Appreciate that, sorry we ran over a little bit, but I think Kelly's got it in hand. So she's gonna start our next session, which is also on some complex deformities and ones that I'm always interested in, because as I said on yesterday, during this time that cavovirus and specifically metatarsus adductus is just becoming increasing. I see those patients, they walk into my office, as soon as I see that picture, I'm like, whether it be a bunion, whether it be arthritis, whether it be fifth metatarsal overload, whether it be a fifth metatarsal stress fracture, whatever it is, it's just always difficult. So I'm looking forward to this session. So I'll turn it over to Kelly. Thank you. Thanks Pete, I really appreciate it. And thanks to all the speakers for being here. As Pete said, this is a session on cavovirus and metatarsus adductus, and I'm really excited to have Dr. Michalski and Dr. Miller here to chat about their topics. I'm gonna do a little bit of a summary talk, so I promise not to go over. You guys take the time you need to present. So starting off with Max from Cedars-Sinai in Los Angeles, presenting on a topic he's an expert on, and cavovirus deformity and CMT, some principles for correction. All right, thank you, Kelly. And thanks Dr. Mangone for the invitation. This is, I don't want to take all credit here. It's more of a Cedars approach to CMT. And here are my disclosures. They don't relate to this talk, but, you know, I call this a Cedars approach, but I do need to, because I've been fortunate to work and train at a Cedars Center, CMT Center of Excellence, but talk would kind of be more appropriate than the Mfeffer approach of those you know him. He probably has more experience or as much as anyone in the world. Last year he did over 90 CMT reconstructions, and I had the opportunity of training under him, and now I work next to him. So I also want to thank Tanya Ahn. She's an invaluable member of our research team. She's going to Stanford next year as an attending. So I'll briefly go over the role of bracing and CMT and goals of surgery, but the majority of the talk is discussing tips and tricks for management of cavovirus for CMT foot. All right, and I only have one slide on bracing. If you were at the winter meeting, you may or may not have seen this, but it's a really important point in that braces can be broadly broken down into two categories. There's functional braces like this one. They provide stability while holding the foot in a neutral position. They're a great option for CMT patients with diffuse weakness or early in disease before muscular deformities and imbalances happen. The second type of brace is accommodative. These provide support and padding to a maligned extremity. Eventually these worsen and have degenerative changes if not already. Using this brace is basically accepting a bad outcome. So please don't brace crooked feet. Management of these patients should really be based on these principles of getting a stable, balanced, plantigrade foot, which may or may not need braces, but hopefully you can minimize them. History is very important to the success of the surgery. You want to know how long they've had it and is it progressing rapidly? What surgeries have they had and what is the natural history of the disease in the family? There's over a hundred different genes associated with CMT and knowing how a family member progressed may provide insight, but we aren't sure yet. We have the ability to put clinical photos directly into my note in our EMR. So I always take pictures of previous incisions, which I think is more than just CMT. It's every principle. If you're doing surgery, I like to take a picture and have it in my chart because when you're trying to plan the surgery, maybe days or weeks later, you might not remember what approaches you have available based on those previous incisions. You want to look at a patient both sitting and standing, see if the exam can be misleading and they don't have weight bearing and use your hands to attempt to reduce the hind foot. You should be able to know without needing a Coleman block, just can you reduce it manually? If it corrects, that's helpful as the patient probably doesn't need a calcaneal osteotomy, but failure to reduce on the other hand is not really determined pre-op. It's an intraoperative determination because you don't know until you release all the soft tissues. Many patients complain they're unstable, but it's important to differentiate instability with walking from ligamentous laxity. Many of these patients are unstable because they're walking on the side of their foot with muscle imbalances, but they really don't have ligamentous laxity. And then finally watch the forefoot at toe off in the gait cycle. Many of these can fool you as thinking that the tibialis anterior is strong enough when the long toe extensors are really masking it. And the entire procedure pretty much resolves around this motor exam. You need to test and retest. And I have a checklist here of all the muscles because you can't simply evaluate plantar flexion, dorsiflexion, inversion, and eversion like in a normal foot and ankle patient. You really need to assess each individual tendon and go through your checklist and make sure you know what it is because you need to understand what surgical options are and plans B, C, or D. You get in the OR and you think you're going to use one, you thought it's strong and you get in there and it has no excursion. Well, what can I fall back on? And typically the M1 through five rating scale isn't that useful. These patients already, even if they're walking normally, they generally have global weakness. So it's more important, what is the strength relative to their antagonist? And Achilles is almost always normal unless it's been operated on. The tibialis anterior need to hold the toes in flexion and watch the tendon, feel it, make sure it's firing. Don't let the toe extensors fool you. Make sure you check the EHL and EDL. They're often less effective than the tibialis anterior and they're very powerful transfers. The brevis is typically weak and can be assessed. The longness is quite difficult. Isolating plantar flexion of your first rate is challenging for you or me. It's even harder if you have CMT and the EHL often drives the first rate down. Posterior tibial tendon, you can't assume it's strong. It's not always, but if you're going to try to transfer it, you better check it. And the FHL and FDL are very powerful transfers as well, but are frequently used in CMT patients. So the other thing, the principle of the exam is hold the foot in as neutral position as possible. You can imagine trying to assess strength of your wrist or your finger flexors and you put your wrist in maximal flexion. You can't really assess it. These feet are deformed. It's tough to really assess the muscles when they're at a biomechanical disadvantage. So frequently you're looking at these images and there isn't really a great reliable way to get x-rays. What do you do with an AP of the ankle and an AP of the foot in the same image? Well, we typically get a weight-bearing CT and oftentimes it's useful for research, but the best view is typically this 3D recon. It really tells you where the center of rotation of the deformity is, as well as it can really look at the shape of the calcaneus. I'm gonna go through this order step-by-step with the tips and tricks now. And this is the typical order, but not all CMT feet read the book. We won't be discussing external tibial torsion. It does have a role in all this, but it's not something typically addressed. As I mentioned earlier, patients frequently feel their ankles unstable. In young patients, actual ligamentous instability is pretty uncommon. They have instability walking on the lateral board of the foot but it's usually later on in the disease process. Well, they always seem to have a fixed equinus contracture, knee flexed and extended. And the question is, should they all get a tendo-achilles lengthening? These are typical lateral radiographs and CMT of capoveris. You know, usually the meris is greater than 20 degrees or higher. If you look at this, do you still think a TAL will get you much dorsiflexion? The talus is already abutting the front of the tibia. So abandon the lengthening or gastroc lengthening? And the answer is no, because the Achilles rotates as it inserts medially and it continues acting as a deforming force. Performing a triple cut really helps moving your calcaneal osteotomy. Also, the most distal cut on the medial side can help remove some of that varus pole. This need to be done first before the tourniquet's elevated. But I like waiting till later because oftentimes you don't think you're gonna get more dorsiflexion. Perform your medial release and see if you need a calcaneal osteotomy. So now the key to the procedure is understanding and correcting the center of rotation. Now we recently studied CMT patients versus controls. And in the axial plane, the largest deviation unsurprisingly is at the level of the navicular. Similar, we looked at the coronal plane and the maximal deviation occurs at the transverse tarsal and the NC joints, which is typically what you're looking at those 3D reconstructions. So again, these are those same X-rays from before, but they're pretty common. What do you do with these X-rays? You know the core is in the middle of the foot from the 3D recon, and you can see it in the X-ray, but keep these images in your head for the next slide and reminder, it's the left foot. We're gonna look at a clinical photo and post-op images next. So how do you take the imaging seen in the previous slide and make it into this foot on the left, seeing the video and these X-rays? This is the same patient. The answer is the medial release. I'll show the video a couple of times here because if you look at the correction you can get, this is why the Coleman block doesn't provide that much information. You don't know if the foot's reducible until you've released and brought the navicular back in front of the talus. So the components of the medial release are the posterior tibial tendon, which is usually transferred to the dorsum of the foot, the spring ligament, tail navicular capsule, and rare circumstances adding the subtalar joint, which was released in this patient. Some people don't believe that we should lengthen the posterior tibial tendon, but I'm a believer that you don't know what this patient's going to progress to and I don't feel like you should do a simple tenotomy of a postive tendon if you don't plan on transferring it because you may need this later. And I want to warn about releasing the subtalar joint as there's been four or five postoperative flat foot development, even with some of these severe deformities. They all had a subtalar release and most of them were adolescents. Here's an example of what can happen. So releasing the subtalar joint in some patient had a very severe cable varus deformity, but a young patient, you can over-correct them. So be careful with that. After the medial release, we move to the hind foot. A varus heel is both an axial and a coronal deformity. If you think about a hind foot alignment view or the long axial view, you're really getting partial coronal and partial axial assessment of the hind foot. A coronal plane rotation is the most obvious clinically when you're looking at the foot from behind. The axial plane deformity oftentimes can show you this calcaneus excurvatus or C-shape of the calcaneus that's not as common in controls which is something we recently looked at, looking at a mesh analysis of the calcaneus and the talus and navicular in CMT patients compared to controls. And the majority of CMT patients have this smaller radius of curvature or more C-shaped calcaneus than the standard patient who has a straight calcaneus. You want to know this for planning your osteotomy. You know, looking at 3D printed models, we compared osteotomies. The most powerful is a Z or Malerba. It's oftentimes complicated and it takes a larger incision where you're also worried about doing perineal work at the same time. A Dwyer makes a lot of sense because if you have that C-shaped calcaneus, you can straighten it back out. You can also add some translation and rotation with about a one centimeter wedge closing down laterally. Now, oftentimes shifting and rotating these feet it seems like easier said than done. So the key is a combination of both bony decompression and soft tissue management to kind of free the heel. In this patient, you can put the heel anywhere you want. So how do you do it? Here are the components of freeing the heel. First, make a cut for a simple lateral slide osteotomy. Put your laminar spreader in and basically move on to another step or close one of the wounds. This allows for soft tissue relaxation, makes your translation easier. Next, you can make the posterior cut with the laminar spreader still in place. It provides some stability and also you can watch the cut coming out. Moving this wedge of bone decompresses and allows for better shift. Third, release the plantar fascia down below you and even make sure you go up above the calcaneus because those soft tissues are oftentimes very tight. And finally, as I'd mentioned before, the tendo achilles lengthening frequently is used to remove a deforming force rather than getting more dorsiflexion when there's already abutment at the front of the tibia. Moving on to the dorsiflexion which is typically weak in these patients. How do we restore it? The most common way is transferring the post-tib tendon to the dorsum of the foot. Now, in some cases, post-tib is weakened or it's already been released, it's not available. The FDL and or FHL can be transferred through the neurostasis membrane and plugged into the cuneiforms. Alternately, you can transfer the EHL or EDL proximally in the metatarsals or cuneiforms. I'm gonna go through a few tips to make a successful post-tib transfer. Most difficult part of the case is oftentimes getting enough length to transfer it into the cuneiforms. You need to maximize your length. Taking away for the navicular and dissecting from the top down allows you to gain the length of the entire insertion. When you look here at the end of the video, you'll see after a little messing around with the beaver blade and the dull one, you gain quite a bit of length that you normally wouldn't have. As you can see. That's good. This gains about an extra centimeter or two that you can use to now dock that posterior tibial tendon transfer. Using a needle driver can often be good to crunch it up and kind of soften the bone wafer. It may provide bone-on-bone healing in the cuneiform. So typically you have to open the post-tib sheath behind the medial male. It always tends to get hung up right there. It seems to be a little stenotic part of the sheath. Other incisions are proximal, medial, anterolateral, and the dorsal foot. Passing tendon interosseous and subcutaneous or then under the extensor retinaculum, that's a preference call. I typically, all right. So large peon clamps are very helpful in these cases. You can take them and they pass it behind the tibia and then spread them wide open. You want to make sure that this tendon is going to pass easily. Now pierce the interosseous membrane, palpate, and then you can make your interosseous, your anterolateral incision. And then usually grab the peon from the other side, pass it through to grab my tendons. As you can see here, the other peon have been grabbed, pulled through. And now with irrigation, help them slide. This patient got double tendon transfer because of lack of full strength in the posterior tibial tendon. Now again, showing this alternatively, you can pass the tendon with suture. I prefer the peon clamps because they're generally nice to use to spread that interosseous membrane open. But the point of the video here is to look at the incisions. The anterolateral incision starts basically at the proximal extent of the distal incision and with a little bit of overlap. You want to make sure you have that travel distally. So you're pulling along that line of pull of the muscle rather than straight from medial lateral incisions. Next, again, using the peons and some irrigation, you can pass the dorsal foot either above or below the extensor retinaculum. Tendons typically insert a lateral cuneiform, which is typically about the center of the foot for providing strictly dorsiflexion, fixed with an interference screw, and fixating is typically the last step of the procedure. There's no answer to how much tension in general you should be placing in, but the mid-range of motion, plus a little bit tighter works well. And it's not the most scientific answer, but usually just a little tighter than the midpoint of excursion. If you can see here, this patient had a similar surgery in an outside hospital and they were tensioned in maximal dorsiflexion. They were unable to get back to neutral. They also stretch out some, but you can't put it in maximal dorsiflexion. You'd be stuck with a foot like this with a calcaneal gait. Dorsiflexion alternatives. So a bridal procedure is great treatment, especially in perineal nerve injuries, but in CMT, these patients are often weak. I prefer that tendon transfers perform a single function. So they're either transferred as a dorsiflexure or an inverter. We studied dorsiflexion strength of the EDL and EHL transfers in the biomechanics lab. And we found transferring both tendons into either the metatarsals or the cuneiforms can generate enough dorsiflexion to neutral with only a quarter of their normal strength. You've eliminated the extra crossing of joints of the of the toes, and this provides the extra power. But if you do these transfers, you need to address the forefoot. These patients don't have intrinsics, so you actually can worsen the toe deformities by releasing the EHL and EDL, which is counterintuitive. So fuse the hallux IP and the PIP joints, depending on what you transfer, may need some flexor tenotomies. Next, we'll move on to eversion. A traditional approach is lungus to brevis transfer, but when you get a complicated case, that's not always available. Sometimes you get in the case and the lungus doesn't move at all, or you tell preoperatively it's not going to, it has no function. What are your alternatives? Typically, you can move the FHL to the brevis while excising the lungus, or even a subtalar fusion, and place them in the position you want them so they no longer have that instability of inversion and eversion. Now, this is counterintuitive to the, or counter to the dorsiflexion, and these tend to transfer the tendon and hold it in maximal eversion. It almost acts as a soft tissue subtalar fusion, but it's typically will stretch out and get you back to neutral. And the final step, not including toes, is plantar flexion. This is what functionally improves dorsiflexion of the foot, because the mirror's angle is so high. Most commonly, a first metatarsal dorsal closing wedge osteotomy works. Sometimes you need to add a medial cuneiform, especially in adolescents with open physes. This can be extremely challenging to close down, and adding a second plantar fascia release, which doesn't intuitively make sense, but it does seem to let, allow a greater correction of dorsiflexion once you do this in the midfoot. Typical post-op protocol is 10 weeks, is at two weeks, remove the splint and sutures, and put them in a short leg cast. Move the cast into a tall weight, tall cam boot, start your range of motion weight bearing. If they're a fusion, I tend to wait a little bit longer, wait 10 weeks, and third post-op week, you start physical therapy. I do think there's a role for MIS. Dr. Bailey also mentioned is that we start to get better with these techniques. You know, using a burr for complex surgeries or avoid previous incisions can be helpful for calcaneal deformity, previous surgeries, and in the forefoot. Thank you. Thanks so much, Max. We'll give Christopher Miller a minute to bring up his slides, and we're going to learn about metatarsal seductus, both open and MIS procedures for that condition. So take it away. Thanks for having us on, Max, great talk. I always learn a lot from you on that topic, and I send all of my really bad cavers feet to LA now. But I'm going to talk about metatarsal seductus, and something I've been seeing more as Pete Mangone was suggesting. So these are my disclosures here. So this is a tale of two Banyans here that came to see me, and both of them were sort of mid-50s women. They've had Banyans as long as they can remember. Most of the pain was of the medial eminence, a little bit of lateral flexion, a little bit of lateral foot overload, and the one on the right here also had some mid-foot pain. So we're going to go through a bunch of stuff, and we'll come back to this at the end. So the goals here, I want to talk to you a little bit about metatarsal seductus. Obviously, I'll talk about the diagnosis, the treatment, and then I'll go over my algorithm for this, and then come back to the cases at the end. So what is metatarsal seductus? It's a congenital disorder, one of the more common ones that we see in the foot, and it's quoted to have an incidence of 1 to 2 in 1,000 live births. I did sort of look into this a little bit more. Where it came from was from a study in 67 in Britain, and it was a congenital foot clinic, and so they were really looking at people that had very severe deformities, a lot of clubfoot in that case, and then some of them also had just metatarsal seductus. So I think that the 1 to 2 in 1,000 is probably underreporting it, and when we start really looking a little bit more critically at the x-rays, we'll see it more commonly. So it often presents in childhood as in-toeing. Our pediatrics colleagues will deal with this pretty commonly, and usually in infancy and early childhood, it can be treated with stretching, maybe some casts and orthotics, and then monitored. But it's defined as a sort of turning in of the midfoot while typically you have a fairly neutral hindfoot, probably due to some packaging in utero, but I don't think people know for sure why this happens. The more severe rigid deformities are likely addressed earlier in childhood. They can do surgeries with various osteotomies in the midfoot to try and correct this, but the ones we see are often clinically silent until they get to adulthood, and then they'll start presenting in their fourth through sixth decades of life with lateral foot overload, and very commonly we see this in the setting of bunions, and oftentimes also with some toe deformities as well. So first of all, how do we measure it? How do we define it? So the most reliable and reproducible method is the so-called modified, and I struggle with this word, but scarlato. I'm sure that's not how I'm supposed to say it. And you can see what we do is we take the sort of center point of this line from the first TMT medially to the medial TN joint, and then each of the proximal and lateral and distal aspects of the lateral of the cuboid, you find the center point of both of those, you make a transverse line through there defining kind of a midfoot axis, you then take a 90 degree angle from that line, and then you take a second line up through the center of the second metatarsus. So, and then this will be the so-called metatarsus adductus angle. You can see it done here in a diagram. So how does that look? This is one of my cases here, significant metatarsus adductus, but how much? So we take that midpoint, make a 90 degree line, we make the line up the second, and now we have a metatarsus adductus angle of about 43. Okay, so we know how to measure it. It's reproducible, much like everything in childhood. We start a little bit in towing, and then as we grow up, or we get a little bit more external rotation. So in early childhood, it's in the mid-20s range, and in adults, we're looking for a number under 20, so typically 10 to 20. And when we look at sort of trying to grade the severity of this, I'm going to use this definition here. So normal is under 20. Mild will be 20 to 25, and so on, up to sort of extremely severe. And this is how they defined it in these two studies down at the bottom there. Okay, so prevalence. I know I said earlier, one in a thousand. More recent things are suggesting maybe two to 10 percent, depending on what population you're studying. And I do think that matches more with what I see in the clinic, but maybe I just see a lot of bunions also. Because we also know that when you're treating people with Halox valgus and bunions, the incidence of concomitant metatarsus adductus is much higher than the background. So there's a strong correlation with MA and Halox valgus, and in these studies, somewhere around 30 to 35 percent. And if you have metatarsus adductus, again defined as an angle over 20, you're about three and a half times more likely to develop a bunion. Okay, so why should we care about it? Well, number one, this can often be painful to correct, as Dr. Mangone was alluding to. You have somebody coming in with this type of x-ray here, and you kind of groan because you know you're in for a long case to try and get that corrected. But in this case, if you just look at the numbers, the IMA is nine. So clearly, the severity of this bunion is much worse than would be suggested with the IMA of nine. It's because the increased MAA is falsely hiding the inter-metatarsal angle. So, and then when we try to correct it, we have no place to put the first ray. So in order to get the first ray to move, you have to move the second. In order to get the second to move out of the way, you got to move the third, and so on. So it becomes a sort of cascading issue where you have to, you want to just do a nice little bunion case, but you have to really now correct the whole midfoot to get it in proper alignment. So we got to talk about this paper here, and Dr. Tabs Iyer, he's down in Baltimore at Johns Hopkins now. Really great guy, and I thank him for this. We had some discussions coming into this talk, and he wrote two papers on the same subset here, the 587 patients who had undergone Hallux valgus at Mercy before he was a fellow there. 414 did not have MA, and 173 did. They looked at the recurrence, and they just said, you know, they defined recurrence radiographically, so an HVA over 20. This was not symptomatic recurrence, so we know that you can have some recurrence and people don't mind, but this was strictly radiographic recurrence. In the non-MA group, 15% of those patients developed recurrence defined by a Hallux valgus angle over 20. In the MA group, it was about 30. So that's the first sort of high-level pass of the data. So if we look at just the patients with MA, so this was 173 patients, and you look at the people with less severe metatarsus adductus, so this is an angle less than 31, there was 40 patients with recurrence, which comes out to be 26%. When you look at the patients with severe metatarsus adductus, which was only 19 patients, there's 52% recurrence. Makes sense. The more deformity you have, the higher likelihood you're going to have recurrence. Okay, let's keep going. Let's look at just the cases with severe metatarsus adductus. So of those, eight of the 19 underwent a lapidus procedure plus a second and third TMT fusion to do corrective fusion to fix the MA. 11 of them did not, and when we look at those, of the patients, of the eight patients that had the correction of the metatarsus adductus, the recurrence was 25% as opposed to 73% if you did not correct it. So first pass here, and the point I want to get across is that if you do have severe metatarsus adductus, it probably behooves us to correct that in some fashion, and here they're talking about doing fusions. Okay, so again, high-level summary, without MA, recurrence in this study was 15% with MA, 30, but when you look at the patients without severe MA, none of whom had any realignment procedures, it was 26% compared to 52%, but then you break that down, and the patients who had correction had a much lower rate than the ones who did not. But I think, for me, this then begs the question, what about this group with less severe MA? You know, can we do something here that's going to reduce and help this population get down to here? Okay, so when we're looking at open surgeries, we have two options, and we alluded to one of them, which was the fusion, but my slide says corrective osteotomies first. So you can do osteotomies, and I talked a little bit about this yesterday in terms of shortening osteotomies, but in addition to just purely shortening, you can also do sort of oblique osteotomies at the base of the foot and rotate it over to correct the metatarsus adductus. I think this is somewhat technically demanding surgery, and I think a lot of us have less experience with this type, and so a lot of surgeons, as you saw with Dr. Iyer's paper, are going to preferentially want to correct this with a basal osteotomy, in part because we're more familiar with doing fusions of the midfoot, and we get, you know, immediate stability. Okay, so the amount of data on outcomes for when I was looking for strictly metatarsus adductus is really poor. In terms of the oblique osteotomies, this was the only case I was able, case series I could find, and there was only four patients. Now, all of them healed. It does require fixation for sure, and you can see they treated it with a lapidus and then these double osteotomies through the midfoot proximally and then distally as well to correct the alignment, but you have to watch for your sagittal plane malunions as well. Okay, so corrective TMT fusions, again, no large studies. Actually, the largest one looking at this strictly for metatarsus adductus was Dr. Iyer's study that I already talked about, and we know that in that study about 50% of the patients with severe MA have arthritis anyway, so fusion may be a good option in those cases because then you can treat both the deformity and the pain generator of the arthritic joint. When we look at doing it just for arthritic conditions, 80 to 95% fusion rates in most studies, and it's certainly possible that some of the data that would be helpful for us here in terms of teasing out treatments for metatarsus adductus is hidden in some of the reports of just midfoot fusions for arthritis, but the rationale would be similar for the lapidus. You're going to end up with permanent stability, and you're addressing it sort of at the core of the deformity here. Okay, so we heard a lot about lapoplasty yesterday. They do have this new adductoplasty. I haven't used this, although I do think it's an interesting technique. It uses a similar type jig to create these lateral closing wedge osteotomies and then allow correction of the metatarsus adductus. I wasn't able to find any reports of outcomes of this technique yet. The citation I have at the bottom is just a technique tip and sort of discussion of how to do it, but without discussing the reports, but I'm sure our friend from yesterday will be publishing on this at some point, and I look forward to seeing his outcomes there. And again, limited outcomes. So Dr. Ayer's paper, 25% recurrence with the corrective fusion, and then only a small case series with this osteotomies here. So why is the data so limited? And I alluded to this yesterday as well, and I think it's an easy answer, and it's hard. And when you're doing a bunion case, you just want to do a quick little case, and now you're having to do all this other stuff. So it's something that's, you know, when this comes into your office, you're frustrated and you've grown a little bit because you know it's going to be a complicated case. And so I think some surgeons look at these and try to, you know, they try to do less, and it's probably not the right answer as we showed with needing to correct it. But there's just not a lot out there on it. So what other options are there? And this is where MIS is going to come into play. So on one hand, we can do the open fusions or corrective osteotomies, which for me doesn't sound like a lot of fun, but I would argue that we might be able to do something kind of slick with the MIS procedures, and that's what I'm going to talk about now. So MIS for metaductus, but how are you going to do it, and is it going to work? So let me first show you how I do this. Oh, actually, let me first remind you yesterday that Holly Johnson stole my thunder a little bit, but she showed some really nice x-rays here of her technique, which involves a more distal osteotomy and correcting the toes, and then doing an MIS lapidus. So I don't have a lot of experience with this, but she was very positive on it, and I certainly look forward to learning more from her and seeing her outcomes when she gets that together. So this is how she treats it, just to remind everybody of our discussion yesterday. But this is how I do it. So this is a case with a metatarsal ductus about 30, and what I'll do is I'll mark out the base of the metatarsals here and make sure I palpate the dorsalis pedis. I want to stay well lateral to that, and then I come in with the burr. This is the same burr I use for my achens, and I start at the lateral apex of the deformity so I can move the fourth out of the way of the third and so on, and I do create closing wedge osteotomies laterally. So I pierce into the bone percutaneously, and then I'll sweep, you know, up and down just at the metatarsal junction, and I'll do that across all three of them, trying to leave the medial cortex intact, at least leaving the medial periosteal hinge intact. So once I have those osteotomies ready, I then brace the foot and I manipulate it laterally to close it down. I like to turn off any music because I like to hear all the pops going, and it's, if you have a new scrub tech, sometimes you can kind of surprise them with the breaking bones. But so I'll close it down, but they're not going to be stable. And I don't fix them as you saw in the first x-ray there. And then I'll come down and you can do, in this case, I'm doing a, you know, MIS bonding correction with a large translation. You usually get at least a hundred percent because now you can really move those lateral minotarsals out of the way. And now it's just their standard fixation. And so this is what it looked like once she healed. You can see the correction in terms of the alignment there. Now, certainly you could also argue doing this with a Lapidus, completely reasonable. I think it's a little bit dealer's choice how you hold it over there and correct the bunion. So how do these do? And so this was a recently published study out of Tel Aviv in Israel. And I actually got the chance to talk to some of these authors a couple of years ago about this. So this was their results on the first 21 feet that they did, a MECA and two to four proximal minotarsal osteotomies. Very similar technique to what I just showed you, although they were a little bit more distal in their osteotomies there. And they showed, again, this is one year outcomes here. Significant improvements in functional scores, improvements in the alignment of the radiographic parameters here. Their minotarsal ductus angle went down from a mean of 29 to 13, although they did do this in cases up to 46%. I'm sorry, 46 degrees. And interestingly, again, if we use the hallux valgus of over 20 as being recurrence, they only had a 10% recurrence rate. And it didn't correlate with the post-op severity or the pre-op severity of the minotarsal ductus. Now, only one year follow-up, so look forward to more of this to come. And if you're worried about the healing, as we see with many of the things in MIS, they heal robustly and reliably. So all 63 of the lesser minotarsals healed here, and they did have one delayed union of the bunion, and that was in somebody who has severe vitamin D deficiency. So I would argue that for me, being able to do this type of correction, but doing it percutaneously, makes it a lot more palatable compared to doing the open procedure, even in somebody who has less than very severe minotarsal ductus. So I find myself much more willing to do this and because I have an option to do it, I see it more commonly and I'm more willing to sort of chase it. So the recovery after this type of surgery, their protocol is that they let people weight-bearing tolerated day one, they were in a boot for about six weeks. I usually keep them off of it or maybe heal weight-bearing at most for the first two weeks and then I let them weight-bearing tolerated and then I restrap them. And then after about two or four weeks, I usually get into some sort of like little putty splint here to help hold the toes in alignment as well. And this way they can take it on and off at home and clean their foot. It helps with the swelling as well. So why do I keep them off of it? You're always treating your last complication and one of my early cases, I was a little bit more distal in the minotarsal and I lost some of the sagittal plane correction. So the coronal plane was still good, but the distal minotarsal shifted up a little bit and he had a little bit of hump of the midfoot that he didn't like. And so I keep them off of it for about two weeks so it gets a little sticky. At least that's my hope. And since doing that, I've been very pleased with these cases. So the next step is thinking about the toes. So here's a case where you have sort of that windswept toe deformity. I think of the toes as often being a buttress at the hallux as well. And in this case, they did a lapis. I think they did a reasonable job, but they left the toes and they left the metatarsus adductus. We know that's going to be high risk for recurrence. And so this went on to failure. And I think in part, you could argue they didn't correct the adductus, which is pretty severe, but also they lack that buttress effect to the lesser toes. So you have to think about this at multiple planes in the foot. This is another example where they tried more of a soft tissue procedure for the hallux and then tried pinning the lesser metatarsals, but this wasn't really a very durable correction of the hallux. And again, that went on to fail quite quickly as well. So it's not something you can do in isolation. I think it's something you have to do kind of all in one package. So limitations, open surgery, probably a longer, more complex surgery for many of us. You can result in sagittal malunions if you don't get the metatarsal cascade proper. You can have non-unions of the arthrodesis site, maybe osteotomy. This is in comparison to the MIS, which seems to be healing quite robustly. And you have more wounds. So advantages, doing a fusion open is probably technically easier than doing an MIS, particularly if you have to correct alignment as well. So you don't need any special training. We're probably much more familiar with this as surgeons throughout our training. And again, arthritis is fairly common. So if you're gonna treat the adductors, you can do it at the same time that you treat the arthritis with the fusion. So MIS corrections, that's a new technique, no long-term outcomes. Although let's be honest, there's no real long-term outcomes for correcting the metatarsal adductors open either. And then the question is how much deformity can we correct? Now I'll point to the MIS study, which had a fair number of patients in that 30 to 46 MAA group as well. So they were doing fairly severe deformities. And in my own experience, I've been able to correct some pretty robust deformities as well. But it does require experience and comfort using the MIS-BUR, slightly different technique than what we're used to. So advantages is quick. When I do this in the OR, it takes me about five minutes to mark and cut all those metatarsals. And I'll get this entire case done in about an hour. And so I find this fairly simple. Once I got comfortable with it, it heals reliably. And it certainly decreased my kind of threshold to consider doing this because I know that I can get a good correction and that it's gonna heal. I think that the risk is fairly small. So this is my decision algorithm. So starting at the top, if you don't have metatarsus adductus, you do your standard bunion, whatever that is. If you do have metatarsus adductus, I then look to see if there's arthritis in the midfoot. If there is, I'm gonna, and certainly if there isn't a symptomatic, I'm gonna do corrective fusions, taking little basilar wedges out in order to swing the metatarsals over. Whether you do that freehand or with a jig, I think is a little bit dealer's choice. If there's not arthritis, then I ask myself, how severe is the metatarsus adductus? If, you know, I think for that adductus angle of 20 to 30, for me, this is gonna be the ideal spot for everybody to get comfortable with MIS procedures. And this is, in that original study with Dr. Iyer, these were the ones that weren't corrected, but still had that 26%, 30% recurrence rate. And so maybe up to you whether or not you wanna chase it, but if you have the MIS skillset, these are the ones I think we should get more studies on to see how they do. If there's very severe metatarsus adductus, I think you're obligated to go after it. And whether you do an MIS, open, osteotomies, or fusions, I think that's gonna be very much dependent on the surgeon's comfort level. And then once you've done the midfoot correction and the binding correction, you gotta look at those toes, think about the buttress of the toes and do something to correct them. So back to my first two cases here. So this was the first one. You can see the angles there on the left. She has some arthritis in the midfoot, which is where her pain was. So in this, and she has some windswept hammer toe deformities. So I went with a Lapidus two and three corrections with hammer toes, and you can see the results here. This is obviously her final outcome here with the x-rays. I don't have final clinical photos, and I apologize for that. And then here was my other case that I treated with an all MIS approach. Again, no pain in the midfoot, no significant arthritis there. So we did the MIS bunion and two to four PMMOs, and you can see her final angles here in alignment. And then I let her wait there on the heel post-op day one, but it would for about six weeks. So in summary, 30% of bunions will have metaductus. Metaductus, I tell my patients, is associated with about 30% of recurrence if you don't correct it. Severe MA, I think we're obligated to correct it to decrease the risk of recurrence and just make the surgery possible. And in that mild to moderate group, I think we need to seriously consider whether or not correcting it will help us decrease it further. Again, in Dr. Iyer's paper, 26%. In this one-year outcome study, 9% or 10% when it was corrected. And for me, MIS is just much more tolerable to make me want to correct those more mild deformities. So final thoughts, metatarsus can be and is intimidating, especially early in practice. I think MIS offers a lot of good options here and we should think about it more seriously, but don't forget about the toes. And I didn't talk about MTP fusion. I think it's a great option here as well, because once you get that MTP fuse, it's not gonna come back. So, but even there, you're probably gonna have to, in a case like this, if I wanted to do MTP fusion, I'd still need to do something to correct those lesser metatarsals as well. So it's out there, it's gonna come for you. And I hope this helps you come up with a plan. Awesome, thank you so much. I'm gonna load up my talk, which will be a little bit brief. It's sort of a consolidation of concepts more than trying to cover a specific topic. So we'll get going. And if you do have questions, just remember to put them in the Q&A and I'll save some time at the end just to address them. And then Kristen and Max, if you see any questions in the Q&A that are relevant to your topics that you can type in a quick answer, you can go ahead and do that too. Awesome. Well, my topic is called Complex Midfoot and Heimfoot Reconstructions, which is kind of covers a lot of things we've talked about this evening already, but we're gonna thank Dr. Mangone as well, because he provided me some slides. And most of the cases are my own, things I've learned along the way in revisions, just to show you that it's not always so easy. These are my disclosures, but none of them are relevant to this presentation. Really the question is how to approach these complex hindfoot and midfoot deformities that come in. And we'll go through a few principles because none of these are the same as the next one. And it's not like having a recipe necessarily, but having some sound principles you can follow to treat these types of patients and deformities is important. So understanding what is causing the deformity would be principle number one. And there are many, many reasons patients end up with feet and ankles that don't look like feet and ankles, post-traumatic and Charcot being two really common ones. And we're gonna have a whole other symposium on Charcot, so we're not gonna get deeply into that here. Chronic ankle or foot instability of the ankle, subtalar joints or midfoot, congenital deformities like residual clubfoot or spina bifida, neuromuscular diseases, inflammatory disease, and then the PCFD and chemo varus group, which we're gonna have another talk on plaintive obvious foot tomorrow. But don't forget the basics when seeing these patients. Sometimes it's super helpful just to take a step back and try and see the bigger picture. Do a thorough history and physical exam. Patients don't end up like this without many layers of things going on usually. And consider your imaging carefully. I can't emphasize enough how important it is to talk to patients about their social determinants of health and the factors that might go into whether surgical treatment is even an option. Consider their metabolic health and certainly try and get on the same page and understand the patient expectations. And really what it comes down to is trying to understand what is actually bothering the patient. Is it pain, is it deformity, or is it both? Or something totally unrelated, which is possible too. And then digging into the history a little bit further, really trying to understand the etiology and if they're a diabetic, understanding whether they're controlled or uncontrolled. Go back to their childhood history of their foot and ankle. Did they have recurrent ankle sprains? Treatment as a child with surgery or orthoses? Was there a trauma, even a more proximal trauma that might've led to post-compartment syndrome type deformity? And how long is this patient living with the deformity they have and why are they presenting now? And not to mention nicotine use. Physical exam, some really specific things when you're considering dealing with a complex deformity and pulses, pulses, pulses. So this patient, if they're going to have any chance at reconstruction, they need to have a foot that has the blood flow required to be able to heal the bone and soft tissues. Is the deformity rigid or deformity is rigid or flexible? And then what's happening with their skin? Do they have massive lymphedema, venous stasis, multiple prior incisions, ulcers or pre-ulcers, prominences, and then do they have contractures? Imaging, again, this is fairly generic. I have a bunch of cases to illustrate these points later, but imaging is standard stuff. Always starting with standing weight bearing X-rays of both the foot and ankle and considering the contralateral side to see what is on their normal side. I'll illustrate that a little bit later too. CT scans can be pretty helpful in assessing a complex foot and ankle deformity and even more so if you have access to a weight bearing CT scan. Also assessing for concomitant joint arthritis of other joints outside the deformity. In general, MRI is more useful to look at the soft tissue structures, but not as helpful in these complex deformity planning. And then coming back to this concept of social factors, it's so important to understand if a patient can be safe after having a complex deformity correction surgery. Do they live alone? Can they have assistance? I mean, many people who work in the U.S. know how challenging it is to explain to an elderly patient who needs a large deformity correction that they can't stay in the hospital and they have to make an outpatient plan due to the way that CMS policies work here. That is a major hurdle and a major challenge for many of our patients. So consider surgical treatment very carefully or you may end up with someone with a hip fracture that is a result of their inability to be safely mobilizing. It's happened to me as well. And then the patient expectations piece is so critical. You really need to understand what they're looking for. And if they're looking for a normal foot and ankle, it's probably best to temper those expectations. Often it's not possible to get them to pain-free. So really talking to them about what to expect and documenting that conversation. And then, like I mentioned, having a normal foot and ankle is probably not gonna be the case after surgery, but establishing those expectations early is really critical. And this I think is the most important principle that I'm learning and Dr. Mangone has already learned is you really do need to know your limits and be prepared to say no if the risk is just too high. These cases are getting into scenarios where limb loss is a real risk. And so having those conversations openly and frankly, collaborating with other surgeons and even referring to another surgeon who might have more resources or greater experience. And sometimes non-ops best. So weight loss, blood glucose control, physical therapy, sometimes bracing and shoe wear accommodations where possible, differential injections depending on the locations of their pain, and then even topical inserts because some patients just really shouldn't have surgery. And then you need to have hard stops for those patients. So here are some of the top concepts we talk about, but medically optimizing means ceasing all nicotine use. We know the risks are incredibly high for wound complications and non-unions and active smokers. Tight blood sugar control, most would say less than eight or less than seven on A1C. Edema control if possible, and consider vitamin D testing or treatment for these patients. Socially optimize the patients and then optimize their expectations. So moving, if you've decided to operate on a patient with a complex midfoot or hindfoot deformity, you move on to your basic principles of preoperative planning, being prepared to make interoperative surgical decisions because these don't always go exactly as expected. So planning for the equipment and the time to be able to accommodate and be flexible with your operative plan. And these are the types of decisions you'll want to make preoperatively where possible and considering whether you're doing a staged procedure versus a one-time correction and what approach will be used. So really considering the skin condition and previous incisions in this consideration. What are you doing with the fibula if you're doing a hind foot or ankle fusion? And is there an MIS approach that that will achieve your goals or do you need larger open incisions? And then have your fixation options. I have rods, plates, staples. I have everything ready when I'm embarking on one of these cases because you just never know. External fixation if there's a patient who you feel would do best to have a thin wire frame. If you have that experience then great. If you need to collaborate with a colleague too that's very very appropriate. And then considering whether you need bone grafting whether that's autograft or allograft or even a bulk allograft. You need to make sure that's available and ready for you if that's something you're going to need. And so some general operative strategy principles. Again it's hard to put all these in one bucket but the the traditional you know principle of correcting the proximal deformity and working distal holds true in most cases. Identifying the apex of the deformity as as Jesse and others talked about earlier and try to correct the deformity through that apex where possible. Always take enough bone to correct the deformity and make sure your soft tissues are under tension and then ensuring you have rigid fixation. A lot of these philosophies are going to come through in our Charcot talks tomorrow. But adapt as needed. Your surgical experience is valuable and you may have to think outside the box and reflect on past cases to help get you out of a bind. They're not usual cases and they require creativity. So I can't emphasize enough about paying attention to the soft tissues and I'll try to get to a case that kind of highlights that today. And really know when enough is enough. You can't always make these feet perfect and that's just a reality. And if you think you might be able to get some of it done but you run out of time or it's no longer safe to proceed because of soft tissue concerns then maybe you need to come back later. So in summary, no two deformities are the same and the success of a painless plantigrade foot allowing for reasonable off-the-shelf shoewear or even a brace is a goal. And follow your principles but be willing to adapt. And I think this is what I've learned. I have to take on these difficult cases but I enjoy it more and more because these patients are incredibly grateful if you're able to achieve some of their goals of being able to walk on a foot that was previously not functional. They truly make an impact and can really help foster surgical confidence for some of the less complex deformities. So I'll just show you a couple of really brief cases and then we'll clue it up. This case one is a patient who was a very delayed presentation after an ankle fracture. She came in five months out and she was afraid of surgery when she presented to another hospital. She was an active smoker but willing to get to quit and very anxious and this is how she came in. So she was a nearly dislocated trimal fracture and she was stiff and she was not able to walk. So I thought about this a lot and my goal was to get that foot under her tibia as much as possible and the main consideration for me here was what approach is going to be most effective to get that talus back under her ankle and I chose to do a posterior approach, a transepileas approach. And so we used a large kind of it's a large fry plate I think because whatever I had planned to use didn't show up that day and we packed a bunch of some of her fibula mixed with some allograft and some other junk in there. We got her talus mostly under her tibia, I would argue not perfectly and she went on to a non-union. She did quit smoking but she has horrible osteoporosis and I probably did not get sufficient fixation to provide compression across that eventually. So then I had to make another plan and so the plan this time is that I went in pro, took everything out, cleaned up the back of her joint, then flipped her and then we did an anterior plate infusion and thankfully this one was successful and she's actually finally very happy. But it's just an example of thinking about the approaches and maybe the approach you use most often is not always the most appropriate approach depending on the scenario. I still think the posterior approach is the right one for it. Case number two, these are patients I'll never forget the names of which is kind of you know a good indication of how complex they were but it's a Liz Frank was treated at an outside hospital. His plates apparently fell out through the skin and came in to see me with a painful deformity. So basically just midfoot instability and deformity with significant lateral translation of his lesser rays relative to where they're supposed to be. He also has pretty significant deformity on the sagittal view at the NC joint as well as some of the TN joint and clinically has very bad hindfoot valgus. So I tried my best. I went in, I bone grafted everything, cleaned it all out, took down all the non-unions and plated one, two and three. Thought it was great but obviously I didn't correct the whole picture. I did not correct the rest of his midfoot deformity and he still had significant hindfoot valgus. And so he failed. Everything broke and fell out and didn't heal. It did not get infected thankfully but we went back in and did a much bigger job this time focusing on correcting his deformity as much as the soft tissues would allow us as well as correcting his significant hindfoot valgus. And he's actually gone on to heal this. I actually used a large iliac crest autograft here to help correct some of the length of his first ray as well. But this was not a small undertaking and it was one where I kind of wish I had done this the first time and really thinking about the whole deformity in the big picture would have maybe helped me avoid the scenario. A couple of quick ones. I know we only have 10 minutes. This is a guy who had a previous tailless fracture a couple years ago. Really funny guy. Diabetes but well-controlled actually. Obese and he can't walk and this is what he rolled in with. He has a tailor neck nonunion in varus with avian and he just wants to walk comfortably. So I did a talectomy with femoral head allograft and a hindfoot nail and he's actually done very well even though I don't like how my graft looks clinically. It's fine. Maybe I would have done a bigger graft to kind of maintain that height a little bit better but ultimately the goal was achieved and he's a happy guy except this is his other side from a previous pilon. So more to come on him. And I'm going to just skip through this one. I just want to show you a brief example of why soft tissues are important. Not this one. Also interesting. Bad stuff. We can talk about it later. I have a lot of cases but not enough time. But this is just a really simple case I did today actually. I just threw it in here. This doesn't look that complicated. It's a trimel ankle fracture in a guy who's 67 years old. Lots of other injuries and my trauma colleague said, hey can you look at this ankle and maybe fix it for me on Friday? I'm like yeah sure no problem. You know bone doesn't look great but fixable. Well this is his leg. So this is just a great example of when the x-ray doesn't tell the story and I was like no way I'm putting plates and screws because he's getting a free flap on Monday. So this is a scenario where I went for a long nine-foot nail and I think the goals are going to be achieved for him as well likely with a lot less issues than poor fixation and osteoporotic bone and small fracture fragments. So that's that. All of these are difficult cases. Complex midfoot and hindfoot fusions are a massive range of etiologies and you know stories that lead to these deformities. But they do require a strategic and organized approach with a very creative flexibility and coming up with those solutions can be very satisfying but you can also sweat a lot when when things aren't going exactly as expected and that's just normal. So thanks so much everyone and we'll see if there's any remaining questions. All right. This is Pete here. Actually I have a question for Max about Achilles lengthening and I modify my approach a little bit but I'd like to hear your thoughts. So these patients obviously some of the Achilles lengthening for these CMT patients is due to the fact that they've got relative overpull of their plantar flexions versus their dorsiflexors but at the same time many of them have a pretty high cavus calcaneal pitch and you know do you get into a situation where you over lengthen the Achilles and they struggle with calcanea dinea or you know inability to plantar flex much you know because they their Achilles is essentially over lengthened in that face of a high calcaneal pitch and cavus foot. Yeah I think you obviously have to be careful for that which I agree with which is why you know I mentioned the TAL isn't necessarily a dorsiflexor anymore so don't just blindly think I got it I need to do that you need to see the whole picture and look at the talus versus the tibia because if you're not if you don't need it to shift that that calc osteotomy you maybe don't need the you don't need to do that the lengthening or maybe a single cut rather than in the full triple. I think you get a lot of leeway in these patients also because thankfully it's a motor and sensory neuropathy so if you get their foot flat on the ground they're oftentimes pretty happy and they will tolerate a lot of pain because they don't I mean thankfully the sensory part of it kicks in. I found that I it was interesting it was you know being in the age where I have to recertify there a couple years ago I think it was last year maybe they had a paper about CMT patients and recurrence and the fact that there was you know some element of recurrent varus in some of those patients over 20 years and they thought it might be due to overpull the medial triceps component and and I've gone to doing more of just like you said almost a medial lengthening so rather than doing a triple cut hemisection I just do the proximal and distal cuts and it doesn't really it doesn't really lengthen from a dorsal flexion standpoint but it's that medial pull and it's interesting if you have these patients you ever get a chance I'd encourage everybody when you do these patients do a calc osteotomy you slide it over whatever you do after you complete that aspect lift the leg up and look at the leg from the bottom and and you can see the Achilles coming down and it actually deviates you know medial it'll be way medial and it comes over to your lateral you know where you've lateralized the calcaneus but it still has it like you said a tremendous deforming force and it's almost stuck over there and so I do two cuts proximal and distal on the medial side and and I don't really get a lot of length which is what I don't necessarily want but I I get that I weaken that medial side and it re-centers the the Achilles to to decrease the pull. Alternatively you can also is you know let the let your osteotomy shift up a little bit a couple things it takes care of that pull it also takes care of some of that pitch if you have a very high pitch. Yeah I agree with that so in that case I'll go more vertical versus rather than most osteotomies going you know oblique yeah bring it more vertical that way you can shift proximally without getting a longer heel. Oh great tip there great tip yeah perfect all right thanks sorry to interrupt. Errol here can I ask Chris a question? Yeah Chris I love your work with the lateral closing wedge osteotomies and the adductus metaductus. I've never done that but it but that's interesting how hard is it to actually close the wedge and reduce that what are you grabbing are you just grabbing the individual metatarsal between the head and necks and try and pulling it over how are you getting that to reduce? Yeah great question there was a question in the chat too. I think the thing that's hard is knowing if you've gotten enough of the lateral cortex it's like when you're doing an Aiken early on you know with the MIS like you sometimes miss a little bit of the plantar medial cortex and then you're trying to horse it over it's not working then you have to go back in and cut it. So you know I found that you know if it if it doesn't close I usually have missed a little bit of the lateral of the lateral cortex. The other thing that I think about is like where do you do the cut if you do it too distally then you're going to be more diaphysial and I think that's where I got into a little bit of trouble with my one patient that I talked about. So I really try and I try and go a little bit more proximal but you can't go too proximal because then you're you don't it won't close down because the ligaments they're going to send you out. So you know I'm I'm hoping to do a little anatomic study and try to figure out is there a sweet spot to go in that area. But so if it's not closing you got to go back in there and recut it and you just have to make sure you're far enough out that you won't that you have room to close down. But then once you do it I just I put my thumb on the cuboid and I just cracked the foot over and as long as you've you know taken most of it out it closes over pretty in a pretty gratifying way. And you can usually kind of feel each individual crack as you go and it probably is you know if you did it slow it'd probably start at two and then three and just the way you think it would. But it cracks over. Okay thank you. Yeah the other question in there was why is it stable? Because they're not they want to come back. And you have to fix the bunion. The bunion is going to like push it over. So whether you do that like I did with the with the MECA technique or if you do that with a lapidus. I think you know there's a strong argument for doing that with a lapidus really hold the medial column over. Are you doing a distal MTP soft tissue release first or do you do that at the end? I do that at the end and actually all of these for me are going to get a distal soft tissue release. A pretty aggressive one like I'll try I'll take the lateral capsule down. I'll sweep you know proximal distal to try and get the the adductor tendons the sesamoid ligaments. And I often will also cut the lateral sesamoid phalangeal ligaments or the lateral head of the FHB. So I think if you're doing this in that setting you definitely need a lateral release for it. Hey Chris a great as you as you embark on your study it'll be interesting with Jesse's talking and given the fact you know we all do at least those distal osteotomies in the tibia obliquely down toward the syndesmotic area. I wonder if those osteotomies if we did them slightly obliquely at the base of the metatarsals you know aiming more toward that proximal plantar medial aspect right and then you might you might we might be able to close those down and and also not encounter as you still get the metaphyseal healing but at the same time you've got a little bit of a hinge your hinge is a little bit closer to the joint. Yeah and I I thought about that part of the reason I do those pretty proximal is that I worry about if I keep it proximal I I have a better sense in my mind and hand control of keeping it um perpendicular perpendicular to long axis right. If I if I'm oblique in this way like I don't want to I can't really see but I don't want to come out this way because then when I close am I going to come lateral and dorsiflexed um so I I thought about doing what exactly what you're saying for that reason and I I do it just transverse because I in my mind in my hand mind control I can feel like I have a better sense of where I am. No I get I don't even do them so god bless you. You should. My dog woke up but I think we're out of time. Thank you guys. All right I'll I'll appreciate it. Okay everybody appreciate everybody being on. We've dropped a few participants but not too many so overall the attendance has been good. Tomorrow hopefully we'll get some more with people uh um being on the weekend. We start at 10 a.m central time tomorrow and it's an extended day. We have uh uh some work on lateral ankle instability then a great session on medial ankle and foot stability followed by our lunch breakout session. Remember those who are on who are in attendance if you want to bring some cases you'll have there are going to be five or six breakout rooms. There'll be an in-person breakout session if you want to bring some cases you'll have there are going to be five or six breakout rooms. There'll be an email that'll go out tonight describing those breakout rooms with the faculty and uh and you can bring cases discuss them during that time during lunch um or you can eat lunch and just hang out if you want to uh and then uh from two to three thirty we'll do kind of a catch-all uh and then a diabetic foot to end the day uh there and uh and so appreciate everybody's attendance um and uh look forward to seeing everybody tomorrow. So thank you very much and enjoy your evening.

complex deformities

cavovarus

metatarsus adductus

bracing

surgical options

hallux valgus

bunion procedures

MIS procedures

complex midfoot

hindfoot reconstructions

closing wedge osteotomies