stryker, Treece and Ardalan. So once again, if you see those people or at a meeting, please say thank you for the support that they provide us. So tomorrow we will be starting back at the same time as today, which is at 4 p.m. Central. Hold on just a second, I'll pull up the schedule. At 4 p.m. Central tomorrow, 5 p.m. Eastern, we will be starting off with ankle arthritis and then we'll have one symposium on that. And then we're gonna have a very interesting symposium and one that I can't wait for on cavovirus and metatarsus adductus because that is a brutal, metatarsus adductus is just always a struggle. And I don't think we spend enough on it and we see more and more of it as people get older. I just see more and more metatarsus adductus patients. So I cringe when I see them. So I'm looking forward to our experts on that panel tomorrow. So thank you very much everybody. And we will look forward to seeing everybody tomorrow at around 4 p.m. Central time. Take care, have a good evening. Bye everybody.

hammer toes

minimally invasive surgery

tendon releases

osteotomies

crossover toes

plantar plate repair

collateral ligament repair

metatarsal osteotomies

metatarsalgia

bunion deformities

toe function

open approach

MIS approach