On behalf of AOFAS, I want to welcome you back to day three of the advanced foot and ankle course. Thank you to the course chairs, Dr. Errol Bailey, Dr. Christopher Miller, and Glenn Shee for putting together such a fantastic course. Before we get started, I wanted to share a few housekeeping items. All faculty will share their disclosures during their individual presentations, and you can also find them within the virtual platform under speakers, and then disclosures. This course offers a total of 11.25 AMA PRA category one credit. Use the tile on the platform landing page to claim your CME and complete your evaluation for this course. The broadcasts are being recorded and will be available under on-demand recordings on the virtual platform within 24 hours of the broadcast. All on-demand recordings will be available on the One Education Center 24 hours after this broadcast. To send questions to the faculty, please click on the Q&A tab in your navigation bar. If you're experiencing technical difficulties, please try to close your browser and logging back in the same way you did the first time. Lastly, we want to thank our sponsor of this course, MedlineUnite. You can learn more about this company by visiting the exhibit hall icon on the platform landing page. With that, I will now turn the program over to Dr. Bailey to get started. Good morning. Welcome to day three of the Advanced AOFAS Foot and Ankle course. We're glad to have you this morning. We've had two great days of talks and dialogue. I'd like to thank my co-chair persons, Christopher Miller and Glenn Shee, for the excellent job they've done throughout this entire process in helping us put this together. Of course, this can't be done without the connective tissue of this entire event, which is Julie Glasson, who contacts each of you, sends the emails, makes sure that IT issues are solved. She just holds this entire thing together. As speakers today, we'd like for you to stay around your 15-minute mark. Some will drift over, and that's fine. We just don't want to get, let's say, longer than 20 minutes or so. If you can keep it close to 15, that would be great. We're going to flow right through lunch. The comments we got last year when we took a lunch break was that that was probably not a good idea because we lost a lot of people at that time. The beauty of this is it is virtual and it's on demand, so you can watch it whenever you'd like. Please ask questions. We want this to be open. We want this to have some camaraderie to it. The panelists are very eager to answer your questions. There's a question and answer box at the bottom of your screen. You can just hit that and ask your question. Then we'll also make sure, if we have time, that we put that question out for everyone to also hear the answer to. Without further ado, let's start Session 1. Good morning, everyone. Again, my name is Glenn Scherr, and I am out of Jacksonville, Florida. In Symposium No. 5 today, we're going to be discussing lesser toes and getting it right. For me, personally, lesser toe pathology has always been a struggle. It seems to be never perfect. That being said, we do have a first presenter today. It's Dr. Paul Telusion. I have known Paul since 2007, when we were serving as medical students together in Boston. He currently is an associate professor of orthopedic surgery at the University of Michigan, specializing in foot, but quickly becoming known as an expert of the plantar plate injuries. He's online today to discuss the plantar plate, etiology, and surgical solutions. Paul? All right. Thanks for having me. Like Dr. Shi said, we were med students together, and he made me look pretty bad. I'll talk about the plantar plate, some etiology and surgical solutions. Here's my disclosures. The plantar plate, its main function is to stabilize the MTP joint and resist dorsal translation. When it comes to repairing them, I think it's a fairly simple concept. It's a ligament that's not working, and so we tend to repair ligaments, whether it's in the ankle, shoulder, something like that. I think one of the issues with plantar plate surgery, and why a lot of people don't like to do it, is because it's technically difficult. You're working in a really tight space, and some people will say you can't really trust the plantar plate, because sometimes the tissue's not so good. In terms of etiology, the plantar plate, I don't know if it just tears. It's usually the result of something, and so if you're addressing a plantar plate surgically, you should probably try to figure out why, and if there's a root cause to go after, you should probably address it, whether it's haloxvalgus or something else. Some of the reasons are, you could have a long second metatarsal, or a relatively long second metatarsal, because you have a short first metatarsal, whether someone was born like that, or if it's from previous surgeries or something. Haloxvalgus is probably, in my experience, I think it's probably the most common reason why someone will get a plantar plate tear, or at least plantar plate attenuation, or stretching of the plantar plate. Others can get plantar plate tears due to Achilles contractures, or gastroc contractures, but kind of going into some relevant papers on some of these etiologies, I think with a short first ray, or surgeries that shorten the first ray, if you start shortening, and I mean the majority of surgeries we'll do on the first ray will necessarily shorten it, and so you shorten by two millimeters or four millimeters, it doesn't seem to really increase the loading of the central rays too much. When you get to six millimeters or greater, you definitely start to see some very abnormal loading of the central rays. One of the things that you could do, if you're doing a surgery and you know that you're going to be shortening the first ray, is you could always plantar flex it, you know, you could do it this way or many other ways, but if you have like six millimeters of shortening, if you plantar flex the first ray, or at least the metatarsal head, by about three millimeters, it seems that you can normalize the loading of the central rays at that point. Other things with a long second metatarsal is the metatarsal protrusion index, so if you have a metatarsal protrusion index by like greater than four millimeters, people have found that you can have a two and a half times like greater risk for having a plantar plate tear. And then as far as like Aquinas contractures, if you have an Aquinas contracture, you are definitely loading the metatarsals abnormally, and so, you know, some would argue that you should be lengthening Achilles tendons. As far as like just kind of jumping into the surgeries, I mean, there's a lot of different ways to address like, you know, we'll call it metatarsalgia, and, you know, there's MIS stuff, there's osteotomies, which other people will get into, but what I like about plantar plate repairs or plantar plate imbrication, if the plantar plate isn't actually torn, is that it addresses the anatomic lesion, and I mean, we try to do that all over the place in orthopedics. It doesn't work every time. I mean, I think trying to repair a plantar plate or imbricate a plantar plate, the greater the deformity, the higher the risk that it could fail or that you could have a recurrence, and so I'll probably say I'll consider doing other things other than a plantar plate repair if they have something that's greater than like a flexible hammer tail. If you start getting into big deformities, plantar plate may not be the right thing. Although I'll admit I will push the indications, but the indications, or at least my indications are, you know, it's metatarsalgia, it's pain on the plantar surface of the metatarsal heads. For some of the repairs I'm going to show, I think that, you know, these are more for like your grade zero tears or maybe your grade one tears where you don't have too much deformity, you know, maybe have a little bit of a cock up second toe because of long standing hallux valgus. Pain with jaw test is the most sensitive test, I think, for a plantar plate insufficiency, and I don't know, I think this is kind of like the patients who, well, I guess I got into this because a lot of patients would end up coming to see me because they've seen other people and they just kind of had this like pain, like metatarsalgia pain, and it was bad, but it wasn't necessarily bad enough that the original surgeon was going to do like, you know, big osteotomies or pin the toes or anything like that, and then so they just ended up with me, and that's kind of how my practice has evolved with this. In terms of the approaches, so there's a plantar approach, it's kind of, it makes sense in a lot of ways because it's a plantar structure, so let's make a plantar approach. Some of the issues with it, though, is, you know, we don't like to make plantar incisions all the time because of painful scars, and so in a series of plantar plate repairs using a plantar approach, I mean, about 8.8% of people would have painful scars, although the recurrence rate was quite low, so you can really, I guess, get a good repair. I've never actually done it through a plantar approach, but this is how it's done, and I wish I could tell you more about it, but I've never done a plantar approach. Through the dorsal approach, I think we have several different options. The probably most well-known one is a dorsal approach. You do a capsulotomy. Step two is you stick them a glamory elevator in there to, like, you know, kind of your first goal is to visualize the plantar plate because it's such a tight area, so one of the first things you do is you stick them a glamory in there, and you're, like, stripping the metatarsal attachment of the plantar plate. Step two, a little bit of a plantar condylectomy, and that's because you want the plantar plate that you've just stripped off of the metatarsal to heal back to the bone, and then the next step is usually, like, a while osteotomy. You push the metatarsal head proximally, and that opens up some more space. After you've kind of maximized how much space you can get in there, the next step is to cut the plantar plate or complete the tear off of the proximal phalanx, and then after you've done that, you can put in whatever device you're going to use to whatever device you're going to use to pass the stitch. There's definitely, like, commercially available ones, like this one from a company that rhymes with Schmarshmex, but there's definitely other ones, too, and you pass the stitch, and then you drill a couple holes into the proximal phalanx, use a suture passer to pass the sutures from the plantar plate from plantar to dorsal on the phalanx, hold everything reduced, and then, well, first you're going to put a screw into your while osteotomy. Some people will shorten it. Some people will say they won't shorten it, and they've only done the while osteotomy to, like, make room so they can see. After you've put the screw in to fix your while osteotomy, then you tie your sutures, and you tie your sutures while holding the toe in slight plantar flexion, and there's other ways to do it. I mean, some people will say, you know, this surgery is something that's done in surgery centers, and so if cost is a big issue and you don't want to spend a lot of money on these products, several people have talked about cheaper ways to do it because, you know, one of the big challenges is just passing the stitch. So some folks will talk about just using a K-wire, and I kind of think of this as it's kind of analogous to percutaneous Achilles repairs. You know, again, you could use kind of the expensive stuff, but some of the folks at Harvard have described basically bending a, like a towel clamp and using that as a lasso. So in this case, it's a bent K-wire, and again, I've never done this, but after you detach the plantar plate from the phalanx, you put this wire loop thing, plant it to the plantar plate, and then you use a series of Keith needles to kind of put the stitches in there. After you've passed all your stitches, then you take this wire loop and you pull it out, and it sort of fishes the stitches out for you, and that's how you can pass your stitch. And whether you're trying to, like, repair a tear in the plantar plate versus just, you know, putting the stitches in the plantar plate so you can attach it to the phalanx, you know, do what you got to do or do what's needed. But kind of the point is, this is a cheaper way to pass the stitch. And here it is in real life. And then, you know, my thing with some of the ways that plantar plates, plantar plate repairs have been described is it requires a ton of stripping. Like, you've cut the plantar plate off of the phalanx, and you've stripped the plantar plate off of the metatarsal. And so one thing you have to consider is what did that do to the blood supply? So the blood supply to the plantar plate comes from the phalanx distally, and it also comes from the metatarsal where it attaches. And then there's also a contribution from the plantar fascia. And so, like, here's the blood supply of the plantar plate. And so, you know, in the traditional plantar plate repairs, you know, you stick this McGlamory elevator in there. But what does that do? Like that strips, the goal of that is to strip the metatarsal attachment that is seen here. But one of the issues I have with this is that it's going to, you know, you're taking out some blood supply of the plantar plate. So you've, you know, taken that thing out. The next step is if your plantar plate is not torn off of the proximal phalanx, and you cut it off the proximal phalanx, you know, now you've like insulted the blood supply a second time. So, you know, in as I've done a bunch of plantar plate repairs, you know, one of the things I kind of thought was, you know, can we do this with less tissue stripping and preserve the blood supply a little bit? And so what I do, if I always get in there, and I will look at the plantar plate, I put a pin distractor on there, I examine the plantar plate. And if the plantar plate is is not torn off of the proximal phalanx, then I'll kind of go to sort of plan B, which is don't cut the plantar plate off of the proximal phalanx. But what do I do? So well, so this is kind of just showing the drawer test that I do. That one's like fine. And then this was the abnormal one. So you see how much motion you get with a drawer test there. And, you know, now the next goal is you want to pass this stitch, you want to basically pass a mattress stitch. So I'll make an incision. And then I'm trying not to put McLamry elevators in there anymore. But sometimes I do, but I do a plantar condylectomy because you want to have some bleeding bone on the metatarsal. So here, I'm going to instead of imbricating the plantar plate to the proximal phalanx, I'm actually going to imbricate it to the metatarsal neck proximally. In that way, I'm preserving the blood supply by not cutting it off the proximal phalanx. So after I do a plantar condylectomy to the goal there is get some bleeding bone so that so the ligament can reattach to it. So next is passing the stitch. And so this is sometimes hard to describe. And even sometimes it's hard to follow this movie. But what I'll do is I'll take the Keith needle with a PDS suture attached to it. I go from dorsal to plantar. I grab the tip of the needle on outside of the skin plantarly and kind of like an arthroscopic type surgery. I redirect the needle and push it back up through the plantar plate and to pass a mattress stitch. And so what that looks like in vivo here is I'm taking the needle, I'm putting it from dorsal to plantar. And after the needle goes through the plantar plate and out the plantar surface of the skin, I'm going to grab the needle on the plantar surface of skin, it's not going to exit the skin, I'm just going to pull the needle just through the plantar plate redirect it and then pop the needle back up dorsally. And that's just a regular Keith needle. And some people have asked me, well, it's not sharp on the, you know, on that end of the needle where you popped it back up through the plantar plate. And I mean, we're orthopedic surgeons, you push hard enough, you can do anything. So you just kind of pop it up. And it doesn't seem to make big holes. After I've done that, because passing the stitch was the hard thing. Then I drill a couple of holes, holes through the metatarsal neck, use a suture passer. And then I'll tie the stitches that way and it stabilizes it. So I think the advantage here is that I didn't take the, I didn't kill the blood supply by cutting off the plantar plate from the phalanx. And we still have proximal blood supply coming from the plantar fascia. I'm trying to get away from sticking a McLamry elevator in there and stripping it off of the metatarsal. And so we've presented data on this at the winter meeting, like almost like a year and a half ago. And, you know, a year after surgery, people's physical function scores was 52.5, which is, you know, essentially in the normal range, which represents like being able to do ADLs plus strenuous activity. You might ask why we haven't published this yet. And it's because every time I get the manuscript done, I realized that I can add more patients to it because our end in this was only like 14. So otherwise to conclude things. So I think when addressing plantar plates, you know, I think you need to look at the root cause and, you know, whether it's lengthening the gastrocs or, you know, lengthening the first ray or, you know, fusing the MTP joint, whatever you got to do, like address the root cause. If you can be kind to the blood supply, try to be kind to the blood supply. And you want to examine the plantar plate before you just, you know, cut it off the proximal phalanx and consider imbricating it to the metatarsal proximally. Here's some references and thanks for the opportunity to be here, and yeah, appreciate it. Thank you, Paul. That was a very nice talk, and we'll ask the audience to continue to send questions. We'll get to them at the end. We'll move on to the next speaker. The next speaker is Dr. Holly Johnson. She's joining us from New York. And she's actually this year's recipient of Career Impact Award, which recognizes surgeons who have made a recognized contribution to our foot and ankle society. So she's here to speak on, I guess this is a little aggressive in title, that we actually made up, I Hate the Second Toe, ObEN versus MIS Solutions. Dr. Johnson. Great, thanks, Glenn, Errol, as well as Chris for inviting me. Paul, that was a great talk, and I like your technique. I might try it. It looks difficult, but it's great. So I hate the second toe. I think we all hate the second toe, but I'm going to show some percutaneous options that hopefully will make it a little bit easier for people to deal with. Here are my disclosures. So I don't understand why evolutionarily the toes would ever do this. It makes no sense. Nonetheless, these are the deformities that we're dealing with on a daily basis. The etiologies are multifactorial and can be atrogenic or congenital, mechanical imbalance, et cetera. Patients will do anything they can to try to handle the pain and correct deformity. But nonetheless, they still show up in our office, and we have to deal with this. So why do we hate hammer toe surgery? It's unpredictable, right? We can do the same operation 10 times and have 10 different results. There's a really high recurrence rate. Patients have completely unrealistic expectations about what we as surgeons can accomplish, and this leads to low patient satisfaction and ultimately low surgeon satisfaction. So this is why we all hate the second toe. So multiple surgeries have been described over the years, and I think for me, the surgical choice is based on the deformity, whether the toe is flexible versus rigid, whether there's joint involvement, and really ultimately what the surgeon is comfortable doing and what success they've had with their different techniques. So when I think about open versus percutaneous and compare them side by side, open, I think, is technically easier for most of us because it's the way we were taught at the beginning, certainly. There are lots of tendon transfer options and tissue repair options that are more anatomic, just as Paul really nicely describes. However, it usually requires some sort of fixation. There are many more wound complications, and I wouldn't say that stiffness is common. I would say it's almost ubiquitous, excuse me, at least in my hands. You know, with percutaneous, I found less wound complications, less pain for sure, less stiffness, and generally the surgeries take a lot less time. However, they can be really technically difficult at the beginning, and it requires much more postoperative taping and strapping and requires a lot of work on the patient's part and therefore can be less reliable. And even with a perfect surgery, you can be really sabotaged postoperatively by the patient's inability to deal with the taping and strapping. Nonetheless, some techniques can be life altering. I always like to acknowledge my mentors in percutaneous surgery, and particularly for lesser toe surgery. Barbara Kee Clay is an absolute master of this, and I continue to reach out to her almost on a weekly basis to help me with difficult problems. So there are a million different percutaneous options. This is a slide that David Redfern gave me. I'm not gonna go through all this, but this just shows you sort of the multitude of options available. This is also a really nice slide that I stole from the MIFAS group, and basically describes the deformities and what your options are to treat each deformity. And when you're thinking about percutaneous surgery, the most important aspect is understanding the anatomy and what each cut or lengthening or osteotomy does in relation to what the normal anatomy and pathologic anatomy will do. It's absolutely critical that you understand that. And then once you understand that, then you can get creative with your different options for treatment. So for really simple, mild, flexible deformities, you can often just cut the extensors right in the hood. And when you cut the extensors within the hood, it allows them to lengthen, but not to completely detach so that they'll sort of heal in a lengthened position so patients will maintain some extension. And this is a much better way to do it than opening it up and stripping the tendons. Then you'll never get any extension back. This is just a really simple example of where I did it through this small incision and really corrected the deformity nicely. Now, most of the time it's not that easy and you'll have to accompany a small extensor release with other options so that when you have this sagittal deformity, you can release the extensor tendon, but at the same time, you really need to release the flexor brevis as well as the plantar plate. And then you could do these little osteotomies, a plantar flexion osteotomy, the proximal phalanx, and or a dorsal osteotomy of the middle phalanx to get a really nice correction and straighten the toe out. This is the plantar plate release. This is a picture that Barbara P. Clay had in her foot and ankle clinics article from 2016. Basically using a beaver blade, you go in, if you're a right-handed surgeon, you're usually going into the medial side depending on what foot it is. And you're going directly under the PIP joint and you're stripping that plantar plate from the PIP joint and then taking the flexor digitorum brevis and severing it. You don't wanna take the longest because then you'll end up with a floppy toe. So this is actually technically challenging. And if possible, I suggest you try it in a lab first, but it can be really powerful to help get the toe straight and to balance out the extensor release. This is just an example of where I start. And then here in the video, I'm sorry for the sound, but in any event, that's the incision that you'll make on the bottom of the foot. For a coronally-based deformity, usually you can just do these little ache and neck deformities if it's mild, but be careful if there's a big MTP joint malalignment because the toes can recur. And I'll show a couple of examples of that later. Again, sorry for the sound. This is cutting from the bottom, doing the osteotomy. And then here, manipulating the toe and green sticking it to get it, to close that osteotomy down and get the position right. So it's really nice if you have kind of simple deformities, in this case, accompanied by a Hallux-Valgus correction to make the toes straight. In this case, the patient didn't have any MTP joint pain, so I didn't really have to address that deformity there, but you can correct the lesser toes pretty easily. Now for crossover toe deformity, this has probably been the most revolutionary part of the MIS lesser toe correction that I've seen. And basically with these oblique osteotomies, it allows the toe to shorten and it takes a lot of the tension off of the extensors and the flexors. So it allows the toe to shorten and to move laterally. So it can correct the MTP deformity, loosen up the tension and really help correct the overall toe position. It's great. It's relatively easy to perform. I'm gonna show this video. There's no, I'm not doing any irrigation in this video because I wanted to put it in this talk so you can see, but it's really important that when you're doing, using the burr in any way that you irrigate copiously or you'll burn the bone. So here, it's just a very simple oblique osteotomy. And then the cuts made and I manipulate the toe and shorten it and the deformity is well corrected. So these are some examples of where, you know, where I made the cuts and accompanied by a Hallux Valgus correction and it worked really, really nicely. This is another example of these oblique osteotomies in a patient who had had multiple prior surgeries, really stiff, painful toes. And I just did these little obliques and she did great. And they actually never even healed, but they stiffened up. And this is the correction on the right side about six months afterwards. And the patient was really happy. So for rigid deformities though, rigid PIP deformities, I am still doing PIP fusions most of the time. And you can do this percutaneously or you can do it open. I'm often doing it open just so I can shorten and get good compression across the toe, just through a small dorsal incision, but sort of fixing in the traditional way with either a screw or K wires. Again, you could be creative in terms of how you hold the correction in place with little sutures. In this case, sometimes I'll use pins depending on what the patient's like and what I think they're capable of postoperatively as well. This is a case where it was a very challenging patient with multiple comorbidities. And I was trying to get acute and do a really easy, quick deformity correction here. And ultimately it recurred. Amazingly, the osteotomy healed nicely, but look at the MTP joint. And the patient still had ongoing pain. And unfortunately, because I didn't correct the alignment at the MTP joint, I had to go back, do an open shortening and correct it kind of old school. So again, you really need to address the MTP deformities in the severe cases. This is another example where initially I was trying to get acute and just do these little aconite corrections. And she was really happy afterwards. This was like an 80 year old woman. She showed up three years later and look, the third toe completely slipped off of the metatarsal and created this hammer toe deformity that you see on the bottom and the third toe that was really painful. And I was forced to go back. This is a recent case where I refixed the toes and realigned the metatarsophalangeal joints. And hopefully this goes well. She's about six weeks out of doing well so far. This is another case, I apologize, my slides are sort of overlapped here, but again, where I did a couple of short osteotomies, the middle phalanx, the proximal phalanx, as well as the first metatarsal pinned it straight to get the toes straight. And this actually worked quite well with this oblique osteotomy. For dislocated hammer toes that are passively reducible, oftentimes you can do isolated extensor releases and then these little DMMOs and that patient did quite well, despite the fact that the fourth metatarsal is still quite long. This was an elderly man that I just needed to get back on his feet as quickly as possible. This is a case where I couldn't reduce the MTP joint. So I just had to open it and go old school. Sometimes you can't use these percutaneous releases. And so this is an example of where I was able to do a percutaneous hallux valgus correction, but had to open the western toe. So you can mix and match and get creative with open and percutaneous. This was a case where, again, sort of mixing and matching different techniques to reverse oblique osteotomies. The second toe shortened and shifted enough. I was able to correct the alignment at the MTP joint, really nicely get the toe straight and she's done great. So quickly, I'm gonna go into metatarsus adductus. I don't wanna spend too much time here, but I think it's important in the setting of the hammer toes to understand it. So I used to do these little aconite osteotomies and I thought I was being really clever, but these recur. And once I did enough of them early on in my percutaneous career, I realized that this is not going to work long-term. As I showed with that woman who had the third toe dislocation afterwards. You have to correct the MTP deformities. And when I'm doing this in the setting of metatarsus adductus, I do the oblique correction. I pin across the reduced MTP joint after I released the soft tissues in the MTP joint and I pin across. And then I do oblique osteotomies of the lesser metatarsals to sort of correct the adductus of the lesser rays. And then typically I'm doing a lapidus procedure to hold everything in place. And I've had great results with this so far. I've been doing this now for about three years and so far it's been pretty successful. This is just an example of a patient where we did both feet and you can see the range of motion. You never get that when you're doing open metatarsal shortenings. And so the advantage here is that you're not gonna get a perfect correction like you never can really with metatarsus adductus, but you're gonna get much better range of motion. This is another example where you can see at six months post-op there's a little bit of recurrence but still generally speaking the correction's well-maintained. These are just some post-operative images of a recent case. Always, I always have this flat plate that you see on the upper left side of the screen. This is a metal plate that Jonathan DeLand made many, many years ago. And so we have hundreds of them at HSS. I open them for every case and I'm always simulating weight bearing to check my correction intraoperatively. And then in the top image, you can see I've pinned. Sometimes I'm using Steri-Strips to try to maintain my correction. And then I build this cocoon around the toes to keep everything in place. And in this case, the patient will be able to weight bear on this and everything should stay in place nicely. Post-operatively, most patients are immediately weight bearing in a hard sole shoe or a short boot. They're coming in for dressing changes every two weeks or they're doing home dressing changes with this Kinesio tape. And it works really well. This is actually, this patient did this taping job herself. But again, as I mentioned, that patients can sabotage you post-operatively. So you have to be really careful. Some people use putty. Chris Miller does this. This is a picture of Barbara P. Clay's on the bottom and I'm gonna try to employ this as well. The literature is limited. I'm not even gonna really go into it. There are no great studies looking side by side yet at open versus percutaneous. My limitations for percutaneous are the rigid PIP joint. I really think you get a better fusion if you open them. You can shorten them as much as you want. And I find that at least in my hands, these fuse more reliably. They can be un-reducible MTP joints. I'm still opening some of those. And just be careful because a simple extensor release without the FDB release can result in recurrence. Complications, anything that can happen with open surgery can happen in percutaneous surgery. Non-union, over-correction, under-correction, recurrence, swelling, stiffness, everything. These are some cases of over-correction. These are some cases of under-correction. This was a disaster where the patient dorsiflexed through the osteotomy sites and ultimately ended up with a dorsiflexed third metatarsal. I took her back and did a fourth metatarsal shortening and actually this cured the problem. If anybody has complications, I've had so many of them that I can help you try to figure out solutions. So let me know. These are patients who are dissatisfied despite what in most cases, I think patients would be happy with. This is how she was taping the toe at home, total sabotage. She was actually taping the toe in dorsiflexion. So this was a case that failed and I ultimately had to go back and re-osteotomize all of the metatarsals that had dorsiflexed and pin it. And thankfully so far, she's doing well. This is a patient that I think the outcome looks really good, but she thinks the toes have recurred and she's unhappy. So it's still, even with percutaneous, you still can't win. But just some take-home points. Always take preoperative photos. I load them into my EMR so I can show patients actually how much better their foot looks. Check simulated weight bearing in the OR always. I video post-op taping techniques for the patient so they can actually look at the video at home so they know they're doing it right. When in doubt, if you're not sure about the patient, how well they're taping, see them back in person. The 15-minute office appointment every two weeks will save you a world of hurt if they do it wrong. And always explain to the patients that the x-rays will look very different and you'll see these floating bones. It's important that patients understand that pre-op. So for me, percutaneous lesser toe surgery has been just another powerful tool. It can accompany open surgery. We do need some good studies to compare open and percutaneous results. Thank you. Thank you, Dr. Johnson. And I see that we have already have generated quite a few questions. We'll get to the end. And also not only patient education, I think we also have to discuss with our musculoskeletal radiologists who frequently call these things displaced non-unions. And the patients, of course, can see their medical records now. That being said, we will come back to this topic, I'm sure, as there are several questions. And our next guest is Dr. Edward Haupt. And he is actually my partner here at the Mayo Clinic in Jacksonville. He joined us two years ago. And he's going to discuss his opinions on the Y Lastyotomy, why he actually hates it more than the failed hammer toe. Dr. Haupt. Hey, thanks, Glenn. This has been a fantastic meeting. And let me share my screen with everybody and we'll get to it. All right, so I'm Eddie Haupt. I'm here from the Mayo Clinic in Florida, partner with Glenn from Jacksonville. I'm gonna talk about why I hate the Y Lastyotomy. Here's my disclosures, nothing pertinent to this talk. For the outline, I think, first let's just try and make sure we're all on the same page with our vocabulary. Let's talk about reasons you do a while, whether it's lesions or toe deformities or forefoot pain. Review some tradition, as well as what's new. I'll talk about some of the traditional indications for the while, as well as little modifications of how to use it. And then some of the other options that are available. Luckily for me, there's been a lot of presenters talking about DMMOs and other things like that. So I'm gonna hit some of the basics, but also some of the advanced stuff. And then as well as pearls, pitfalls, and complications. So, I think when it comes to what you're gonna think about doing a Y Lastyotomy for, I think the first thing is that we all have the same terminology going here. As it pertains to toes, is the toe deformity a hammer toe? Is it a claw toe? Is it something else? I think all of us can very concisely tell somebody what a hammer toe is versus a claw toe. But I think in the literature and clinic from a patient's point of view, these aren't all the same terms. And so, what's in a name, I think is very important. And so I'm going to try and use the term lesser toe deformities, but I'm going to, I'm going to, I'm not going to lie. I frequently use the word hammer toe to describe any lesser toe deformity. So, uh, as long as we're all on the same page here, the most important thing with these toe deformities is distilling the issues, looking at each joint separately, figuring out in which planes of the deformities is a deviated medial lateral dorsal planner, uh, or their tendon, uh, imbalances, other contractures that you can't reduce. I think being very specific in particular about these problems is the right way to think about the toes. So I actually learned about this classification system from Dr. Johnson and Dr. Bailey at a MIPHA scores two years ago. And I think this is a big step forward in trying to, uh, discuss these problems and move the field forward. And it's, it's another plug towards, uh, Barbara P clay, but yeah, this is exactly what I just described, not calling them hammer toes and being very particular about exactly what you're trying to fix. So, you know, some good reading for, uh, the team here coming out of Europe, you know, let's, let's flip. So we talked about toe deformities. We can also talk about this bland term, metatarsalgia. That's a great example for what's in a name again, you know, and so there, what is the classification of metatarsalgia? Well, there isn't one except the one because there's myriad ideologies ideologies. And I think none of us would really all have the same definition of metatarsalgia. So again, being very particular about the things that cause pain in the plantar forefoot. And that's what I think of when I think of metatarsalgia is anything that makes the person's ball, their foot hurt, you know, and these can be problems from the metatarsal, uh, whether that's a barren lengths of the metatarsals have been the forefoot cascade, malunions of previous osteotomies or fractures, you know, historically productive arthritis from RA and just a really thick florid rheumatoid pannus was a problem in the plantar forefoot, but that's essentially been removed with the modern biologics. You know, toe problems could also cause ball the foot pain, whether that's due to distal fat pad migration from a sagittal plane deformities of the toe, but MP joint subluxations, IP joint contractures will increase the pressure underneath the metatarsal head. So those should be looked at. And then, you know, I called this non-surgical, but clearly Aquinas, you know, as a previous presenters have discussed also increases, uh, forefoot pressures. And so that's something to think about as well. And then things that aren't really items that we can treat with surgery, such as just what's the patient doing on a day-to-day basis. What are their activities? Do they have decreased, uh, fat pad in the plantar forefoot? Those are, that's not something that I know how to address. So before we get into surgical techniques, I think, uh, you know, we all would agree that the exhaust not on management first for me, that means the same things I use to stabilize the toes postoperatively generally work the best preoperatively as well. And at least then the patient has some familiarity with like boot and splints, taping, strapping, et cetera, the spacers, or even using the, uh, the putty that as previously mentioned. So, uh, that's the same kind of stuff that I use ahead of time. There we go. And so for surgical management, I'm going to talk about a bunch of different things here. The blessing and the curse here at forefoot surgery, as we'd all agree, is that the patients are all unique. Uh, the techniques are heterogeneous. The problems are heterogeneous. A lot of the techniques will address multiple complaints simultaneously. So you really need to choose wisely. So traditionally the wild osteotomy, I think it was the workhorse for many forefoot conditions. And it's a, it's a pretty good operation, right? And so it's, uh, as originally described, and I can, this, uh, review here from Spain, they go through the great history of this procedure between how it advanced from low while, as well as the Europeans in tandem, you know, it's an open oblique interarticular shortening osteotomy. There's many modifications, whether you do it with a single cut, whether you do a triple cut or a way for resection, um, there are ways in which you can rotate the capital fragment to treat medial and lateral deviations as well. Uh, and then the fixation strategies that can be used are obviously variable. You can use screws. You can also pin across the impeachment. I think one point of contrast I'll bring up a lot is, uh, in my own practice, the pinning across the MP joint is something I usually leave towards while osteotomies as opposed to percutaneous techniques. Uh, but, you know, clearly just from watching a Holly's talk, I have even more to learn than there is this generally something I've been staying away from. So the while, as we know, results in shortening of the metatarsal, these are all the things that the wild treats. It's going to treat the plantar pain of metatarsalgia. It's going to treat axial or excuse me, sagittal plane deformities of the toes, as well as, um, medial and lateral deviations, depending on what you do. I can treat flexible sagittal deformities of the IP joints, and there's a fixed shortening amount after you fix it. I think all of us have done lots of wiles. And so it's one of the most satisfying thing in orthopedics. I think with a, with a well done while, as soon as the cut is completed for like a flexible hammer toe, watching the metatarsal head kind of spontaneously decompress itself and shorten kind of removing the excess tension in the tendon system. There is a very satisfying thing. I think we're all very familiar with that. So what are the downsides of the wild? I think this is why I hate it. The main one would be number one, which is the floating toe, which is a dorsally displaced toe that may not make purchase with the ground. And some series is this can be up to 36%, which to me is kind of insane that we're thinking about a surgery that has a known complication of up to one in four or one in three. There can be deformity recurrences for lesser toes. I think depending on how much you shorten it, you can create transfer metatarsalgia. The other metatarsal heads can obviously lead to stiffness, which perhaps that's due to it being an intra-capsular osteotomy, but also it's an open approach in the dorsal skin. There can be soft tissue contracture, which can contribute to that. And I think we all have many patients that have some pretty thin dorsal forefoot skin. And so that, you know, those incisions there really don't take a joke, especially if you need to do multiple wilds. So what else can you do that can accomplish the same goals? And so this is a chart that I showed earlier. There's metatarsal problems, there's MP joint problems, and then there's toe problems. I think for the metatarsal problems, the different strategy would be DMMOs or variations, which would be like the oblique, or the the DOMO or the DICMO. The MP joint itself, in my opinion, is the MP joint subluxations are the hardest to address with alternative strategies. And so I think a lot of times I'm still employing wild osteotomies for those, whether it's combinations of soft tissue releases or phalangeal osteotomies. And so Holly just talked about the phalangeal osteotomies. I think those have been the biggest difference maker in myself once learning minimally invasive techniques because they are quite powerful. And so let's compare the wild and the DMMO. I think the wild is obviously going to be open versus percutaneous, there's a stable shortening. And I think this is something that isn't always brought up in a lot of the meetings that we all know the DMMOs are floating osteotomy. In my own practice, I think these people stay swollen a lot longer than does a wild, which I think is, you know, it doesn't lead to any big changes in the end. But it's like a frequent marker of a successful surgery to me is at the six week or three month visit, the patient's like, why is my foot still swollen? The fact that it's an unstable osteotomy does create, in my opinion, a larger inflammatory cascade there. The wild has this possibility for metatarsal head depression and floating toe unless you were to take away for resection. In the DMMO, on the other hand, essentially can only really create an elevated metatarsal head. So kind of avoiding that chance of floating toe. There are some variations of how you cut your DMMO. There's some pictures from one of the reviews from Redfern, where if you the obliquity in which the metatarsal head is finished with the burr, you can also create additional translations of the metatarsal head. So the extensor tendons are going to cause some drag of the head laterally. And so if you end up cutting it with something that kind of has a slope pointing laterally can increase the displacements of the metatarsal head. So something to keep in mind, that would be what is referred to as a DOMO. So in my own practice, I learned the minimally invasive techniques a year and a half ago after having not done them in training, mainly because I wanted to get away from doing wild. So I just hated the idea of a one in three cock up toes for something that didn't have a great answer. And so, you know, I went to learn these. And I think the DMMO, if you haven't done it really shines in certain settings, bunionettes being one, diabetic foot ulcers, I think the plantar forefoot ulcer is an obvious situation of a plantar forefoot overload situation. The DMMO is fantastic for that in comparison to TALs and total contact casting. And then elderly folks with recalcitrant forefoot callosities also do really well with DMMOs. Yeah, in my own practice, I can't use the DMMO the same way I would a while for a flexible hammer toe. And so I lean on these kind of digital specific techniques, which like the phalangeal osteotomies or PERC osteotomies for those. And like I was saying before, if there's a big NP joint problem, then I'm almost certainly going to have to use an open procedure. Things that I think need more investigation as it pertains to the DMMO is doing an isolated one versus plural. I think there's some concern about doing an isolated central metatarsal DMMO. I think it's probably okay, but there's obviously risk of transfer. That's my level six evidence for you. What actually needs to be done with the post op dressing and management? I think I didn't learn well enough from the European folks on how to do their dressing. And so I do something different. I do like kind of that skin suturing that was at least taught to me by Pete Mangione in North Carolina. That works very well for me, or I pin them. But the pin itself may be kind of a weird looking extra. And I think it's great that Holly highlighted that you need to talk to your radiologist ahead of time. I think there's some effect that if you do shorten multiple metatarsals, that since they're connected by the inner metatarsal ligament, they may have kind of like an increased amount of shortening if you do two through four, two through five, as opposed to just one of them. But we'd really, you know, those are answers that we still need. There is a quick case kind of illustrating that. This is a patient that's had multiple forefoot surgeries in the past. Whoops, spoiler alert. On the right foot, she has a lot of hallux and P joint pain, has heterolapidus with fourth heart removed. The first race already very short. And so after going through all the options with her, we decided we're going to fuse her hallux and P joint. But the big problem there is it's already very short. So we're going to basically plan for an interpositional bone block fusion, which is fine to try and at least not shorten it anymore. But we're still probably going to have weight problems. And I think this is where DMOs and other situation where they very much shine, that for somebody with lots of incisions already, you can shorten their other metatarsals that create a much more balanced forefoot cascade with with PERC techniques. And so, you know, here's an example of what that would look like and a comparison of kind of the forefoot cascade before and after that. So I think that's it. That's why I hate the wireless geometry. But you know, I can't say that I don't do them anymore. I just try to stay away from it as hard as I can with treatment of MP joint problems. So thank you. All right, thank you, Dr. Hopp. And we'll have move on to the final speaker for this session. So the next speaker is Dr. John Chow. Dr. Chow is originally from Texas, and he has over 10 years experience at Petrie Orthopedics in Atlanta. And today he'll be teaching us about how to deal with the failed hammer toe. Dr. Chow. Thank you for all the court structures for having me. And so I thought that this would be sort of a therapeutic lecture, kind of looking going over what we actually use in our toolbox, but also looking at things that I struggle with and things that we just can't get right. I think Dr. Johnson hit the nail on the head a few lectures ago about it's just not being satisfied and setting expectations. I have no disclosures. Traditional hammer toe surgery, and corrections with or without osteotomies can lead to a lot of stiffness and unpredictable outcomes. Just kind of going through sort of a short history of what we use in our tool belts where things came from. So Coughlin about 35 years ago talked about just taping, using eccentric tenotomies, lengthenings, capsulotomy, soft tissue procedures, and also flexor eccentric transfers, while osteotomies and pinning the MTP joints. So kind of going through what I look through today, what I use. So one thing that I do use that in sort of elderly patients is what Giorgio talked about in 05, just amputating the second toe for a really bad crossover toe for someone that just wants to get going. They don't want to tape, they don't want to do anything else. They just want to live life, wear shoes. Sort of the MIS technique, but with OPEN back in, Dr. Davis talked about it. And even more recently, Dr. Ray talked about closing wedge osteotomies, the proximal phalanx to deal with mainly isolated coronal plane and some side of the plane deformity. Just looking at their previous technique with OPEN techniques on the left side from Dr. Davis, and then percutaneous techniques with Dr. Ray on the right side. I think a lot of these have been discussed, so I'll kind of move through them more quickly. Dr. Ellis talked about EDB transfers. Meyerson also talked about EDB transfers, but a little bit different. I think Ellis talked more about creating collateral. Meyerson talked about using the EDB underneath the transverse metatarsal ligament for a correction force of a coronal plane deformity. And so options wise, I think this paper, Watson talked about earlier before, plantar plate repair, and then also Flint talked about the same thing. Wild osteotomies, there's multiple different types of wild osteotomies. You can do intra-articular, which is how I train. There are extra-articular osteotomies to try to minimize the intrinsic dorsiflexion through the MTP joint, as well as more translational or macerotype osteotomies to correct coronal plane deformity in addition to decompressing the joint. Meyerson also talked about using structural allograft when you have short toes. Patients are unhappy with a failed hammer toe correction because they've had bigger sections of the proclinal phalanx. And then implant wise, I've used all over the place. I've used KWARs, I've used intramedullary implants. What I still find is with basically a good fusion through PIP joints, patients are still not happy because their toes don't touch the ground, even if it looks like it's a good surgical result. I usually leave pins in for about six weeks just to try to minimize that risk of repeat deformity, whether you have a true union of the PIP fusion, or whether you have a fibrous union that is stiff enough. So basically, when I look at a hammer toe that perhaps has failed already, or the things that I will look at are, have they done a PIP fusion? Have they cut the ED? Have they cut the FDL? If I could still have it for a transfer? Have they done wall osteotomies? Was there a plantar plate repair? What soft tissue dorsally have they done? And then also I'm starting to get into, although I would not consider myself an expert in lesser toe MIS techniques. So this is one other thing that just to kind of remember historically, although works not too bad in patients that have had multiple, multiple, multiple surgeries. So Hoffman procedures, MTP joint fusions, and then resection arthroplasties of the metatarsal heads, the lesser toes. This was a patient that came and saw me it had, I think about 15 surgeries had ended up like this. And then she couldn't play with her grandkids. So we just did Hoffman on both sides, she actually is doing quite well. So learning points sort of like I thought case examples would likely be better. So this is the latest 62 she's had multiple surgeries, had a scholastic implants put her second MTP joint, didn't know but she was allergic to it. So basically, she has this very, very painful synovitic second MTP joint with a lot of bone loss, both on the proximal phalanx side, but also with that intramedullary, you can see that look intramedullary stem. And so got in there, remove the implant, I tried to basically do soft tissue releases, tried to pin it, but the way the implants or the scholastic implant pin had kind of created a almost a conical type hole in the second metatarsal, any pin basically tried to kick the toe into more valgus. So on this one, I threw Hail Mary did a flexor extensor just to kind of keep that toe down, it's actually staged, she's still painful a little bit, but a lot better. And so this one, let's say I kind of got away with it. This one is just the example of how we hate like good intentions, but lead to horrific results. This is a lady that's 55. This is her initial x ray came to see me after she had a couple surgeries. So the first surgery was a Lapidus with an Aiken, and they shortened her first ray quite a bit. You can start seeing the second third toes really starting to drift into valgus. And then subsequently, she had another provider do what they described as hammer metatarsal, lesser metatarsal head resections. And so now the deformities even worse, they're valgus deviated dorsally sublux, and I got a CT just to see what we're dealing with. And so this is the second metatarsal RMTP joint where they I'm not sure what they recepted, but there's a huge deformity now huge cavitary lesion, the second metatarsal head, and there's not much plantar release. So we talked about could we even try derotational osteotomy to get the the bone plantarly up to the second met head strip distally. The third, not as bad, but still an incomplete metatarsal resection. But so I tried to do derotational osteotomies, and I tried to do FDL transfers on her. And like Dr. Johnson mentioned, I did not succeed very well in correct correcting the third, and even the second to lesser degree MTP joint deformity. So she's still having a ton of MTP joint pain over the third. And she also has a partial non union of that third metatarsal osteotomy. So we've talked about doing a Hoffman procedure, she's just done with this, she just wants to move on with life. A couple what I've done, this was a 50 year old professional who basically loves hiking. And she had this varus growth and deformity. This was probably five, seven years ago, and I wish I had known about the MIS techniques back then. I'd done a sort of a translational while osteotomy with a PIP fusion and FDL transfer, I thought she looked pretty good where she was essentially lined up. She said her toe just felt very stiff in terms of she couldn't dorsiflex when she went hiking on uneven surfaces. And so we said, well, let's cut the FDL transfer. And she said she felt better, but still went back hiking still, so I can't hike. And ultimately, she said, I want to tell amputation. So I did a toe amputation, she's doing a lot better. But unfortunately, this is still a failure of a hammer toe correction. This is another lady, this one was done elsewhere, she had had complications with her first metatarsal osteotomy with a perioperative fracture. And then she had had a second hammer toe correction where they just pin the toe when they pulled the pin out, she developed this fairly significant flexion control flexion deformity at the second toe PIP joint. So I thought this would be fairly simple, I would go fuse refuse the PIP joint with a an intramedullary implant and then do an FDL transfer and lengthen her extensor to drop that toe down a bit more. But if you look here, she's starting to really plantar flex and lever up at the MTP joint. And then I was going back saying, did I over tension her? Did I over tension the FDL transfer? Did it just completely stretch out? I'm still not completely sure how this went from it to a sublux joint. Luckily, clinically, she's not unhappy, she has no pain. And so this is one that it looks horrific. It's a failed surgical outcome, although she's doing well from it. So this is a lady that super active runner tennis player 38 had a pretty big bunion. And then this is a initial x ray from a couple years ago. And then in her 40s, she has gotten a little bit worse, but then she's essentially completely torn her plantar plate. This is one where I went in and did an MIS bunion thought I would do a while osteotomy and then repair plantar plate, but her plantar plate tissue was just so, so crummy, it kept pulling out, I just could not get a good repair. So I ended up bailing to what I trained on, which was the traditional capsulotomy, eccentric tendon lengthening, all open and a FDL transfer, which looked pretty good on initial post ops. But then eight months later, she's sublux again, luckily not having too much pain, but she's stiffer, but she can still run. So in my experience, a lot of these were even radiographically, they don't look as well. My patients are not as dissatisfied. They are a little bit unhappy, but not terrible. And so I said, well, here's my second chance. This is a different lady that was very active, let's run. Doesn't look too bad, has a little bit of a more of a flexible hammer toe, but instability and pain at the second MTP joint. And so over time, her hammer toe had gotten worse as we continue to follow her, or sorry, her subluxation at the second MTP had gotten worse, and then I ended up doing my, at this point, go-to, although I am very interested in learning more about the MIS technique. So while osteotomy with a UFA fusion and with a plantar plate repair, and she's very stable, the toe actually looks pretty good, but she still hurts. So with her, we've got her orthotics, but I'm not sure what's more to do about her. This is another one where clinically looks good, correction I think looks pretty decent, but still unsatisfied. Then finally, one that worked, this is a lady that basically had crossover toes or varus deformity, a little bit of a crossover toe. She's alert to every pain met alive, and this is probably to my benefit that she did not want to open procedures because she's had horrific pain after any hip replacement, knee replacement. So I just did closing wedge osteotomy. She didn't really require any narcotic medications, and she actually did really well. So I got away with this one. That's kind of what sparked my interest in MIS procedures, which I'm trying to expand my practice here as well. This is one where I probably could have done MIS, but this was about five to seven years ago also where I did translational Wallace FDL transfer, not significant correction and made worse by the fact that she has really not much hallux valgus at all, but she's very happy her toes don't sit on top of the foretoe anymore. And so in summary, kind of looking at our toolboxes, my failures, my experiences, what is actually predictable? I'd say most things about hammer toe corrections are not so predictable in terms of how the patient is, how they'll do, how your correction will maintain. So coronal plane deformity through the either varus or valgus without MTP joint pain seems to be one of the most predictable where you can do closing wedge osteotomies, and then patients are quite happy. Saddle plane deformity, even with partial plantar plate instability, FDL transfers have worked very well for me, even without while osteotomies, but when they start crossing over, those are where they become very unpredictable. If a patient has failed multiple procedures, I have done a few Hoffman's. They actually have been, the floor is not too low. The ceiling's not too high. They're just okay, but it's good enough given what they've gone through the last few years in their lives. I think while osteotomies have helped a lot in predictability for pain relief, but the floating toe, the toe not touching the ground is an absolute complaint I get in clinic. And then in my fellowship training, we were always discouraged to pin the MTP joint just because it was a sign of failure that you couldn't control your correction, but I've started to pin in the last couple of years, the MTP joint, and it actually has helped me maintain some of my correction when the soft tissue or boning work is not sufficient. The biggest thing also, I think all the other panelists have talked about is setting expectations that the toes won't move so much, although MIS will help them move more. And then the toes may not completely touch the ground, but their pain will be better. Thank you. Thank you, Dr. Child. That was excellent. So right now we have a few minutes at the end of this session here to talk about some, address some of the questions, if that's okay with the panelists. There were some questions that were answered by Dr. Toulousian, but I think it's reasonable to bring it back up. I'll try to summarize the questions to merge them together a little bit. So, Paul, some of the questions are related to attenuated plantar plate injuries. For patients who are coming into your office, my question for you is, how do you, what physical examination or perhaps clinical intuition that you have to determine whether or not a person is highly likely to have an attenuated plantar plate and you have a backup plan, or do you always have a backup plan? And if it is your backup plan, how do you decide when to deploy that intraoperatively? Yeah, so I think the biggest thing for me, like I used to get MRIs like all the time, especially in board collection. The issue with it is like, you know, radiologists will almost never say there's a torn plantar plate. You know, they say it sometimes. Our radiologists here at my institution, I mean, because I sort of talk to them about it, you know, sometimes now they'll actually read plantar plate tears. But, but yeah, so like, I mean, MRIs are unpredictable. It'll show big tears, but it's not great. People talk about doing ultrasounds. And, you know, I mean, I don't use an ultrasound machine personally. I know a lot of surgeons kind of have one that attaches to their phone or something, but I'm not big on ultrasounds for them. We'll like really rely on their, their symptoms, you know, which is kind of like mostly pain and the lesser metatarsals or, you know, like metatarsal type pains. But I think that the drawer test for me is a very sensitive test. And yeah, as far as what did you mean by backup plans? So, so oftentimes we have speakers in our society talk about attenuated plantar plate or the term irreparable plantar plate. How do you personally judge whether or something is repairable or irreparable? Yep. And I've, I've learned this basically the hard way is that, you know, I think that the sort of the technique stuff that I was presenting, it, it, it works best in like, if you want to call it like the sporty, sporty metatarsalgia where they don't have like big deformities and stuff. And, you know, these are patients where otherwise you're kind of like, I know you hurt, but I don't really have a good operation for you is kind of who I think this applies to. I've found that like, you know, the irreparable plantar plates are the ones where, you know, someone's been dislocated, have a big hammer toe. Those are the ones where I would go in and plan on doing a plantar plate repair and either not be able to find a plantar plate, or you pass the stitch and the sutures are just tearing right through it. In that case, I'll go back to what we did in fellowship was which is pretty much a while osteotomy and a pin. And so that's, that's my backup plan. And that's plan A for bigger deformity. Thank you. And also for your plantar plate injuries after repair, what for you, do you, do you pin them, tape them? What's your post-op protocol for that? Yep. So so the post-op dressing is sort of like a four by four sort of unfold and do like a ribbon type like dressing thing for it. And then, you know, they keep their bandage on for two weeks. And then we see them in the office and we'll have them kind of like once then I have them tape them till it's been about two months, two months after surgery. And then, and then we let them go. And then actually sometimes they're a little too stiff. But I tend to get people in physical therapy not, I mean, I operate everybody because one of the things I try to battle is scar the extensor tendons. Because I think that there can, there can be a lot of scarring in the extensor tendons, which will try to dorsiflex the the MTP joint. Thank you. There, there's a question here from Dr. Morthy for Dr. Johnson specifically. He would like you to clarify perhaps the order of multiple lesser toe deformities and MIS corrections. I just assume it's a hammer toe deformity correction. What's your order of correction? It depends on the deformity actually. So, you know, where you're trying to correct the inner metatarsal angle. So say for metatarsus adductus, you have to be really careful if you fix the bunion first and then you fix the lesser metatarsals, you could create a bigger IM angle and recreate the deformity at the hallux valgus. And if you, the sesamoids or the plantar plate with the sesamoids are completely attached to the entire plantar plate complex of the lesser toes. So if you're in the OR, you'll even, you can even see this on fluoroscopy where you move the lesser toes and you'll see the sesamoids move with it. So what I usually do in a case where I'm, where there's significant metatarsal phalangeal joint deformity is I'll address that first and then do the hallux valgus correction, or I'll start with the hallux valgus correction and just have my pins in place, whether it's a lap percutaneous lapidus, or it's a percutaneous Chevron Aiken, but I won't put my final fixation in until I fix the lesser, the lesser toe and lesser MTP deformities. If I'm, if I know I'm going to do, you know, if somebody has a dislocated second toe that's rigid and I know I'm going to do, I have to do an open shortening, then I'll do the bunion first. Just one thing I didn't really mention in my talk or that in the MTP releases, you still often have to release the collateral ligaments. I just do it through a very small incision under fluoroscopic guidance, but that's still part of any MTP joint correction. Yeah, thank you. And I, and I, your, your, your pictures of the oblique osteotomies of the metatarsals are very intriguing because when, when we apply orthopedic principles to the hallux valgus corrections, obviously soft tissue corrections is not typically used to correct the bunion. But yet we expect to, in the past, to do a wild osteotomy and do soft tissue release and not correct actually the bony alignment. So that being said, you did show a slide where I believe that you had essentially non-union of the metatarsal neck and also several slides to show that there was essentially a non-union of the P1s. How often do you see them to be symptomatic? Because nowadays many patients do have access to their medical records universally. The radiologists will call this a displaced non-union. And, and, and sometimes I have to dictate that this is a resection arthroplasty, you know, to just to assess the patients, don't get confused. How are you, how are you counseling patients and also how are you dealing with them and how often do you see them to be symptomatic? You know, it's funny, the metatarsals rarely go on to non-union. So, you know, you may, I may have shown slides that were six, the ones that weren't completely healed may have been six months out, but by a year, I would say, you know, a non-union of the, of the lesser metatarsals is probably 5% or less. And so eventually they do heal. What, what happens is they do say stay swollen for a while because they're essentially, you know, non-unions for a long time or delayed unions. And that's why they get the swelling, but, but they do all heal. Now I, I have had, you have to be really careful again in counseling patients because in where I am, there aren't a ton of people doing MIS. And so a patient goes and gets a second opinion with somebody who doesn't know MIS, talk about sabotage. I mean, you, you'll end up with a lawsuit. So you have to be really careful with patients and explain to them that, you know, your X-rays are going to be funky. It's not going to look this way, even with that patient still don't get it. And it's very, very hard to explain. I luckily have X-ray in my office. And so I read my own X-rays. So I don't have a radiologist reading them. But they rarely go into non-union. Now in the proximal phalanx, the woman, the one that I showed where she did have non-union, she had had so many surgeries on her toes that her phalanges were completely sclerotic. But if the non-union is stable, then it doesn't swell or hurt. You know, you think about resection arthroplasty, the PIP joint that we see all the time that the podiatrists often use, and oftentimes the toes look great and they're not painful. So that doesn't, it's not really an issue. I would highly, highly recommend and insist that everybody do these osteotomies off tourniquet and with copious irrigation though, because if you burn the bone, they will go on to non-union. Thank you. Let's see here. And a question for Dr. Hopp. That being said, you are a big fan of DMMO. What are the situations where you would still consider using an open while osteotomy? Thanks, Glenn. For me, the one that's the most challenging thing to treat are MP joint problems. And I think it sounds like all the other presenters would agree, like a really bad crossover second toe, or, you know, somebody with a capoeira foot and dislocations of all the two to five, things like that. I don't, I really like DMMOs and I use them for a lot of stuff, as you guys have just heard, but I just haven't had success trying to pin it, or, you know, I just thought that was kind of off limits that I was afraid that the lever arm would be too big to the metatarsal osteotomy. And so for me, the while is still there for people that, you know, you need to treat an MP joint problem. And in my opinion, if you're already there for something else and you need to shorten your planning treatment for that, if you're already making an open approach, you know, I don't know for a flexor to extensor transfer or something like that, then I think I don't see why you wouldn't do a while if that was part of your treatment plan. So I think the MIS techniques are really powerful and a lot of it comes from, I think, shortening the bones and kind of fracturing things into position. But, you know, there are still certainly approaches where the while is helpful, but the crossover toad is really, you know, in fellowship, it seemed like that's the literature of one in four patients kind of ending up with a floating toe of some sort was worrisome to me. And I was, I just didn't have a great answer for that. And I don't think anybody else did either. And so that was the big impetus for me to learn MIS techniques. Glenn, can I just add one more thing? Absolutely. Um, it's so important that you correct, in most cases, correct the NTP deformity. You know, when I first started doing MIS, I did all of these little oblique osteotomies. And, you know, I've been doing this now since 2017. So I have a lot of follow-up. I promise you they will recur. And even some of my crossover toes that I simply did an oblique osteotomy on, um, they're, they're coming back, you know, three years later and they have some recurrence. So you, you have to address the soft tissue deformity at the same time. Um, and in some cases it doesn't, it doesn't matter. Um, and you're just trying to get a minimal correction or get an elderly person back. But if you have a young person with a crossover toe deformity, you can't just do an oblique osteotomy. You have to correct the deformity at the MTP joint. You just, you have to, or it's going to recur. I can promise you, if you, if you have enough follow-up and you've been doing MIS long enough, you'll see the recurrences. Yeah. I tend to agree with that because I've seen them myself. Um, and in that being said, can you please just clarify what you mean by, um, uh, uh, corrections that, that mentors applying to a joint just for everyone to be clear? Sure. So, you know, I showed some, I showed some images of where the, the lesser toes were off at an angle and you do the cut and the toe goes straight. But if the metatarsal phalangeal joint is still totally, you know, off, it doesn't matter what you do to the toe, the metatarsal phalangeal joints off, it's going to recur. So when I say correct the MTP joint, that's what I mean. You, you can do it, um, you know, Paul's way, or the way I do it as I do a release and I get the MTP joint straight. And that's what I'm often pinning through the MTP joint. If the MTP joint is not reduced in the operating room, it is not going to be reduced in a year. So you, you, you really just that, that's what I mean. You just like in traditional open surgery, it's the same principles. I have one little pearl to add to what Holly's talking about. Um, when you do those base, basal osteotomies at the proximal phalanx, when you start early, you tend to be too distal with your cut. You want to be metaphyseal. And, uh, when I was doing those early, I would be a little too distal in the proximal phalanx. So, uh, and when you make that incision planarly, you think you're far enough down and oftentimes you'll be a little too distal. So one little trick early is I'll take a, like a five, four K wire dorsally and put it perpendicular to where I want to make the, uh, uh, my cut. And then I drive it through the bottom of the foot. And then I make my incision there. And then I know where I am because if you're too distal, you don't get the same control and the toe just starts flopping around. So that's just a little pearl. That's a, that's a phenomenal technique trick, Errol. I'm going to use that in teaching. That's a great idea. Um, the other thing that, that I do is instead of going to the bottom of the foot, you can go on the base of the proximal phalanx on top as well, but I like your technique. That's great. Um, some of the MIS masters will advocate doing the less, the phalanx osteotomy is actually distally at the distal metaphysis. Um, Paolo Carvalho does it that way. Um, and he finds that he gets better corrections that way. So I, again, there's a lot of different ways to do this and, um, you know, Errol just, that's a great technique. Yeah. Yeah. Thank you. Um, and then we do have another, uh, attendee, Eric Linford asking, uh, how many people do gastric recessions on a regular basis for hammer toes? I guess I would also add, uh, you know, perceived metastasis overload. Um, so, so Eric, for me, I don't routinely do it unless they have, um, obvious contracture and, and also, um, uh, evidence of overload that I can't, I don't think I can address through the forefoot. So I don't do it routinely because, um, I just don't think the risk and benefit, uh, is going to, it's going to be favorable for the patient given they have, they do lose some strength. I was turning to the panel as well. Um, let's say, say, your opinions on that. If you have one, you don't like, don't like them. My gastroc, I don't want that. I mean, there's certain indications for gastroc, but to me, it would take a lot for me to do it in the forefoot unless they had a really severe Aquinas contracture. Um, but I think cosmetically it's, it's, it flattens the calf. Um, and it does like, it's not the weakening, it's the cosmetic deformity that a gastroc causes. Um, and so, I think for, certainly for, for most young people, they're not going to want that. I would also say, um, I don't know if this is gaining popularity, but I've seen my clinic had to revise a couple with FHL transfers for, um, forefoot deformity procedures and, uh, percutaneous triple hemisections that have torn. Like in the last month, I've seen two of them that are, I guess, doing more around in our community here in Atlanta. So I would definitely never, I agree with Dr. Johnson. I wouldn't, and I wouldn't try to do something quick and do a triple hemisection cause you'd end up burning a big bridge. Yeah, I don't, I don't routinely do them. Um, you know, in the state of Michigan, I have some friends, uh, who are surgeons here who are pretty famous for kind of doing like strayers on like almost everybody. Um, I'll admit that I probably don't do them enough. I think I've had a couple of recurrences, uh, of either, you know, forefoot overload or even recurrence of, um, of a plantar plate tear. Um, and looking back, it's kind of like, well, I guess lengthen their Achilles. Um, but it's something I do pretty rarely. Same here, but my, my training was that like every, almost everybody needed a gastric recession. I don't find myself doing that in practice. Thank you. We, we do have a few minutes and I do have a case. I wonder what everyone's opinion is. So, so this, the surgeon who did this case may be speaking right now. So just be gentle. So this is a 62 year old school master at the local Catholic school. I'm coming to our clinic with 10 years worth of right foot pain. So obviously the bunion, and also she didn't like the way the second toe is drifting dorsally. That being said, Eddie, what would you consider your options for her? She has no grind test, largely housed by all this deformity pain. So her pain, I think the big distinctions I would want to know is, is it like a Alex medial eminence pain? Is there also plantar forefoot pain? You said there was dorsal pain at the second MP joint? Plantar. And then she has irritation of the PIB joint, classic hammer toe irritation on the shoes. She just wants to have it fixed so she can walk better. Yeah, sure. So after non-op management, I think the, is exhausted and trying to tape and splint them, et cetera. I think you're going to struggle. This is already like a crossover toe situation. And so I think that, you know, almost certainly is going to end up in surgery. So I'm not going to talk about that. I think this, this patient is very interesting. And in my own, I think you'd be right to treat this in multiple different ways. Like I think a plantar plate repair certainly is a reasonable option. I think you're going to, for me, the first ray is going to have to be fixed and move it out of the way of the second toe. So it can lay flat. And so there are various ways to do that. And then the second toe, how you tackle it, I think there's a bunch of different ways to do it. I personally wouldn't do a plantar plate repair, but I think that's a fine option. Paul, plantar plate repair after bunion correction for her? 10 years? Based on this x-ray, it doesn't, I mean, it looks like there's a little deformity at the MTP joint, but it doesn't look like dislocated. So I think in my hands, certainly a candidate for that. Sure. Well, since we have experts of MIS here, so I decided to try my luck. I think I did okay. Maybe you can argue that maybe the bunion was a little bit under corrected, but it measures out to be about 14, 15 degrees, which is, I think in my books, acceptable. And as much as my partner hates to while osteo, I mean, that's what I did. And maybe I should have done a DMMO like he has recommended I do. And this is what she likes. She has a toe that is downwards when she's in the resting position, but as soon as she puts her foot on the ground, so she had an extraordinary amount of stiffness as well as not pain, but she does like the stiffness and also the elevated second toe. It's about two millimeters off the ground. At this time, what options do we have, Dr. Chow? She had no pain. She has this elevated second toe that she dislikes. So I think in this, as you said, you did a while. Did you do any soft tissue procedure or was it just a pinning through the PIP? I did not do soft tissue procedure at the time. It had a reasonable correction, so I just let it be. So that's what I did. So I think for my training, what I would do is I would do like a FDL, like a Girlstone-Taylor procedure in length, thick, centered tendons, although I would probably, I'm dabbling more in MIS, consider like a closing wedge osteotomy of the base of the proximal phalanx at this point. Okay, gotcha. Yeah, I mean, like I talked about some of the options. I think, Holly, you would agree that at this point for your floating toes, a closing wedge P1 MIS technique will be the best for her, you think? Yeah, I think that would be great. Again, if it doesn't hurt her, I probably leave it be. The one thing you want to make sure of is that the big toe doesn't recur. But for every single patient that I do shortening osteotomies on, I literally demonstrate with my hand what a floating toe looks like and tell them they're going to have this. So they go into it expecting it. And I try never to shorten the metatarsals unless I absolutely have to. So I don't do it routinely at all because of this. Because even in DMMOs, you'll see floating toes and you'll see the proximal phalanges come up. So number one is patient education. And number two is if they don't have pain, let it go. And number three is if it really bothers them, you can do a plantar closing wedge. That would be fine. Yeah, I think one of the biggest things that we all, at least I do, we all struggle, is to spend that initial time with a patient and educate them about the limitations and expectations of what we can achieve even under the best circumstances. With that said, I want to thank every panelist here so much for joining us this morning. We are at 11.30 Eastern time and the show goes back to Dr. Errol Bailey.

hammer toe

claw toe deformities

surgical techniques

oblique interarticular shortening osteotomy

metatarsalgia

forefoot pain

percutaneous techniques

DMMOs

Y-osteotomy

complications

plantar plate repair

MIS techniques