Thanks for joining, Alistair, and I just want to quickly plug the MIS section here. I'm really excited for it. But just like we have people from Florida, Boston, and British Columbia, and Vancouver, MIS is really sort of a global thing, so it's fun to bring people from all across North America, and if you get interested in this, really the whole world. So Alistair is really one of the leaders here, and excited to learn from him about MIS Lapidus and see if he can convince me to do one. So thank you. You're welcome. My pleasure. And I hope you can all hear me. Can you hear me okay? Somebody give me the thumbs up. Yes, we're good. We can. Awesome. So I'm going to talk about the MIS Lapidus, and is it worth it? I'm from Vancouver in British Columbia, a member of the AOFAS, a proud member. I thoroughly enjoy my colleagues internationally of this organization. So MIS Lapidus, I got into this to avoid wound complications, and it's actually how I got into percutaneous surgery, my experience dates all the way back to 1998, when I just hated seeing wound complications, and I decided to do things arthroscopic. I do have these conflicts here, and I do have a conflict with this presentation. I'll try my best to make it under control. So this is why it's worth it. This is one of my forefoot procedures, this is a wound breakdown. Obviously, it can be associated with risk factors such as rheumatoid arthritis or smoking. So percutaneous for the surgeon is beneficial. It means that you have better patient relations, nothing worse than walking into your clinic and seeing a wound breakdown. And I think it's one of the complications of surgery that really don't talk about as much as we should. It'll give you a larger practice share, because patients really like the less pain, assuming good practice principles, better outcomes. So my challenge is to do the operation as well as I could do it open with regard to fixation correction, and also the big benefit, fewer wound complications. So percutaneous for the patient, at least mine tell me that they are really excited about it because it's less pain. They always see a bunion surgery or a forefoot surgery is really painful, and they're happy not to have to experience that. They clearly have a shorter recovery, and I get these patients walking after 48 hours and weight bearing at two weeks, they have less bleeding, shorter hospital visits. So inpatient becomes daycare and daycare becomes sort of block rather than general anesthetic. They have less returns to the emergency department for pain and bleeding complications. And from what I can tell, less non-unions, not in the ankle, but in the other joints. So currently with the forefoot and hallux valgus, there's only one percutaneous operation, which is the distal chevron and variance, and I think it gets pushed to the limits because there's no other alternatives. It's obviously limited to lower end metatarsal angles. Some may argue this. It doesn't really, in my mind, address second metatarsal, elevated second ray, may not address rotation and may not address metatarsal seductors. So here's, you know, in my mind, a fairly typical distal chevron candidate. These are my screws going in, and this is kind of what it looks like once you're done. But what about this? Could this be MIS? This is a case of metatarsal seductors. I don't hear many people talk about it, but I see it quite a lot. I don't know if this is some weird Canadian thing or whether everyone else sees this, but it's a big problem in my practice. Also the raised intermetatarsal angle, I mean, this just is too far gone in my book to ever be a distal chevron candidate under any circumstances. So we need a comprehensive halexvalgus solution that is MIS, and we need it for all patients for low and high MAs, the elevated first ray, second metatarsalger, and this complex issue of metatarsal seductors. So I do MIS lapidus in 90% of my halexvalgus cases because I can control rotation, metatarsal height, halexvalgus angle, and I can correct large intermetatarsal angles. I'll do distal chevrons occasionally, but I find that this is my workhorse. In 2017, I switched from open to percutaneous, and these are two of my cases. One side's percutaneous and the other side's open. The case that has these three cross screws is open, and this is the percutaneous case. So how do we do it? This is a sort of presentation put together by one of my previous fellows, Sebastian Grego, and as well as with one of his residents, Andy Valkovich. The equipment you need, we're currently doing this 2022 style with a 2x12, Shannon Burr, and this equipment. And we're also using arthroscopy to make sure we get all the cartilage out. This is a typical case. This is a lady with sort of a bit of a crossover toe, so we didn't deal with this at the same time. And this is how we position the patient. This is in a procedure room. It's a swing room, and obviously need to rotate the patient so that we can get appropriate exposure. And this is what the room looks like, excuse me, from the other direction. So two rooms working side by side, mini C, and the arthroscopy tower. So first of all, we mark out the skin. We can see here where we're going to do a lateral release, where we're going to do medial eminence resection, and where we're going to come to the joint. This is a percutaneous lateral release. This is described by Mickey Dalmau, and so we come up over the top side of the joint and release the lateral side of the MTP joint and then go back in. And if we flex the toe down a bit, we can come up and release outside of the sesamoid metatarsal head ligament. And then finally, we do an adductor release up the lateral side. Then you can sort of correct the toe once you've done it. We then make a small incision on the dorsal medial side. We'll sort of expand that portal with a snap, and then we'll put the bar in and use that to do a medial eminence resection. So it's a bit like doing a sliding trochanteric osteotomy in the hip. It allows you to bring the medial soft tissue back with your dressings. Once we've done that, we find the first TMT joint, use a beaver blade. We can get into the joint through palpation. And then we will confirm the position of the joint using a blunt instrument. So this will train your hands where the joint is before you put your Shannon Burr in. So you can see my left hand is used to feel the joint line so that I can actually feel where the two bones are. And this just confirms on C-arm that we're in the correct space. Again, just doing the same sort of release and also making sure the joint's tight. Now I've got my left hand on the two joints, and as we've got the Burr in here, you can actually feel both joint surfaces move on each other. So if I can feel the metatarsal moving on the medial cuneiform, I know I'm in the right spot. Then we put the scope in, and we make sure that we've got all cartilage out. So cartilage is evil, it's the anti-graft, and we're going to get rid of all of it. So I can make sure it's all out, I put the scope in, I'll shave the joint, and we can see the shaver in the joint. Because we've taken all the cartilage out already, we've now got two millimeters each side of the joint gain plus the joint space, so we can easily get a four to five millimeter instrument into this joint. This is also what the Burr looks like in the joint. So I can put the Burr also back in the joint, use it to trim the corners of the joint, as we can see just here. So then we've got to control rotation. So I'll put in the wires to do my reduction, in this case, you can see an incision over the second ray, because I also reduced this, and then derotate the first metatarsal by putting these in at an angle, and then close the IM angle, and also check to make sure we've got the right degree of plantar flexion using palpation. Then we'll use two, well, usually one partial thread candidate screw, I just didn't like my fixation on this one, the first one, so I put another one in, just to hold the IM angle down until we've, and this will hold our position of the first ray until we put in our distal to proximal screws. So we'll then put in three, four millimeter full thread screws, non-variable pitch in this configuration, so that these then will go across the tarsal metatarsal joint, obviously taking care not to damage the extensor hallus as long as tendon, so we'll open that up and make sure the EHL is clear of the screw as we put this down. This is roughly what it looks like when we're done, in this case, I also did a fifth metatarsal osteotomy to narrow this patient's foot. You also add an Aiken procedure, our paper did show that we didn't get quite as good correction as the open, so Aiken is a good addition to this operation if you need it. And so in this case, I've done my Aiken and I've held it with a screw, changed the way I do my screw, I now take it from distal to proximal, because when you screw this down, it does tend to get a bit prominent. So in this case, we also did a plantar plate repair for that sublatching second ray. So it was sort of basically hybrid, partial open, partial percutaneous. This is what this patient's foot looks like at the end of the procedure, and we'll start heel weight bearing at zero to two weeks, at two to six weeks, full weight bearing in a walker boot with dressings, obviously in the initial time period, and then we'll wean out of the boot to a normal shoe after six weeks. This is putting the dressings on, which is an important part of the procedure. This allows you to take those medial soft tissues back and allow them to scar down in a position to hold the first ray in a corrected position. I like to use a two inch cling, I find that it's a little less occlusive than a Coban, but you know, use what you like to hold everything in place. That's roughly what it looks like once we're done. This is the same patient at six weeks out with healing of the tarsal joint and healing of the fifth ray osteotomy. You can see the correction here. So we've reduced the second MTP joint, and we've significantly narrowed the foot by almost a couple of centimeters, and patients often complain with these really broad feet of not being able to wear shoes. This is kind of what it looks like in the clinic when they come back for follow up. And just another case showing a fairly significant intermetatarsal angle, again, a combination of a percutaneous lapidus and an acan, done I think a while ago, because I don't use a screw configuration anymore. Again, another post-op case just showing pre-op, this lady's deformity, the pronation, the raised intermetatarsal angle, and also the elevated first ray, which is corrected here with the percutaneous incision, they must have done an ankle scope too. And also you can see the pronation is corrected, the hallux valgus is corrected, and the first ray is also brought down into plantar flexion. And this, I think, is the same patient showing the x-rays and the correction. You can see also the correction of pronation and the reduction of the sesamoid station. So what's the literature? Well, not too much to date, I'm afraid. This was a comparison of scar of acan with lapidus acan as a case series study. And this was also a modified lapidus procedure with hallux valgus and a systematic review. This is mainly sort of referring more to the lapoplasty, but still the principles hold true whether you're doing it open or percutaneous. And again, they showed that there's reduction of intermetatarsal angle, hallux valgus angle, and also sesamoid station. The other thing that they didn't really measure in this is the elevation of the first ray, which obviously you can plantar flex. And finally, metatarsal length may be an issue. However, they did show significant derotation of the tibial sesamoid position, as well as reduction of the hallux valgus and intermetatarsal angle. Repeat surgery was reported as being roughly 6%, mainly for pain for hardware and nonunion, one and a half percent in this systematic review. So what's my experience to date? I've done over 300 since 2017. My first case was in July 2017. I've had one nonunion and one delayed union. And when we look at this, we've got a comparison series of my open lap, this is done before I started doing this. And then after six months, I took a series of patients after. This sort of relatively early series. So this is my open procedure. You can see the cross screws and the type of reduction I was achieving. So we look at the demographics. They were fairly similar. The open group may be a little younger, sorry, a little bit more female and a little bit older. BMI was sort of similar. Smoking was similar. Minimal diabetes. However, in the MIS group, there was slightly less deformity. So my IM angles were slightly greater in the open group and slightly hallux valgus angle slightly higher. I think that's maybe just slight change in my patient demographics and time. You notice the sesamide is stational, so we measured it millimeters, not according to score. And this showed post-op measurements showing similar results, although slightly less correction of IM angle in the MIS group compared with the open, a slightly less correction of the hallux valgus angle. I think we may have got on top of this now, but this paper helped me sort of think about doing more ATKINS. Certainly, I think patients are happier because they maintain range of motion less stiff. So obviously that's something we need to study for the future. This shows the IM angle reduction of 9.4 degrees in the MIS group versus 12 in the open group. The open group were also more deformed beforehand and sort of a similar reduction of the hallux valgus angle. But again, there's significant difference in these two groups. Otherwise, the sesamide station reduction was much the same. We also looked at first-ray length that didn't change too much, and first-ray elevation also didn't change too much. Adverse events, that's really where things kind of start coming in their own. So wound healing problems were more common in the open group, as you'd expect. The nonunion rate was higher in the open group, but four out of, I think, the 50-odd that we studied. There was recurrent deformity in some of the arthroscopic and in some of the open group. In the arthroscopic, it tends to be more under-correction. The open group, it was over-correction, and some reported neurovascular injuries. And so we have to be careful about that. And this was the survivorship curve, because obviously the open group had been followed for longer. So I come back to this sort of question of metatarsal seductors. So this is a 60-year-old female patient with bilateral bunions. And again, it's something that probably sees you, but you may not see it. So you've got a plane of valgus deformity, as we can see here. And she's got the metatarsal seductors measured here. And so we did a percutaneous lapidus and percutaneous basal osteotomies. And this shows the basal osteotomies being done percutaneously. You can see how this corrects the base of the metatarsals here. In this particular case, I just used a lapidus procedure that stabilized pretty much the forefoot, and then did phalangeal osteotomies for these lateral drifts of the lesser toes. So this is what she looked like with arch correction, and this is what she looked like post-op. Another case in which I actually transfixed the basal osteotomies. I'm not sure we need to do that. And again, this is kind of what it looks like. This is sort of the opposite side and the correction on the operative side. So percutaneous lapidus, I think, is a comprehensive MIS-haloxvalgus surgery solution. With a low IMA and no metatarsal seductors, you can do your distal chevrons and your achins. But if you have a high IMA and no metatarsal seductors, you can do isolated MIS-lapidus plus or minus achin. And if you have a low intermetatarsal angle, but significant deformity on the hind foot and metatarsal seductors, you can do an MIS-lapidus and basal osteotomies. The benefits, lower nonunion rate, as I pointed out, we've got one nonunion out of 300, lower wound complication rates, potential reduced correction. We need to bear this in mind. Patient preference, though, is always MIS. And facility and cost preference is always MIS. So anyway, thank you for listening. Wanted to remind everybody of coming to Canada in January 2025 for the ARFES Winter Meeting. Thanks all. Thanks, Alastair. Super impressive, all the stuff that you're able to do. Next up, I think we have Dr. Steinloff from Miami and talking about more forefoot and metatarsal osteotomies. You're still muted, Steve. Hold on one second. All right. I know I'm unmuted. For some reason, I'm having trouble sharing my screen, though. Do I have your permission to do it? Go for it. Interesting. Not letting me do it. You want to go to the next speaker, and I'll pop on and figure out how to do this? Sure. So that would be Dr. Craig Ragney coming up from across the state. And also muted, the Florida guys. Can you hear me? We hear you. Let me try. Let's try this. We got it. It's working? It's working. OK. Great. All right. Well, thanks for having me. So the topic of the talk is it looks easy, but show me how. I would argue that amateurs are never easy. You're in the open, and especially MIS. All right. Hopefully some of these techniques will help you with your assimilation. All right. So these are my disclosures. All right. So amateur deformity, very common deformity, but really complex density. So this is a very common deformity. Typically in the aging female population. Typically results. Of imbalance with your dynamic stabilizers. Become dorsally subluxed, progressive PIP flexion. MTP hyperextension. From a variety of theologic factors. And it can range from your more mild to moderate, reducible deformities. You can eventually get distal migration. And other secondary deformities that can also develop. So classically non-operative treatment. Modification. And classically the historical corrections were really divided up into flexible form. It was really focused on soft tissue options. As you can see, a lot of these techniques were developed over a hundred years ago. So the open correction, we would typically expose the joint. Either through a longitudinal decision. Liptical resect the extensor hood. At least the collaterals. And then resect the proximal phalanx and or the base middle phalanx. And then perform some type of soft tissue releases, depending on what we needed. For corrections. The K-wire fixation was eventually used to stabilize it. External strapping was also recommended at one time, but we found studies that show there was a lower recurrence rate when you had the wire fixation. Especially in patients that have greater preoperative deformity. Numerous recommendations throughout the literature for postoperative protocols. 20 years ago, we thought that early removal might lead to lower pin breakage and infection. But since then really no studies demonstrated significantly higher pin shock infection. Even with longer pin duration. It's been shown to have lowered it from performing recurrence and revision. The longer you leave it in, typically around six weeks, other studies show no difference. And then we found that there was a lower recurrence rate when you had the K-wire fixation. Especially in patients that have greater preoperative deformity. Numerous recommendations throughout the literature for postoperative protocols. And then we found that there was a lower recurrence rate when you had the K-wire fixation. Typically around six weeks, other studies show no difference. Other pin related complications. Malalignment, migration, bending. Breakage. and articular damage since you were passing the wire out through the potentially normal DIP joint, advancing across an MTP joint, risk of trauma to the toe pole, vascular compromise, and potentially infection. The newer implants were designed, pushed by industry to find other ways to internally fixate this, sometimes even with K-wires, and trying to potentially avoid some of the complication rates from the wires, but eventually questionable whether these were really more efficacious, and if you had to take them out, that was definitely more of a difficult procedure. So over time, really open hammertoe correction, had decent results to be able to help reduce pain, improve function, satisfaction rates around 80%, but certainly over the last 10 to 15 years that we've seen the advantages of MIS throughout the foot, with all these benefits that we've seen throughout the literature, the question is, would it be beneficial to apply these techniques to the hammertoes? And Yasin looked at this in 2016, found similar healing rates in alignment and pain relief as well as satisfaction, but significantly fewer infection than the recurrent trends with the MIS hammertoe. And of course, when you look at it clinically, which one would your patients prefer? So as with all of MIS, I think it's a leap of faith. For me, I would say the transition to MIS hammertoes has been a bigger leap of faith, as opposed to maybe the Halox-Valix and the other techniques. As we know about, certainly there's a lot of new technology instrumentations that help us. We have these special burrs that help, but you still have to make sure you keep cool. Focusing for the lesser toes, really on the two-by-eight Shannon burr for most of our procedures. Positioning is really the same as we've already seen. I typically do use a block. I typically use a tourniquet or Xangui with an S mark just because I don't like blood in the field. But I set up my patient the same way every time, whether it's a right or left foot. So it's hanging over. I put in a little Trendelenburg. My scrub nurse is always on my left. I'm a right-handed surgeon. Mini C-arm is always to the right. And use the C-arm as a table. This is a great summary slide from the Redfern and Vernois about some of the bony procedures and soft tissue procedures that I'll help describe here. And again, trying to re-stabilize and realign the dynamic stabilizers to stabilize and reposition the toe. You can use these soft tissue procedures and bony procedures to help us correct the flexible and rigid deforming. So starting with the bony procedures, typically these are joint sparing osteotomies. Again, trying to restore the balance. Generally try to start proximal to distal. The P1 osteotomy is really the workhorse. You can see here that you do it between the plantar digital fold and the metatarsal head. You're using a non-dominant hand to give yourself the balance and extend the toe. You want to avoid the flexor tendons. The ideal site is that proximal metaphysis, which has better bone healing. It's closer to the vector of the deforming. You want to go too proximal because you don't want to become intra-articular. You don't want to nick the flexors there at the base where they're in a pulley. But basically, you close down the osteotomy. And if the PIP joint is still flexible, then the extensors now act to extend those IP joints instead of extending just the MTP joint. It can be unicortical for your more mild to moderate or bicortical for your more severe. And it's very useful for flexion deformities, varus valgus to meet a lot of deformities and even just shorten them. There's a case early on where you can see I'm doing my MIS helix valgus, but then my second hammer toe was a little bit more rigid. So I did open and I K-wired it. And my third one I thought was a little more flexible. So I did MIS, but I still fixated it percutaneously. They had a good result. This was another case where I did my hammer toe with a percutaneous phalangeal osteotomy and I still opened up for my distal metatarsal osteotomies. It's very useful as we've heard about with these achinects for metatarsus adductus and these transverse osteotomies. It's also very helpful with rheumatoid forfeit reconstruction in a similar fashion. And again, we're not treating the X-ray system, we're treating the patient clinically. If patients have a toe deviation without a flexion deformity, these osteotomies are very successful really just a transverse osteotomy and a metathesis to correct the deformity. If they do have a, without a flexion deformity, you can see here again, you can do this transverse, you could also do oblique. And this one, we also added the distal metatarsal osteotomy percutaneously. The P2 osteotomy is very helpful. If you can't fully correct your PIP joint flexion deformity with the P1 osteotomy, a P2 osteotomy sometimes can get you over the hump. These typically I do mid to half a steel, can be unicortical, again, it can be bicortical. This is your workhorse for your client adaptorly. These are really a layup case where you just do a closed image osteotomy. And you can see that here, how I do this. And again, this was early on, I was still fixating these, but certainly you can treat this with external bandaging. This was a case of these where, again, if you have this hamstring deformity, flexion deformity, you do your P1, it's not adequate, so you go on, you can do your P2. And you can see a nice correction here. And again, these are the bandages to help hold it reduced without any additional fixation. And this is what it looks like clinically as well. Condylectomy, I would say, is rarely used if you have prominence. Typically, if it's that rigid where you have an osteophyte there, I think you need to go really to open procedure and have rigid fixation and orthodesis. And orthodesis is also fairly straightforward at the PIP, DIP joints, mid-axial, especially these orthodesis burrs. And then you really want to use your non-dominant hand to push the bone against the burr to make sure you're removing, again, all that cartilage irrigating, and then fixating it typically with some type of cross wires or screw fixation. This was a patient with this rigid aquinas that actually did the same thing for the alexite P joint. In terms of soft tissue procedures, the Prado had originally talked about FTL and FTB. I think this has fallen out of favor because basically when you remove these, they're only left with the interosseous in your lumbar close for inflection, which leads to a toe grasping defect. So you lose that toe propulsion if you can do rapid walking or sports. So now the workhorse is really a selective FTB. We have, and you can see these elegant pictures from Piclay where you plantar flex the toe and you come along the plantar base at the tip of the proximal phalanx. You can do your PIP joint release arthrolysis, and then you can release in the base of the middle phalanx the FTB. So this is very helpful in correcting deformity. It also is helpful to sometimes convert what may be a rigid deformity to a more flexible deformity. FTL is very helpful in your malato deformities, and sometimes some of your neuromuscular deformities. Your extensor tenonities are helpful if you have an MTP hyperextension. I would wait to see if you can correct your hematoma first before you release this, because if you can release a flexible deformity, then your extensors will then help extend that IP joint. If you do have to do this, you can do this at the level of the MTP joint, and that way there's still attachments to the extensor sling, so you avoid retraction approximately in a drop toe. Typically, if you plantar flex the toe and you see that one tendon is tight, then you can even do a selective extensor tenotomy about two centimeters approximate to the joint. These are also, you're going to think about this more if you have a subluxation dislocation of the MTP joint. Certainly with toes that have more deviation, they're going to be an increased risk factor to develop postoperative deformity. And a lot of these cases are very difficult, as we saw in the last talk with these MTP instability crossover toes. And so you can see a deformity like this, where I treated this about a year ago. I treated this open still and got a good correction, but now certainly you could address this percutaneously looking at your bony and soft tissue deformities and proceeding typically with an extensor tenotomy, an MTP release if they're already subluxed or dislocated. You can then convert the hammer toe into a flexible deformity with your FTP tenotomy and the joint release. And then you can do an osteotomy either transversely or obliquely, depending on severity of deformity. This was the case of Holly Johnson's where she did a more oblique osteotomy for this more severe deformity. You can do astute stages and then you can see a nice correction here. And this is what it looks like clinically. So a lot of application, a lot of utility here. So when would you do bony? When do you do soft tissue and when will you combine? So Frey looked at these deformities in every case. They did the FTP release, the PAP joint release, and they did a P1 osteotomy. And even though they didn't have severe, what they called severe arthritic toes, 75% of these deformities were fixed and they had 90% satisfaction, 86% preserved action and really minimal complications. A few years later though, Nietzsche Garcia had a population of mainly reducible, flexible toes and they found that 60% only required osteotomies. And they found that if you added tenotomies, they actually had worse outcomes, higher complication rates. So in general, when I look at these, my algorithm is to, again, use all techniques that are needed, make your plan up, work proximal distal. In general, I tend to go to my bony procedures first and assess the need for soft tissue releases afterwards. You want to make sure you address all components of the deformity. If it has a helix-to-helix deformity, you need to address that to get a good outcome. If the MTP joint is dislocated, you're likely to need MTP joint release, although try and avoid doing that unless your joint is dislocated because otherwise it will sublux or dislocate. You might also need some type of combination of a shortening osteotomy, extensor tenotomy, as well as collateral ligament release or leashing. Neurologic cases depends. Sometimes you can get away with tenotomies. Sometimes you might need to add P2 osteotomies or even a fusion. Klanodactyly, as I said, is a layup for P2 osteotomy. Post-traumatic, you may need multiple phalangeal osteotomies. In general, for your flexible deformity, these are really the layup cases. You do your osteotomy, and most of the time that could correct it. If you find that you don't get accurate correction, you can then release that joint with your FTP tenotomy and your joint release, and if you still need additional correction, then you can do your P2 osteotomy, and that will typically get you there. If you have any residual hyperextension of the metatarsophalangeal joint, you can do your tenotomy at the level of the joint. If you have a lateral toe deviation without a flexion deformity, that's typically really a transverse P1 osteotomy. Occasionally, deconstruct the deep pressure as a distal metatarsal shortening osteotomy. If it's extremely rigid, you can consider doing first some releases to try and make it more flexible, but if it's really arthritic, very rigid, just consider opening that and doing implant, or you could do a percutaneous fusion as well. If it's a malatote deformity, distal flexion, you can start with an FDL release and then add a P2 osteotomy if needed, and if you have a distal interval and joint medial lateral deviation, then usually you can get away with just the osteotomy for that. Postoperatively, I typically have them healed on a full weight brand over the first four or six weeks in a rigid shoe. I maintain compressive dressings because this can help support the correction. You want to make sure you keep those dressings on until the soft tissues heal and the bony osteotomies consolidate. I typically, in the OR, put on a sealing silk dressing, plus, minus, and the last advantage, and you want, and this is really important techniques to learn, you want to bandage opposite the position from the initial deformity, so typically flex the MTP joint a little bit, extend the IP joints a little, and have the lesser toes and slight varus, and this is kind of what it looks like, and really the success of your surgery, for everything we do in the OR, it's probably the postoperative bandaging that's probably as important, so again, when you're assessing your patients before you take them to surgery, you want to make sure they're going to be compliant with your dressings, you want to make sure you have enough support in your office to help manage the dressings. Are there contraindications? Probably not. Certainly, if it's a very proliferative arthritis, again, a fusion, but you can probably do that MIS as well. Really, the non-compliant patients, certain revision cases, though you can see here in this case, even revision surgeries are amenable. So, in conclusion, our techniques are continuing to evolve, but I think most of these techniques have been proven now to be safe, effective, reproducible, with better outcomes. It is a very complex procedure, there is a learning curve, and so I think you need to incorporate these techniques gradually as you develop more experience and more comfort with a lot of these techniques. I think it's important to approach each patient individual plan, make sure you're treating their complaints, you want to do your best to minimize the risk of recurrence, make sure you address the etiology, correct the deformity, rebalance the toe. It seems to be planned according to the patient form, also, again, your experience and your comforts, you need to master all these techniques and do step-by-step to decide which procedures will help you with your conclusion. Again, I always like to mention Alistair's paper from years ago, that you need to manage your patient expectations. Similar to other fields of surgery, there's direct correlation between increased satisfaction outcomes with better expectations met, and so you really need to know your community, know your patients, have these discussions with the patient beforehand. I always let them know, even though they're coming in sometimes for cosmetic reasons, sometimes they may need to use a larger incision to get a reduction. I let all of them know that they're probably gonna be sore, swollen for longer than they anticipate. I like to delay their impact activities in terms of running or jumping for typically up to four months. I always tell them for any procedure, full function recovery can continue to improve up to one year. And again, I stress compliance, compliance, compliance. Thank you. Greg, that was awesome. Really great talk. And I agree with you, these are really challenging cases. So I'm looking forward to a little discussion after the talk here. We're having a little bit of IT issues here, but we're gonna proceed with Dr. Steinloff's talk here. And I'm looking forward to this. I think it's nice to do these together because so many times we're doing hammer toes, you're also adding distal metatarsal osteotomy. So it feeds right into each other. Take it away, Steve. Well, thank you for your patience. I hope this goes nicely. The hospital gave me a beautiful brand new computer, but never gave me permission to do anything, but I figured out how to get around their firewalls. Anyway, we're gonna talk about distal metatarsal metaphyseal osteotomies. And the bottom line is I do have some disclosures, probably the most important disclosure. These are hard cases. They seem simple. They take five minutes and you can do everything wrong and come out with every complication. So understand that you have to take some formal training and practice. So the goals are to understand one, the rationale of why we use these, learn what the indications, contraindications are. And then I'm gonna give you my pearls, my pitfalls, and explain to you why they're not always the greatest cases. So the whole idea is that if you have pain below your metatarsal heads, in other words, metatarsalgia, this is an option. It is an option instead of doing big open while osteotomies or other fancy long oblique osteotomies. It is rarely used. Even our European colleagues like Vernois will tell you, he rarely uses this, but there are indications where it works very nicely. I think if you have limited shortening that you need, it works very nicely. If you have people who've had a bunion and they're not happy with the results of the bunion because they're short, and therefore they've developed transfer metatarsalgia, this works well. This is a nice option because it's not a big open procedure that they've already been through. Inflammatory arthritis, post-traumatic cases of metatarsalgia and neuropathic ulcers are all good indications. So the whole idea is you wanna reestablish your parabola. You want to elevate your metatarsal in that sagittal plane. You want to get a correction in your horizontal plane and in your coronal plane. And by elevating and letting these metatarsal heads shift over, all of these goals are accomplished. So how? Number one, I will see people who do this on a single metatarsal. You can't. If you do it on a single metatarsal, the transverse endometriosis ligaments will not let the isolated metatarsal shorten adequately. So you have to do two, three, and four. And at times you even add in five. It's rare because five is usually so much shorter, it's not giving you a problem. So how does it work? The pull of the extensor tendons pulls the lesser metatarsal heads two, three, and four laterally, and it pulls five medially. That's why we can do these for bunionettes, and we'll talk about that at the end of this talk. And here you can see a bunionette. Here's your head. And this is what it looks like after the DMMO. And what's nice about that is it elevates nicely as well. That head went up beautifully when we let them wait there immediately. So what is the difference? DMMOs are dynamic. You have someone get up, they walk immediately. The while, you set their height in the operating room by using a screw. And there is shortening in both, but the while will gain more shortening, and you'll see why that's necessary in certain cases. You do get limited elevation really with both of them, but you can control how much elevation you get to an extent with a while, because you can take out a bigger wedge. The DMMO is extra-articular. So theoretically, you shouldn't have the stiffness you get with an intra-articular while. So benefits, less invasive, biologically friendly, less stiffness, like we talked about, and probably less floating. The while is, again, a bigger open approach. You change the center of rotation, and you end up with floating like in one of my cases here. And that's always been our frustration. That's why I pursued the DMMO, so I could end up with hopefully a better overall result. And so here's a procedure. You may have seen something like this in Dr. Rodney's case, because you can see what I'm doing. This is someone who comes to me with, in essence, a bunion deformity that's recurred three times. She's a doctor. She doesn't want another big surgery that can fail. So I said, let's go ahead. We'll go and do a first MTP fusion. You can see I did something with revising her hammer toe at two. I did a P1 osteotomy at three, because three was riding on top of four. She had metatarsalgia under four, and she had a painful bunionette. So I did my DMMO at four. Three was already short. I didn't have to do anything there. Two was already short. I didn't have to do anything there. She turned out to be very happy, and this was her fourth surgery. So I think, really, in these revision settings, it works nicely. So not recommended, though, if you have a dislocated MTP. You're simply not going to get a centimeter of shortening with a DMMO. And so this is something where Wiles worked a lot better. How about if you already have a bunion deformity, and you're not necessarily going to treat the bunion deformity? This is from, I believe, Dr. Vernois. You end up with multiple metatarsal shifts, and therefore, you get a windswept deformity. The bunion gets worse. How about if you have stiff MTPs or stiff TMTs? I think it really does not work well in these settings. I had a case today. Today was my DMMO and bunionette nightmare clinic, where I had complications coming in. And sure enough, someone who had very stiff TMTs who had metatarsalgia, I did DMMOs, and he has two non-unions at two and three, or delayed unions. It's three months. They probably will heal, but this was another case here where the patient ended up with a delayed union, took a year for the second metatarsal to heal. How do you do these? You have to be very, very accurate in the way you do them. You have to do, again, two, three, and four, even five. You have to let them weight-bear immediately. You have to explain to them they're going to elevate for two weeks because the swelling will be significant. And you have to tell them, they're going to be clicking. They will feel the bones moving for the first month at least, and they may take a lot longer for the swelling to go down than where you have fixation with a while, but they're fairly predictable. So technique, use a two-by-12 Shannon burr. You have to have saline cooling. I do not use a tourniquet. I want blood flow cooling. I isolate my saline now. I take my time. I don't put the burr on six or 8,000 and hit high speed and keep it on high speed. I oscillate it a little bit. You do not want to burn the bones, especially the second metatarsal. That's your thicker, harder bone. And that's where I've seen the delayed unions. Technique is absolutely the most important thing. You want a 45 degree angle. You want to exit just proximal to that articular surface. If you have a higher angle or a lower angle, you will end up with problems, either non-union or with a real low angle, you end up in the joint and you get stiffness. So I set this up. The foot's off the edge of the bed. Mini C-arm comes in. I'm looking it off to my left-hand side. And so I have very good control. You're going to take your fingers. Your fingers become your navigation. After a while, you will not need the fluoro. You put your burr in, you set your 45 degree angle and you rotate your hand down, pulling from plantar proximal to distal dorsal exit right in front of your thumb. And that keeps you out of the joint. It works very, very nicely. And that's what it looks like with the navigation. So right foot, you basically go two, three, four. Left foot, you go four, three, two. That's for a right-handed surgeon. The reason you do that is when you cut your first metatarsal, it drops out of the way so you can get to the next one. It drops out of the way. You can get to the next one. Left-handed surgeon, you simply flip the order. So Pearl, you need to know if you have a complete cut. I do a push-pull technique. There's my height. Now I'm gonna push. There's my height. I know I definitely shortened that one. Pitfall, here's a case. And basically you can see they had a dorsiflexion osteotomy for cave ovaries. They ended up with metatarsalgia. Floral, this is real floral. This is not just a bad image. The floral was bad. I thought that I had adequate cut and I did not. In essence, basically it was too short. I didn't piston. And she ended up with a incomplete osteotomy. Post-op protocol. You wanna do some type of strapping. It doesn't have to be for too long. First couple of weeks. And you basically let them, again, wait very immediately, dark or flat shoe. I continue that six weeks. Then I get rid of it into a good, like a hoka or a sketch or firm bottom and tell them it's gonna take a while for your pain to go away. Post-op, what to expect? Immediate decrease in pain. If they have very bad metatarsalgia, they actually feel better immediately. It is miraculous. If they have ongoing pain at like three months, now you have to think about that non-union. They will get some dorsal pain, but that tends to go away. And again, that clicking, feeling, feeling, about four weeks, that's gone. Swelling, six months or more. So complications, again, non-union occurs. Here's that case where you can see in the second pain, the metatarsal osteotomy seemed to go very nicely. Third pain, you have some basic callus formation, but it took her a year to completely heal. Can't boot bone stem. She was very happy when she was done. I think I got to her at a fourth revision, fifth revision on this one. And that's what she looked like in the end and was completely happy. You see that combination of P1 osteotomies as well to get the toes aligned. Complications, errors in cutting. If you cut too proximal, that head's gonna pop up too much and you'll end up with floating toes. You cut too distal, too flat of an angle, you're gonna go into the joint. They'll be very stiff. That's not a good complication to have. Here's a nice idea. You have a patient, primary metatarsalgia, probably because of a Morton's foot, short first metatarsal. This is that concave bottom of the foot, central keratosis. Go ahead, you do your osteotomies, the foot flattens out and they're very happy. Here's another case. Neuropathic patient had a TTC fusion, ends up with a callous ulcer underneath of a metatarsal head. You go ahead, you do your osteotomies, they all shorten nicely, they elevate. These are really the patients who do the best, probably because they're neuropathic. If they end up with a non-union, they don't feel it and their head elevates, so the ulcer heals very quickly. And this is what it looks like when you're done. Here's another case. This is someone who had a previous hallux valgus bunionette outside, came in, the first metatarsal was short. You can see the right foot and you can see how long that first metatarsal should be. You can see they only need about five millimeters. They're shortening at two, three, four. And so we go ahead, we do an osteotomy. He had a floating P2 or floating second toe. So I did a P1 osteotomy there. There's that convex foot and you can see the osteotomies here. He has a little bit of delayed union, but so far very pleased with his results. Full weight bearing, he's getting back to sports at three months now. And he came down nicely. So there is a significant learning curve. When you look at the literature, complications do occur. Non-union is not as common as I may make it sound right now in the literature, but it happens. And I think you have to warn people that it can take a long time to heal. Metatarsal head necrosis, that's if you do your inter-articular cut. And what I tell people is this is an 80% surgery. It's pretty good. You get good results about 80% of the time, you're about 80% better. Meaning you have to set expectations. You heard Dr. Radney say that. You have to let them know they've been through multiple previous surgeries. You're giving them an option that's less invasive and it tends to work most of the time. So DMMO versus Weill, similar outcomes. And then conclusion, everything we talked about, be perfect in your technique. Use this in the right setting. It's simply another tool. It's not going to replace every Weill osteotomy. So bunionettes are a DMMO of the fifth. That's all they are. And you have to say, how bad is my bunionette? This is a patient who had more of a type two bunionette. They had no plantar pain under five. They simply had some discomfort. They had had multiple hammer toe surgeries and all their extensor tendons were cut. All they want to do is to have their lesser toes not impact into the ground and get rid of their fifth metatarsal head pain. I did an exostectomy and I did dorsiflexion osteotomies, all the lesser P1s, and they did really well. They were very happy, great salvage when we didn't have salvages before. So what about more significant bunionettes? Type twos, type threes, what Redfern will call his type two. I think you can do different osteotomies. I do a distal metatarsal metaphyseal osteotomy, but you can see Benevente, they popularized a Chevron osteotomy that worked for them. And Dr. Younger, you can see he is a wizard with this stuff for very bad bunionettes, these real wide type threes. You can do a proximal closing wedge osteotomy and get very good results as well. And so technique, everything again, the same as your DMMO, foot is off the edge of the bed. You can bring your fluoro in, you can do it under fluoro. This is someone who had a crush injury to the foot. They had a floating fifth toe that gave them a lot of pain, callusing, and tremendous pain underneath of the fifth metatarsal head. So I did a P1 plantar flexion osteotomy. I did my DMMO and I did a extensor longus release, not the brevis. The brevis is what pulls that head over and you can see what it looked like preoperatively. You can see setting my cut angle, coming through just proximal to the articular surface. That's what your hand looks like when you're done, where you're laying parallel. My other hand, my left is my navigation hand. This is what it looks like when we do our P1 osteotomy. Here's my angle, a little above 45. I'm not completely happy with that, but not bad. And here's the P1, you can use it for derotation, not only a plantar flexion, but you spin the toe exactly where you wanna get that nail up. And you can see, even with my extensor lengthening, as long as I left that brevis intact, he shifted over immediately. He's at about six weeks out now, showing early signs of healing, very happy so far. There's my P1 osteotomy. And so this is another person, we did some minimally invasive chevrons. You can add in minimally invasive bunionette at the same time. And I think that's a good option, but you have to tell people that again, these are not perfect either. And so you see all of my cases have no fixation. I'm gonna get to that in one second. You can add a medial capsule release, just like with a minimally invasive bunion. You can resect the overhang if you need to, not all need it. You can still resect the lateral eminence if it's really big. And this is fixation. Prior to today, I would say you'll never need it, but this is your option. So when do, why do I now say maybe you need it? So I'll get to that in my next slide. Post-op protocol, I hold the toe in the position for about a week, they come back, then you can just do some taping, weight-bearing is tolerated in the Darko flat shoe for six weeks. And then, you know, the Europeans, I'll let them go into regular sneaker at four weeks. I'm not gutsy enough to do that yet. So this is someone who came in today. This is a neuropathic patient, idiopathic neuropathy, had a very painful bunionette. And you can see the bunionette here. He was getting a callus and ulcer repetitively under the fifth metatarsal head. I did a bunionette on him. I never saw him again. He came in today, three years later. He knew I was giving this talk. And he said, Doc, I was great for two years, but now I have this new sore on my foot. But that's not where his old one was. That's under, I'm not sure what. So I gave him an x-ray with BB markers. He formed so much callus in this area. And when you look at the BB here, you can see that it is exactly underneath of this exostosis that formed. And you have this very prominent new exostosis. So I'm going to go back now with a minimally invasive wedge burn, take that one down. But just so we know that these are not all perfect either. You have to tell people that you're going to be a pioneer. We're going to do a minimally invasive technique. If it fails, we could always put in fixation or you can simply use fixation. All my other cases, I've not had a problem. I've done a good number of these now. They've all healed. But as you can see, sometimes you get exuberant callus. So MIS bunionect, good results. I think you can even do severe deformities. I'm booking my first one with Dr. Younger's technique because they have a true type three, very high, IM four or five angle. I'm not going to do simply a DMMO on that one. There is some risk of that dorsolateral cutaneous nerve. And there's a good article that showed if you stay within certain parameters, you can avoid it. I refer you to that article and that's my talk. So I'm sorry about the delay the first time around, but enjoy Friday. Thank you. Thanks, Steve. That's awesome. And I agree that those are all very challenging cases and they're not all perfect. I have a case I got to ask you about at the end here, but in the meantime, Dr. Martin from Boston with me, and she's going to talk about how MIS has changed her practice. So looking forward to it. Thanks, Liz. Fantastic. Thank you, Chris. Can you guys see my screen? Yes. Okay. So thank you guys so much for having me. I am at Brigham and Women's in Boston and Chris and I are actually partners and I didn't warn you, Chris, but you're actually in my talk. So, and I'm going to talk about how MIS has changed my practice, which frankly is a lot, hear my disclosures. So I started doing MIS in approximately 2019. That's when I started training. And I'm sure you've all heard the saying, if you're still doing what you learned in training, you're not evolving as a surgeon. And some changes are big, some are small, but MIS basically completely blew up my practice and really changed a lot of what I do and a lot of even the way that I am willing to approach problems. So how I started, I get asked this, how did you start doing this? How did you feel comfortable? It's really hard to start doing something new, especially as an attending when you're teaching. And so I started with cadaver labs, serving colleagues and sort of basically growing from there and also growing based on the procedure choice. So how did I choose my first case and what did I do? So for me to start doing it, it was actually a case of incision management. My first MIS patient was a patient with a really small foot who needed both an open perineal tendon procedure and a calc osteotomy. And I said, you know what? This is the perfect patient to start this on. As someone who previously, I either would have spaced the incision a bit more than I wanted, or would have maybe made something larger to incorporate both in one incision. And we all know this problem where you have a perineal incision and then the MIS or the open osteotomy incision sort of right next to it. And this patient was particularly small and it was so much better to be able to do this option for this patient. And so that's what encouraged me to start. And I think a calc osteotomy is a really good procedure to start with, both with the ability to get imaging and the size of the bone and the forgiveness with the procedure. So I think that's a good one to start with. I also wasn't really prepared for how quickly those osteotomy patients were going to feel good afterwards. So I wanted to keep them non-weight-bearing. I always did. And then found that they were, you know, starting to put weight on it sooner than I thought. And things were fine at first. But after my two-week visit, I kind of say, you know what? If it looks good, it feels good. You know, you can start putting a little weight on it. Cholectomy is also a good choice for an earlier procedure. This has changed my practice a lot. I think because they're able to move them so much sooner because the incision is so small. And so I feel comfortable letting them really start pushing it and ranging it pretty early, as opposed to the larger, long incision on top. The picture on the bottom was actually the first cholectomy where I put a scope in afterwards. And I was really surprised at how smooth that surface was, actually looking at it afterwards. I now scope most of my cholectomies just to look for bony debris and look for any type of deeper pathology. But I was quite struck by how smooth that bar actually gets that cholectomy surface. So I think there are a couple of challenging problems that for me, you know, MIS has really... Was one of those people who never had a really great bunion procedure that I loved. I would do chevrons, I would do Lapidus. I never really, for me, loved a scarf. And so for me, for my practice, this is where it's probably changed the most. I used to tell patients, yeah, this is like childbirth. This is awful. This is, you know, you're going to be miserable three to six months. I really do and gloomed it. And this was my first bunion patient. She was a 55-year-old woman. She was a runner. A good one to start with. Her IMA is not, you know, too small. It's a bit more challenging to really get your shift and get your hardware in. And so when I started, before I did my first bunion case, I actually went to the OR and I observed. And I found this really helpful in starting just to really, if you have access to a surgeon that does MIS, or even if you want to go visit somebody who does it, I found this really helpful. So I went to Chris's OR and I took a bunch of pictures. I watched him do it. I saw how he set up the OR. I asked him questions about how to, you know, move the bone and fixation. And I found this for me to be really helpful just to get down the logistics. This is basically that. And I show, will kind of show these images to patients. People free bone is the bone that's been running within about three months. So this was a practice for me, just the speed of recovery of these bunion patients. And I found this really helpful in starting to get a better understanding of how to move the bone. And I found this really helpful in starting to get a better understanding of how to move the bone. Also, you know, this, I learned this, you know, you want to make sure you get a good lateral. So this is the same patient, basically a little earlier in the, a little earlier in her progress and a little bit later. And you can see, you know, it almost looks like the osteotomy is plantar flexor, translated plantarly, but truly that was just a, she wasn't really putting weight on her foot. And it, because of the way you translate that osteotomy, really it can appear to, laterally you can see she actually formed a lot of robust bone. I'm a little nervous about her being prominent eventually, but she hasn't come back. So she either went and saw Chris to get it removed or she's doing really well. But so the importance of just getting a good lateral is something that I learned as I incorporated this into my practice as well. Second toe, this has made such a big difference for me in my second toe practice. I mean, I still don't love the second toe. Oops, sorry. I still don't love the second toe. Hold on, fail. There we go. I won't go through all the technique and everything because we just talked about that, but the ability to treat a crossover second toe with some, you know, phalangeal osteotomies and strapping versus the, you know, big open procedures, scarring in the second toe, this has really been huge for my practice. Sometimes I'll incorporate, incorporate a retention stitch, mainly with strapping. And fusions, this is something that I'm sort of getting a bit more into. This was actually an MIS Lapidus. It's not quite as short as it looks in the picture. She wasn't really putting her full weight on it, but I have to admit, sorry, Alistair, I don't actually put a scope in it. I just kind of use the burr and debride the joint down. And I think in somebody who's really tight with a lot of soft tissue tethering, I think it's really challenging, but this was a hypermobility patient. She was pretty easy to correct. And this was one that really, you know, was able to do sort of percutaneously. And I started doing this by kind of putting a burr in an open incision and just seeing what that felt like to debride cartilage and how the burr felt in the joint and using instruments that we know, using a curette, something where you can say, I know how that feels when the joint's prepared and using that in addition to just the burr. And then for first MTP fusions, I find this, I've started doing almost all of my first MTP fusions, minimally invasively, as opposed to taking the toe in that kind of extreme plant reflection of the cup and cone. I find that, you know, in particular, post-operative pain has just been phenomenal by not kind of doing all of that exposure and stripping. And so I started doing that similarly by making a small incision, putting the burr in, and then kind of going. Pain management, hugely different. Most of these patients don't require opiates. I still, sorry, I'm having spastic screen. Often they don't require opiates. I still give some just because in my practice, my residents aren't allowed to prescribe opiates at night. So I still give a small amount just in case they need it, but most of them don't. And this has really changed the procedure, sorry, my post-op protocol as well. And lastly, metatarsus adductus, this has really changed my practice for this. This patient used to come into my office on the left and I felt nauseated. You know, it's like, it's never going to be easy. It's never going to be good. And so, you know, the option of treating this either with some distal oblique osteotomies or with some proximal closing wedge osteotomies, as opposed to doing shortening and fusing and plating and Wiles has just been really practiced well in the ability to weight those patients earlier after this procedure. So a couple of challenging patients. So diabetic foot, I find, especially with foot ulcerations, being able to do an excessectomy or a DMMO minimally invasively has been really helpful and very practice changing for me. Patient of mine with a plantar ulceration who also had previously a TTC nail that got infected and removed. So he... Fourth. And so for this patient, you can see the kind of the second the second, third and fourth are all very appreciably longer and more plantar. Weight-bearing, so I did some, you know, shortening and osteotomies on him and the ulcer. This is the almost healed ulcer. I don't have a picture of the healed ulcer, but you can trust me, it healed. But again, these are great patients to do that. The... Wound healing benefits. So this is an 86 year old woman with a bunion and a second toe wound. And prior to MIS with that kind of, you know, I would have looked at this empty second toe. So I offered that to potentially, you know, fuse the first MTP. She said, absolutely not. She wanted to be able to wear like a little one inch heel. And she just said, absolutely not. I'm not fusing it. So we talked and this is somebody, if you look at their IMA it's huge. It's somebody, if I were to look at that, I would say, you know, really you should have a Lapidus. But an 86 year old, I'm not too excited about doing a Lapidus. So her bunion wasn't what was bothering her the most. It was the second toe. And so I opted just to do an MIS bunion correction and do some kind of closing wedge osteotomies of the second and third. And it didn't correct crate as well. You can actually see the metatarsal shifted over which I'm not very surprised about because her IMA was so high, but she's actually super happy. Kept her second toe. 86 year old woman who I would have amputated prior. 56 year old active renal transplant. You know, she's a renal transplant patient. She has, you know, on biologics. She is on anticoagulated. It's not something I'm excited about fusing or making, you know, metatarsal osteotomies. So this one, I didn't even really, I was nervous to make base osteotomies in her as well. So I actually went with the sort of distal oblique. I actually kept, Steve is going to yell at me, but I kept the fourth kind of as a base because the fourth really was, you know, I didn't really want to shift her. She's a bit windswept. I didn't want her to sort of keep going laterally. So I actually kept the fourth as a base. I just let the second and third kind of shift toward the fourth. And I, you know, did a bunion correction. Hopefully that doesn't end up bothering her and being prominent. She took her strapping off because she didn't like it, but it gives you a good option. Somebody who's, you know, a transplant patient, they really don't want to make big incisions on, they actually have an option to treat their bunion without ductus. And then lastly, this is a 59 year old woman with CRPS. So, you know, she has helix rigidus. I was like, oh, maybe we can get away with a chylectomy. She has, you know, minimal motion, arthritis all the way to the base. And so I ended up doing an MIS fusion on her. I basically, you know, debrided the joint and put some screws across, percutaneous incisions. She's, didn't get her CRPS reactivated. And I think for somebody like that, it's a really good option for somebody who you don't really want to do a lot of soft tissue stripping or make a big incision on. So lastly, the not so good, the learning curve. But first the importance of strapping, I think I learned that the hard way, how if you really don't strap, they, you know, particularly when you're doing non-fixated toe corrections, it's really, you know, if you don't strap them, they can very easily recur. Staff, the importance of that and having somebody that you. For me, I found the teaching to be extremely challenging. I wasn't really prepared for that, but when you're educating and learning how to do a new procedure on your own, especially with a burr, it's really hard to sort of give that burr up without true training. And so I'm lucky enough in my program to work with a good training program for the fellows. But I think especially for residents, it's really challenging. I think setting expectations with your trainees and saying, this is what you're going to be doing during this part of the case, trying to let them do what they can, you know, putting in hardware, but in terms of using the BRRRR, it's difficult to teach. And that was something I wasn't really anticipating. And then lastly, I think the patients were almost opposite for this. So, you know, this patient was in correction and a bunion and toe corrections. And she's like, why am I so swollen? But we did so much surgery on your foot and look how straight your toes are, and this is great. And, you know, just setting that expectation of just because you're doing percutaneous surgery doesn't mean it's going to be, you know, an immediate recovery, kind of making patients aware that they're still going to swell and that they still have a lot of work internally, I think is important. And that's something that I think I wasn't anticipating at first, but definitely has affected the way that I practice. So basically it's changed my practice so much. It gives so many options for things that we really didn't have a great option for before, or at least for me, a good option that I liked before. I would say, you know, it's kind of hard to bite the bullet and learn and do it and train yourself. But I think it's, you know, it's, I wouldn't hesitate to do it. There are so many, you know, options and opportunities for training on, you know, cadavers and doing courses like this to learn how to do it and be prepared for the learning curve, but it's definitely, I think, worth it for the benefits in your practice. So thanks. Thanks, Liz. Some really great cases you got there. For the questions, I was just going to, we have a couple of questions in the chat, which I was going to bring up first. One was, before surgery for these MIS cases, are you guys routinely checking labs at calcium and vitamin D to make sure patients will heal their osteotomies? Alistair, you already typed in your answer here. I just see, it just came up for me. But so, you know, he says that he does give vitamin E to everybody because he assumes everybody's deficient already and rarely checks it. But what about the rest of the panelists? Is this something that you're doing routinely, even down in Florida where there's enough sunlight as opposed to up here? I'm more of Alistair's camp. I usually just recommend they take it as opposed to checking it, unless there's something I'm really worried about or they already have a non-union. But I don't- Well, I'm ordering vitamin D on everyone. I was in a meeting recently and Bob Anderson said he was having a lot of trouble getting it approved by insurance. And I said, well, I'm not having that problem. And sure enough, the last couple of months I've had a few people get denied vitamin D levels. And so in those settings, I ask if their kidney function's good. And if it is, I put them on 5,000 units daily. But even down here in Florida, when I checked a few years back, I was checking everyone. 80% of people were vitamin D deficient. I mean, really deficient, like around 25. And so I think it's important, especially in these hard to heal osteotomies. I think age plays a role in it too, especially in the female population, over 70, 75. And a lot of our patients are also snowbirds. So a lot of them, you have to assume that their vitamin D levels are going to be low. So I treat everyone regardless. I had some surprises though. You know, I've had, you know, one was a ballet dancer and she got a really bad osteo-coronal defect, a distal tibia, and I couldn't get it to heal when I first treated it. And her vitamin D levels were in her boots. And the soccer kids, you know, can often have low vitamin D levels because moms are slathering them with sunscreen. So you can be sort of caught a little bit unawares, even in the young patients, and it might be part of their pathology, like osteo-coronal defects. Other questions here. One was, are there specific high yield hands-on courses that we recommend to improve MIS skills during the learning curve? And I will put a plug in for the MIFAS course, which is coming up in Philly this year, I think in November. And it's actually where I first got to meet Errol and Steve. So we all teach for that. And I think that's a really, it's a couple day course. And I really enjoyed that. I actually traveled to Barcelona myself to do that one. And it's a lot of didactic and hands-on. If you can't make it to that, you know, I think the different companies do have industry sponsored ones that teach it in sort of a day. I think it's more complete when you go to one of these other multi-day courses, but that's a lot more time out of your schedule. I don't know what the other panelists think. To get a Dremel or even an old box and hand piece and use it at home on chicken bones, pig's feet work quite well too. You can do a cow costeotomy on pig's feet or just use saw bones and get your rep to help you out. You know, they can lend you some equipment. And so a little bit of hand-eye coordination time in your garage goes a long way. I agree with what Chris is saying and Alistair too. The MIFAS course, which stands for minimally invasive foot and ankle society. It's every November in this country. The only issue is there's only about 29 or 30 positions. So it gets filled very quickly, but you will be able to go through every one of these osteotomies that you've seen today and very qualified instructors will be teaching you. So it's a great, great course. To further reinforce what Alistair said, here is my Dremel in my office. This is for my residents. And so you better believe before I'm letting them start to do this in people, they need to log time on saw bones, chicken bones, whatever. The other thing, you gotta have courage to start doing the surgery. And, you know, I've always explained to patients, I'm gonna try percutaneous. And if I'm unsuccessful, I'm gonna bail to open and work out what that bail to open might look like. But if you try, you will succeed. If you never try, you'll never succeed. And I think there's nothing wrong with trying and going to open, you know, and even if you try and you think it's equivalent doing an open or percutaneous, at the end of the surgery, you'll be a better surgeon. And it's always worth considering that because unless you can figure it out in your own OR, it's always gonna be a challenge. Another question here from Dr. Morelli Murthy. To MIS surgeons, thoughts in regards to costs of, to the cost of these burrs and specialized screw implants. How many burrs do you expect to use for these multiple osteotomies, exostectomy cases? Liz, you wanna start with that one? I mean, I think it's, it depends on a lot of things. It depends on your practice model and where you are. I think I don't usually go through a ton of like burrs. I don't find that over the course of a case that it's really getting dull, at least for myself. I think that it depends on the system you use, kind of the cost structure and purchase sort of a box or your hospital needs to purchase burrs or both. It's different sort of based on what you decide to use. But I usually, I don't go through a ton of burrs. I don't find personally for me that they get very dull, but I think a lot of it is just based on the model that you have and whether you, the company that you go with and the cost has to come from somewhere. And so it's either from the box or the burrs or both. Yeah, I think you have to educate your hospital, supply people and it's certainly gonna be more expensive than a single screw that you might put in for an open Chevron, but helping them understand the benefits for you and for your patients and for growing your practice can also be helpful. And I had a number of conversations with my team about that before we got very busy with it. Yes. It's worth pointing out that at least the NIH has shown that number seven on the cost, if I remember right, of all of healthcare is complications of treatment. That includes having GI bleeds when you've taken anti-inflammatories and you name it. But the cost of revision surgery is major and the cost of wound complications is very significant. And so, and it doesn't make your hospital look good and they don't like having to do risk management and all that sort of stuff. And so there's way less bed utilization. And for us, one of the drivers was the fact that with COVID, the beds went down the toilet and they've never really come back again, but they still want the cases done. Hospital wants to see the volumes. And so we've got to get inventive about how do we get the surgery done without admitting people? And so they've been much more willing to, at least in the system that we're working in, to consider more expense and equipment if we can convert cases from admit to daycare. And the cost isn't huge, and the buyers are not a big cost. I mean, I typically will use one, maybe two a case. It's the screw fixation that is the cost. And sometimes the biologics, if you're no longer using Iodine Crescraft for some of the procedures. From Jeanine Hu, who I think gave a great talk yesterday, if it's the same person. So she asked for big shifts with a bunion, of the residual sort of a medial eminence at the osteotomy site. So the residual ledge at the first met shaft is an issue for our patients long-term. I've noticed at the end of some of these cases, a new more proximal bump from the residual ledge because I'm limited by the screws as far as how much I can shave it down. Any tips to mitigate this? I'm not going to ask Alistair because you don't have that with your technique. And so you're excluded, but maybe Craig can take that one. Yeah, so I find so a couple of things. And when I make my, before I make my osteotomy, if I see that there's a prominent median eminence, I'll shave that down first. But in terms of the ledge, just approximately osteotomy, I think you have to make sure you get your screws proximal enough. So really you want to get on that oblique face at the medial base of the first metatarsus. And I find that it's of course, it's harder the less severe the deformity because then you're really pulling your hand toward the leg to get those screws up into the head. But if you're able to start the screws proximal enough, then there's enough of a gap between your distal screw head and the osteotomy that I find that then it's much easier for me to shave that down. So if you have your screws too far distal, even entering into the diaphysis, it's going to be too close to your osteotomy and that's difficult to get. Sometimes then you can then put your wedge bur through your osteotomy incision and then kind of work backwards and shave it off that way. Yeah, I think I agree with you, Craig. I think the most important thing to avoid that for me is getting that first screw, right at the base of the first metatarsal. There's like often not a little flare right there that you can kind of have a landing point for that. And if I start there, then my next screw has enough room to make some space as well to shave that down. You can also put a small bone cutter through the osteotomy incision and a ronger and just pick at that dorsal medial ledge. Don't leave it, don't leave it. It will look good in the operating room, but then six, nine months later, once the swelling's all gone, it's prominent and they don't like it. Yeah, I keep like a small pituitary in my set and I trained with Dr. Redfern back then. And I kind of, I don't even use floral when I do that part of the case. I just feel it with my non-dominant hand. And so once I don't feel any prominence and it's smooth, then I- Okay, that's awesome. That's great. That's fine. Great. Thank you. So last question here was, do you add strayers or gastroc recessions to MIS-DMMO procedures? So that's for Steve. You know, so the answer is yes, if I think they need it. And I'm very big on doing strayers and people who have very tight gastrocs and forefoot overload. So if they have gastroc tightness, I will say to them, listen, I know this sounds crazy. I know it's a forefoot problem and I'm going to go up to your leg, but I think it gives you a much better chance of having resolution of pain. Do you have to? I don't know, because there's some people who've said, look, I really don't want you to do them. I've done the DMMOs. And like I said, these unload the heads very nicely. And so their pain does get better, but it's not a bad thing to add in. You know, I want to ask each of you guys just sort of one more question here and maybe we can end about 15 minutes early because it's a Friday and we had a little bit ahead on the first schedule as well. But, you know, all of your talks were so excellent. I always learn so much from these things. And I guess my question to the panelists are, what's sort of the next thing that you want to do with MIS? Like, where do you think your practice is going with this? And, you know, one of the things I really love about Alistair, your stuff is, you're always combining the burr with the scope. You know, MIS isn't just the burr. It can be the scope. It can be other things, but, you know, where do you think you're going with this and what do you want to kind of try and tackle next? Well, I mean, I would say that 70% of my practice is now MIS or MIS hybrid. For example, flat foot reconstruction. I like the navicular conform fusion. It corrects the deformity at the level of the deformity. So instead of doing that open now, I'll do that percutaneous and using the same techniques as we've described. So, you know, I can correct things that way around and then I'll do a lateral incision and put in a wedge place for a lateral column lengthening. So, you know, you got to look at all your practice and say, okay, you know, maybe parts of the operation can't be done MIS, but other parts can. And the more you make MIS, the less pain they have, the less revisit, the less wound complications, and the more you can do daycare. So, you know, flat foot reconstructions have gone from being a three-day admit to a nerve block daycare procedure for pretty much the identical operation. I think there's a lot we can do going forward to figure out the anatomy with standing CT. I think that we're really beginning to, you know, open all of this up with regard to things that we wouldn't have considered before because we wouldn't have done the surgery open. I mean, the metatarsus adductors, you know, we used to, I mean, I used to do it by doing one, two, three TMT fusions open. It was just a massive dissection and patients just didn't want to consider it and I didn't want to do it. And being able to sort of rethink all of this has been, I think, really important, but we need better information on what we're actually operating on, what we're correcting, particularly in the forefoot. So I see standing CT being a big way forward to understanding the anatomy better. Steve? No, I would think that we're all doing a lot of these things now. We need to do them better. We've had our ability with open techniques to get better and better and better over the years. So I think Errol has really come up with some great ideas and guides. I think there are ways to cool the bone better. I think that if I'm not accurate on all my DMMOs or accurate on all my chevrons, I want to figure out platforms that allow us to take every doctor that wants to do this and make it easier for them and more reproducible. That's where I would like to see the future go. Loser Craig? So I would agree with both of everything that both of you said, and I would add sort of becoming more facile with fusions and sort of the soft tissue stripping associated with those and sort of learning a bit more about being able to do percutaneous soft tissue releases and that type of thing for fusions for reconstruction. I think that is another place that we can really go with this, but I agree with everything that both of you said too. Yeah, I would agree too. I mean, again, as we get more facile with these things, so I've always thought Charcot, a lot of Charcot we could address with MIS and maybe not everything, but I think a lot of it, especially those patients with all the comorbidities and swelling. Stay tuned for tomorrow. We have a whole section just on that. Feeling the thunder. Yeah, I think there's a great opportunity there. You know, I have to sort of say for everyone that's listening in, you know, you go to the OR and you say, okay, I'm gonna commit to do this MIS and you're sweating and you're kind of cussing and you know, maybe things aren't going quite the way you wanted, so you're planning, but you know, you get back to the clinic and it's in the clinic, you see the huge benefit. You go from being this situation of people grinding you out. I had to go to a merge. I had too much pain. You didn't give me enough pain medication. I went to see my GP because I had swelling and all my wounds bleeding and they, you know, all this sort of stuff and they come back and they're just not remobilizing. And then you've got the wound complications and I know other people say they don't have them, but I have them and I'm willing to air that laundry. And it's hell when somebody has a bad wound complication. You know, they're all of a sudden back every week. They're getting dressings, they're high anxiety, you're high anxiety. All of that just disappears, you know? Like it becomes just a different, completely different ball game when you just walk into your clinic and got no pain and they got no wound complications and they're all just gung ho to get going and they're just super stoked. It's just such a different experience doing things percutaneous. And once you sort of experience that in your clinic, you just go back to open surgery. I mean, you're sort of saying, you got your open procedures sitting alongside your percutaneous and you're going, I can't stand this, you know? How can I make this percutaneous now? You know, like, and then your brain gets thinking and you get start working on all of this. These are all tools. You know, the arthroscope is a tool and I've learned how to blend it. You know, the Shannon-Burrs with the osteoscopic fusion. So when I do an ankle fusion, I'm using the Shannon-Burr to take off all the anti-osteophytes and taking out 50% of the cartilage. So much of the techniques are transposable too, you know? So you can start using it for your triples and, you know, you name it and you just keep expanding your skills and trying. I like to piggyback on what Alistair is saying that there is a learning curve. Do training, do as much training as you can and then start doing it. Your first Chevron or Chevron Aiken, you know, the nurses are looking at you, it's an hour and 10 minutes, you're struggling and they're telling you that you did this open in 30 minutes last week, what are you doing? Okay, these kinds of things happen. But if you stick with it, you start finding additional ways to use this tool. I think every orthopedic surgeon, foot and ankle specialist should have some of this in their armamentarium. Once you do a MIS calcaneal displacement osteotomy, you'll never open one ever again. It's that simple. And so, but the key is- That's the gateway drug. Yeah. It was mine. Well, Errol, I think I'll thank our panelists. This was amazing. And I'll turn it over to you to sort of wrap up the evening. This has been another great session. I'd like to thank all the panelists for participating. Every time we do this, I learn a lot. I know the audience has learned a lot too. Tomorrow, we have a big slate. We start at nine Central, 10 Eastern time. And we've got some really good controversial topics and great cases to share.

minimally invasive surgery

MIS

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osteotomies

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bone removal

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Advanced Foot Course

2023