Welcome to the last session. Thank you all for staying attentive. And we are going to talk about seriously you can scope that arthroscopy in the forefoot. I'm Alistair Younger and this is Mr. Clayton. And hopefully we have some good information for you. So I'm going to talk about arthroscopic hallux MTP fusion. I do have some conflicts. I worked and done some research with Acumed as well as with Wright Stryker on this particular topic. So Dr. Clayton and I are actually, or I was neighbors because I grew up here in St. Andrews in Fife in Scotland. And he practices here in Kakati which is about 20 miles away. So it's kind of a bit strange that we're both sitting here together halfway across the world. But I got dragged off to Canada for reasons a bit hard to understand and lived there now for 35 years. So why arthroscopic? Well, wound complications, really the thing that puts fear into us when we get to our follow-up clinics and when we see something like this, it brings your day to a halt and you have an upset patient and you kind of think, how can I stop this from happening? This actually led to me starting arthroscopy. I didn't do any arthroscopy in foot and ankle before I started practice. And everything I've learned has been since. So the goals of arthroscopy are to complete cartilage debridement. So a message to take away, cartilage is evil. It is the anti-graft. So if you're trying to get a fusion, get rid of all the cartilage. It creates a physical barrier. It creates growth inhibition through growth factors and cartilage chips work against the bone graft. So fixation, that's going to be your next question. If you're going to do an MTP fusion, do you really need a plate and screw? Well, this led to a paper with our pre-coast chair here, Ken Hunt, and concern in 2015 was that the screws would fail and they would not be adequate to get fixation. So where did this all start? Well, in Spain in 1999, this is the first description I can find of an arthroscopic MTP fusion. And so we need to know if the screw was enough and can you abandon the plate and this cross screw. So this was a biomechanical study that we published in Foot and Ankle International in 2019, done at the labs in Denver. And we use this construct. So we used removal of the cartilage, left the subchondral bone intact, which is important for you to bear in mind because subchondral bone gives good fixation. And then we did this model. We loaded these two constructs and saw which one was doing better or not. And we actually wanted to show equivalence, but we showed first of all that the screw construct is actually better. It gives less plantar gapping. And the other thing that we found was that it actually, failure load was in favor of the screws, not the plate and the cross screw. So you can win if you use a full thread screw, but it's important to bear in mind this is a full thread screw because you're going to use the subchondral bone for your fixation. The only proviso is so long as you're not osteoporotic. So the plate and screw construct was relatively stable across osteoporotic patients, but if you've got osteoporotic patients, the screw construct was not strong enough. So how do I do this? Well, I use a 2-9 scope, a 3-5 shaver, full thread cross screws, either cannulated or solid. So this is a case I did probably 10 years ago, a patient had vascular disease. So sometimes people say, well, you're doing the easy ones through the scope. I'm actually doing the high risk ones through the scope. So this is a patient that I use cross screws again. I tend to use three screws because I want an insurance screw because I don't know that all of them grabbed when I'm doing it arthroscopic. It's the indications, relative, good bone stock, younger patients reduce post-op pain. It's beneficial though in higher risk patients such as those with vascular disease or well-controlled diabetes. Chondrodications of bone loss, infection, joint too tight to get the scope in, severe deformity, or osteopenia. So it continued to use the scope until 2017 on its own. I still use the scope, but I've changed the technique a little bit. So this is end stage MTP joint arthritis, shows the technique. We use two dorsal portals, get the scope in. A large scope gives better flow and it also gives you better visualization. It's actually easier than a small scope. It's a bit counterintuitive. And use the shaver, clean out all the cartilage, use a curette if you have to. And then in this case, I use solid screws, neutral position, mini C-arm, and across the joint. And this is what it looks like when they come back and follow up. So you don't have that awful feeling. I enjoy my clinics because I know these people are going to heal. So an alternative fixation is headless variable pitch compression screws. And these are just cases illustrating this. Again, three screws across to make sure that you've got rotational control. And I try and increase the spread across the joint so that we get the joint well immobilized. And this is the end result and follow up with solid healing. So biology works in favor in this because you're keeping the soft tissue envelope, you're getting all of the cartilage out. And I find that the fusion rates are higher if I use the scope to make sure all the cartilage is out. This is what it looks like afterwards. Another case, again, with three cross screws. And what it looks like in follow up. So current technique, I now use the Shannon and wedge burrs percutaneously to initiate the procedure. I get rid of the dorsal osteophytes. I get the Shannon burr through the joint, gives me better space. And then I confirm complete debridement with the scope. So things have changed a little bit. And I use headless non-variable pitch screws at the current time. So this shows the use of the wedge burr to take off the dorsal osteophyte. This just shows the technique. So I'm going to just come across. I'm using my left hand. I'm teaching my fellows how to have feelings. I use my left hand to feel the joint and make sure I'm in the right place. So it's really important to control the surgery in three dimensionals using your left hand. The C-arm is just a confirmation machine. It's not your guidance machine. So this is what it looks like once you're done. Get in there with the scope. Take out all this residual debris. This is another case, a lady who had bilateral forefoot pain. Slightly unusual situation here because look how elevated that first ray is. So I ended up doing an arthroscopic first TMT and MTP fusion using non-variable pitch full thread headless screws. And she went on to good results. So how to train this? You need to commit to learning. It's really important to take the plunge and do it. So do cadaver labs, visit surgeons, consent patients for arthroscopic techniques. I often say I've done things through the scope. I've done this operation often. I just haven't done this operation through the scope. The benefit to you is less wound healing problems, less pain. They usually will consent if you explain it to them that way around. So cadaver course is really important. Go learn this stuff. Consent patients. Go see surgeon champions, the AOFES surgeons, Dr. Han, Derek Lui in Hong Kong, the MEFAS surgeons in France and Spain, and various others that have published on this. Derek Lui in Hong Kong, if you ever have a chance to go visit him, really smart guy, really keen arthroscopist. Outcomes, this is from Becky. There's various studies available. The benefit, fewer post-op visits to emergency, less bleeding, less wound complication, less pain, happier patients and follow-up, less stress in your clinic. Thank you. Next, I'd like to introduce Dr. Carrera, who's going to come and talk about arthroscopic dorsal chialectomy, joint preserving surgery. Dr. Carrera, thank you. All right. Thanks a lot for this opportunity to present this topic. I do have disclosures, but they're not relevant to the talk. As background, first MTP arthroscopy has been associated with lower post-operative pain, scarring, and complications as compared to open. It was first described in 1972, and Dr. Ferkel reported on his experience back in 1996. So this has been done for a while. In terms of indications and contraindications, our suggested indications are osteochondral lesions, grades 1 and 2 of Hallux rigidus, which is the main talk of today, loose bodies, synovitis, arthrofibrosis, septic arthritis, and of course, first MTP arthrodesis now. This is a case of a 59-year-old male. He had pressure and discomfort while wearing shoes was his primary complaint, but he also had pain with prolonged walking, especially at barefoot. He had had an open catelectomy on the opposite side, and his main concern was related to recovery time as he was a general contractor and was interested and sought me out for this procedure, just given recovery time. So this is his pre-op and post-op, essentially, but he had grade 2 left Hallux rigidus, and we did a catelectomy and joint debridement. And looking at the setup on the left side here, I like placing the tower at the level of the foot of the bed and having the bevel of the screen so that it can be moved to the left and right. And as a surgeon, I can stand at the side or at the end of the table, depending on what procedure I'm trying to do, and can look at the screen comfortably as well. Using lidocaine and epinephrine to insufflate the joint as well as the tourniquet, I think, is helpful, especially in the early experience to minimize bleeding as the visualization is difficult. Consider fluoroscopy as well to make sure that your placement of the portals is good as well as the resection. This is what it looks like in terms of an 11 blade just making the incision. I also like to use a mosquito clamp. Once you've made the incision into the joint, I suggest trying to open up the space manually with either a mosquito clamp or with the arthroscopic shaver. Generally using a 3-0 shaver. Needle localization for the lateral portal. So here I am using the needle on the bottom screen and checking to see its placement. Because of the dorsal osteophytes, it can be difficult to optimize your angle for resection. So taking the time early to make sure the portals are good is important. This is what portal location looks like with the dorsal, medial, and lateral cutaneous nerves in mind. If you look at the right side diagram there, the solid black line is the traditional medial incision made for a bunion correction, which is medial to the dorsal, medial, cutaneous nerve. And this portal is designed to be placed just actually lateral to it. So portal establishment is important. As I mentioned, you can also add a direct medial portal, although generally I haven't needed to do that. In terms of the joint assessment, a release done manually with the shaver and mosquito, I think, can be helpful. Also, potentially with the beaver blade, if more medial resection is needed, just to elevate the capsule off of the bone. Removing scars, synovitis, inflammation in the joint, and doing a full diagnostic arthroscopy. By manipulating the hallux both up and down, you can see different parts of the joint better. And considering using a sterile finger trap is fine, but it's not essential. Just using a gauze like this can be effective. And most of the work can be done without distraction. At the time of the procedure, correcting any offending pathology is the goal of the procedure, in addition to the calectomy. So here it is assessing the metatarsophalangeal head. So using a shaver, the spaces increase over time. The procedure actually gets easier as time passes and as the spaces are opened in terms of the capsule, as well as the surrounding inflammation and synovitis. Then we define the dorsal osteophytes. So first, just looking at them with the shaver. Sorry, I'm going to go back here. For some reason, that's not playing. So we identify the dorsal osteophytes with a shaver first and then start the resection. And a typical, like a sub-microbial decompression in the shoulder, trying to maintain a single plane and moving from one side to the next is effective. Then we look at the joint cartilage loss. One of the advantages, I think, of arthroscopy is that you can debride some of this loose cartilage. And in some cases, I'll perform a microfracture, especially if it's a limited area of involvement that's full thickness. Using a hooded bur to resect the dorsal osteophyte protects the dorsal soft tissues and particularly the EHL from being injured. So I think that's an important aspect of this joint, from a safety perspective. Locating and resecting residual osteophytes on the proximal phalanx. So here on the top of the screen is the proximal phalanx. And we can move from left to right, in this case, resecting osteophytes on both sides of the joint. Finally, palpation and assessment. So looking and feeling, particularly those any prominences that a patient wouldn't like on their shoe where you can really feel for that. The standard range of motion, which I think traditionally in the open, has been explained as 70 degrees. I don't know that we need to get that. I think that's an unknown in arthroscopic, how important that is. Because I've found that my patients tend to be less stiff in the arthroscopic approach anyhow. Some technical tips, just minimizing micromotion. So resting your elbows down as much as you can, as is seen in these left-sided pictures. And then using your fingers just to minimize micromotion. I think our instrumentation is lacking for this procedure in that the instrumentation is just too big. It's too long. And so the control of the instrumentation is important. I usually have my assistant really focusing on holding the foot firmly, too, so that there's no micromotion. Pitfalls, portal placement. If you start out badly with your placement, then it makes the rest of the procedure more difficult. Incomplete calectomy has been shown to be a reason for failure, especially in open procedures. Using fluoroscopy is helpful at the end of the case or to check your progression. Joint space is limited. This procedure requires patience. It's difficult at the beginning. And it gets easier as the procedure goes on. The indications related to the size of the osteophyte is certainly something that needs to be considered, especially with less experience. And I do encourage cadaver practice with it. In terms of the recovery, the post-operative plan, using a post-operative shoe with immediate weight-bearing is tolerated. Initiating range of motion by days 3 to 5 with simply wiggling their toes. And then formal physical therapy starting at 10 to 14 days after surgery. In terms of looking at outcomes, there's been five publications. They've ranged anywhere from 0% to 30% in terms of their failure rate. We're looking at our early outcomes. And some of the notable points, I think, here are the surgical time. It takes me, on average in my initial cases, 50 minutes, which I think a lot of surgeons would say, well, that's crazy. I can do it in half the time. I understand that. But early on, we're seeing less pain than in the open procedure and including at one month post-operatively. Why not just minimally invasive surgery? I think it is my opinion. I don't think this is really evidence-based. But MIS alone, I think, can miss some aspects of the procedure, including removing some of the debris load, the bone, the synovitis, any loose bodies inside the joint. The arthroscopic fluid alone throughout the case is flushing the joint, including the recesses. The direct visualization allows you to optimize the articulation more. And technically, I don't always visualize while I'm doing the arthroscopy, meaning you can use the burr. Thanks very much. Thank you. I'd like to introduce our next speaker. I'm keeping up the Scottish connection. Our next speaker is Ros Miller, who works in Lanarkshire, which is halfway between Edinburgh and Glasgow. So the third person with a Scotland connection on the podium. Ros Miller is going to talk to us about minimally invasive dorsal coelectomy. So Miss Miller, thank you. Thank you. Thank you. Thank you for the introduction, Robert. It's been certainly an infestation, I think, of the Scots today. As Robert says, I sit in the hole in the middle between the two buttcheeks of Glasgow and Edinburgh in Lanarkshire. And Alistair and I have got the same alma mater in Aberdeen. So thank you for inviting me and for Bofast coming to join AOFAST this year. It's great to all be back together. So dorsal coelectomy and minimally invasive dorsal coelectomy. And I think the first question I would want to ask is, is this still really the gold standard? Or should we be asking a somewhat different question? Why do we take a sledgehammer to break a nut? And I think for me, the biggest thing that has geared me towards minimally invasive surgery is it's what my patients are now asking for. They want joint sparing procedures. They want rapid return to work and activity. They want day case procedures. And they want small incisions. So for me, the minimally invasive dorsal coelectomy sits within a pyramid of treatment. Yes, we all start with conservative management, footwear, orthotics, injections. But as we move up that ladder, we then want to think about joint preservation, be it interposition or coelectomy. And for me, that's either minimally invasive or arthroscopically before then potentially moving on for joint replacement or joint fusion in certain circumstances. So for the patient, the hallux rigidus really does start to affect their gait, particularly for women. And going up on their tiptoes when they're wanting to wear a variable heel height can cause significant problems for them. And so the vast majority of women, and I have to say an increasing number of men, want to preserve that joint range of motion. And certainly, if you work regularly with podiatrists and orthotists, one of the things that is frequently mentioned after joint fusion is the fact that there's still a significant alteration to their gait. And much as you might get a decent fusion, you often get a high incidence of transfer metatarsalgia and, in some instances, lateral ligament issues. So for the minimally invasive dorsal coelectomy, it's just exactly the same procedure as you're doing with an open procedure. You're wanting to resect the dorsal third of that first metatarsal head, plus or minus taking away part of your proximal phalanx. And really, the godfathers of this, certainly in the UK, have been David Redfern and Joel Venoir. And most of us that are using this technique regularly in the UK and, I think, in North America have, at some point, been trained in their techniques. And it's a great course if you've not been on it. It's certainly something that I would highly recommend. And I think one of the key things for any minimally invasive surgery is there is a learning curve associated with it. And so you do need to get some hands-on training. But they've written a great outline of the technique and the setup. And it's a minimally invasive modified dental burr, which is utilizing, essentially, Shannon burrs, which is a cutting burr, or a 3.1 wedge burr, which is a bit like a mill burr. And it's done with fluoroscopy. And for the vast majority of patients, it's done as a day case procedure, either with general anesthesia or sedation, plus or minus regional block. The patients are positioned supine on the table with their feet off the end of the bed so that you can get, ideally, a mini C-arm at the end of the bed. You can use larger fluoroscopy machines, but it does make it much more difficult to get yourself positioned nicely around the foot of the bed. So as I say, there's these specialized cutting burrs and the burr machine, but the setup is really fairly straightforward. And we utilize saline irrigation throughout so that it keeps the bone cool. And the technique has now been reproduced by a number of people and published. And it uses a dorsomedial incision through a small, tiny stab incision, and then using a periosteal elevator to elevate off the soft tissues so that you can get down to the bone, which is then milled into a paste. And that can effectively just be squeezed out like toothpaste out through the same incision. Copious irrigation is imperative, though, to ensure that you don't leave any of that bone paste behind because it is one of the things that can cause stiffness if not thoroughly irrigated. So this is my setup in my theater for all my minimally invasive surgery, whether it's for a chialectomy or for a charcoal correction. And one of the key things I would say is that you really do need to get yourself comfortable with how you do get yourself set up with the fluoroscopy machine coming in easily from the other side. One of the major complications, or one of the major things that's discussed and is of concern is that nerve. And so you do need to make sure that you place your incision slightly plantar to the dorsal cutaneal nerve so that you don't cause any irritation afterwards. The other thing when you're starting to go in with your burr is that you want to keep the toe actually slightly dorsiflexed about 10 to 15 degrees so that you don't put any tension on either the nerve or the tendon that's overlying it. And often if there's a lateral osteophyte you may want to take a secondary incision on the lateral aspect so that you can clear that because quite often that's where patients actually do get quite a lot of their pain. But you can attack really quite large osteophytes and as I say both on the metatarsal head side but also the proximal phalangeal side. So this is a typical patient on table, sorry about the noise if I swear I apologize, but you get a really good range of motion at the end of the procedure and for the patient who is just a week later and they get an excellent range of motion and are really happy. One of the things I would say this patient was a physiotherapist herself and quite a lot of patients don't get adequate plantar flexion and that's because a lot of physios concentrate on just doing dorsiflexion and but she worked really hard on doing her own plantar flexion and at a week I'd have to say a range of motion was excellent. She was back driving and at the end of the week and back dancing doing the jive at four weeks. The literature has started to come on leaps and bounds with with this technique and we are publishing more. There's still not enough studies out there in long-term follow-up but I think certainly minimally invasive surgery whether it is a pure chiolectomy or whether it's arthroscopic or a combination of the two is definitely the way to go. As I say patients are asking for it, the complication rates are low, the satisfaction rates are high, the recovery rates are faster and patients are much much happier. Thank you. Thank you and finally we have Mr. Clayton is going to put us all to shame and tell us the scope is a waste and the open technique is better. Well thank you very much again to AOFAS for the invitation. I'm Robert Clayton I'm from Fife in Scotland in the UK and I'm one of the council members for BOFAS and I'm delighted to be here to talk. I am in a minority of one on this podium aren't I? I'm the only one here to try and defend what I hope I can defend and this is not indefensible. Open techniques are better I put it to you all. None of my disclosures here have anything to do with this. This disclosure is important. I'm not a Luddite. I'm standing here talking to you about old-fashioned techniques. British love to indulge ourselves in a little bit of history. The Luddites were a movement in the 19th century who went around destroying the cotton mills because they were putting all the old weavers out of business. So you went around destroying the old technology and destroying the new technology to protect the old. I'm into new technology we've had some great talks about plenty of things I do and so I am not a Luddite. Fife. Fife is that red bit of Scotland between Edinburgh and Dundee and it's beautiful look at these pictures it's a stunning place. I think you do all know Fife you might think you don't but you do because it's famous for this institution as Dr. Youngest just said it's just a few miles up the road from me the old course and it's also of course famous for Dr. Younger. So why do you want to do minimally invasive surgery in the first MTP joint? This is George Mallory British climber died in almost a hundred years ago 200 meters from the top of Everest. It's rumored that he may have made it there but suddenly didn't make it back down again. He was asked why do you want to climb Everest and he said because it's there and I think a lot of this type of surgery is similar. Why do you want to do it because we can because we're clever surgeons just because you could do it should you. Or as one trainer put it to me are you going to do this operation properly or are you going to start pratting around with telescopes taking a very long time over something we can do quickly. So this talk is how I do it and it really is I think the easiest operation in foot and ankle surgery and why I do it what the evidence is because we've heard a little bit of allusion to it already. So how I do it dorsal colectomy and I combine it with a mobile golsteotomy for most times because it's the dorsiflexion that people want to preserve and regain. Now this is a British expression I don't know if you use this over here never teach granny to suck eggs and I'm here telling you how to do a dorsal colectomy which I think is second nature to everyone so I apologize I don't mean to insult anyone's intelligence so I'll just whip through my technique very quickly. So here's a standard patient fairly restricted dorsiflexion of the first MTP joint. Here are the x-rays good sort of grade two I know there's a bit of inter observer variability I call it a grade two hallux rigidus and the bottom left picture is the post-op picture with the dorsal chylis removed and a simple staple to fix the mobile golsteotomy. She does yoga which is particularly relevant she wants dorsiflexion she wants me to give her more dorsiflexion than she has. So straightforward incision preserve the tendon approach I don't normally retract as hard as that that's just for these photographs I want to preserve the soft tissue so I don't get those ugly pictures of post-operative infections. Expose the joint so there it is typical sort of hallux rigidus dorsal third osteophytes and ebonation and the remaining of the articular cartilage well preserved. So I use this as we call it a nibbler you call it a ranger take off the osteophytes at the base of the phalanx which is really important it's not always well described but that's a major impinging lesion you've got to remove it and it's not just a dorsal chylectomy it's a medial and lateral chylectomy as well so you've got to expose the side so you can expose so you can debride all round and then you take the saw you saw off the osteophyte and then you again you saw off around the sides to smooth all that off and and then I do a Moberg osteotomy and if there's a little bit of early hallux valgus you can add you can make this slightly more medially so that it's a sort of Moberg aching type osteotomy but one saw blades cut width cut stop on the plantar cortex and then if you need to make another cut you can close up the osteotomy introduce the saw blade again to take another saw blades width and and so on to titrate up the amount of correction you want and then I can fix it with a very simple staple introduced with with a K wire as a driver and that's really it that is the operation and there's the amount of dorsiflexion you can get so there are the before and after pictures so why do I do it it is an evidence-free zone I think we've just heard that there isn't a lot of evidence there are certainly no high quality trials or anything to hang our hats on and there are a lot of small case series and not much more so we go back to the original Cochrane and Shurness gold standard paper 20 years ago nearly 110 feet 80 dorsal colectomies mean nine-year follow-up 80 90% good or excellent results everything says that doesn't it all papers we ever published say 80 or 90% good or excellent results quite a high starting pain score my patients probably don't all have a mean visual analog pain score of 8 before surgery but good post-op result more recent paper this one is one of the few that I could find which actually talked about the Moberg-Aitken osteotomy that I routinely do as well disappointingly small increase in range of movement on average and Miss Miller presented this paper from Sheffield I think this maintains my side of the bargain rather than hers and they this is the only comparative study I can find Sheffield's a good well-respected group all the Bofast people know these people well-respected surgeons senior members of our society they've compared fusion sorry they've compared open colectomy with minimally invasive colectomy they found after three years follow-up only 2% of the open group converted to fusion but 12% of the minimally invasive group did and they found an 11% rate of additional complications in the minimally invasive group compared with two so you can do an operation with a 5% complication rate or an operation with a 25% complication rate which are you going to choose here a Tanaka's group again well-respected group of surgeons from Wales this time they have looked at minimally invasive colectomy they found the irrigation is time-consuming they've talked about radiation dose and they found quite a significant risk of reoperation and complications as well so I don't think we're seeing evidence that these minimally invasive techniques are better than tried-and-trusted measure measure means and the only moderately big size series I could find on arthroscopic or fluoroscopic first MTP fusion and this meta-analysis if you can call it that was a mixture of both hundred and nine patients 87% union rate it's alright isn't it not great it describes it as a promising technique and the results are possibly comparable to open surgery but with no proven benefit so we're not seeing evidence that these techniques are better we're possibly seeing evidence that they're worse so I rest my case thank you so Dominic what do you think no I'm a lot of good points in the sense that we don't have the data to support it well and we need more comparative studies which we're doing so I think that's that's clearly a limitation but I think if you look at can you achieve the same goals surgically in an arthroscopic approach I would say in in most cases that I'm doing I'm able to achieve with one or two exceptions where I needed to open in my early experience where I wasn't able to achieve what I was trying to accomplish in an open fashion and the incisions are a small fraction of what an open surgery is with we do know that the earlier recovery is easier I think it's obviously very important to know long-term goals whenever on vote we need this to be powered we need power they come on oh come on you guys come on come on okay and Ross just use the scope now or with your dose your perk colectomies or are you still washing them out I do both and and so where I tend not to use the scope one of the places that I use minimally invasive and one of the reasons I started minimally invasive a lot was I do a lot of diabetic patients who have a lot of neuropathy and but they have high pressure areas that are rubbing and shoes and so and to be able to go in with a very a traumatic way of operating to remove these bumps that cause a lot of pressure and risk of ulceration and amputation was one of the major advances for me and the other thing is that you know you wouldn't ever think of doing an open knee arthroscopy now so I failed to understand why we still want to disrupt the soft tissues as aggressively as we do with open colectomy and I agree you know long term there's probably not a lot in it but in the short term and the early first three months the return to activity which for for many patients is extremely significant it means they've got a much less painful post-operative experience most of them are off painkillers within a day or two the range of motion is much better back into normal shoes within a couple of weeks and driving with within a week and for people particularly people that are self-employed and these things are critical for them so I come back to you know just because you can should you we have a responsibility to sit down with our patients and have a conversation with them and to really listen to what their needs are and what it is that they're trying to achieve not what we're trying to achieve. So in contradistinction to Mallory we're still alive and the other thing to bear in mind are we Robert are we sort of like we're asking somebody if they do an open or an arthroscopic ACL in 1980 I mean is this just the response we'd have got then and is it time to get with the future I mean what if we ask this question in 20 years from now what the answer be? Let's generate the data to prove it because I'm not seeing that yet we've heard some wonderful ideas about quicker recovery I don't see the bone heals any quicker if you do the fusion arthroscopically rather than open I don't see that there's a great different speed of recovery and I certainly don't see any evidence in the literature to support that theory. That may change when the facts change I change my opinion what do you do? Well I try and make myself a better surgeon and in that might way I want to get I want to do the same operation you do but I want to make sure that I do it without causing any complications that the arthroscope may create so I'm careful with nerves and I want to get the same resection I want to get the same result so if I can get the same result technically than you can get but do it percutaneous we can only win because you've got a big incision and your patient has a big incision and mine doesn't so that's that was driving me my drive to arthroscopy right at the beginning was I didn't want wound complications it's still my number one drive to stick to arthroscopic procedures maybe not so much here but if you do it open you're not going to be a better surgeon after that operation but if I do it percutaneous and arthroscopic I'm going to each time I try I'm going to be that little bit better at it and if I can gain that in the easier cases and the cases like the dorsal chialectomies then I'm going to be so much more facile at the ones where I have to do it through the scope and it's going to be way more challenging so part of it is making myself a better foot and ankle surgeon all round that's why I do it. Would you consent them for the five times higher complication rate that Chris Blundell's group showed? Well I don't think it is I think maybe that group needs to come to a cadaver course and we'll learn how to do it better so it's early in the learning curve and I'm sure if you went to early days and ACL reconstructions you'd show all of these complications but would you get your ACL done open that? I don't think so so let's get with the future anyway thank you so much for staying and thank you for listening Ken.

arthroscopic hallux MTP fusion

wound complications

fixation methods

full thread screws

minimally invasive dorsal colectomy

complication rates

Moberg osteotomy