CME OnDemand: Complex Hammertoes - How To Get The Best Results-Foot & Ankle Focus: Complex Hammertoes

Foot & Ankle Focus: Complex Hammertoes - How To Get The Best Results

Video Transcription

Complex Hammer Toes, How to Get the Best Results. Tonight's moderator is Dr. Jason Barreto. Joining him are Drs. Jesse Doty, Scott Ellis, and Paul Toulousan.  You can find their full biographies and disclosures, as well as disclosures for program planners,  in the program document posted in the chat box and in the AOFAS On Demand Education Center.  2024 webinars are provided free to AOFAS members and orthopedic residents, fellows, and medical students  with funding from the Orthopedic Foot and Ankle Foundation, supported in part by a grant from Stryker.  To support education programs like this, donate to the foundation at our website, or by texting GIVEAOFAS to 41444.  I'd like to run through a few housekeeping items before we kick off the presentations.  For technical difficulties, please try closing a browser and logging back in the same way you did the first time.  Registered attendees may earn one hour of AMA PRA Category 1 CME credit by completing the evaluation and CME claim form at the end of the webinar.  You can find the link to claim CME in the chat tab, and we will follow up with an email following the conclusion of this broadcast.  This webinar is being recorded and will be available for on-demand viewing on the On Demand Education Center content library in approximately 24 hours.  We encourage you to ask questions during the presentations. To send your question to the faculty, click on the Q&A tab on your navigation bar.  If we cannot get to your question during the live broadcast, the faculty will reach out to you following the broadcast to respond.  Finally, please visit our website to register for upcoming events, including our next foot and ankle focus webinar on Halex Valgas  and our new in-person course, Sports Injuries of the Foot and Ankle, taking place this April in Boulder, Colorado. I'll now turn the program over to Dr. Barreto to begin. Thank you.  I just want to welcome everyone tonight. I think we have a great group to talk to you about these difficult patients and difficult problems with complex hammer toes.  I first want to welcome Dr. Scott Ellis from the Hospital for Special Surgery. He's going to talk to us tonight about managing patient expectations with hammer toe surgery.  Scott, please take it away.  Okay, Jason, can you guys see my slides?  Yep, I can see them. Yeah, I gotta go to presentation mode here. Try it, there we go. Can you see a full screen now?  Yep. Okay. All right, so thank you everybody. It's an honor for me to be with this distinguished group on such a distinguished topic. We have a good turnout  and our own group was marveling why that would be because hammer toes are something that most of us would admit that we don't even wanna see.  But even at that, it's a challenging topic. And so learning from each other and I'm gonna learn tonight too is key.  I think there's a lot to be discovered about this. I think also commiserating about how we can deal with problems is key. And I'm gonna talk about how you can manage expectations  because really some of your outcomes in terms of how patients feel like they did after surgery are gonna be all about managing what their expectations are  before and after lesser toe surgery.  And it will set the stage for the rest of the discussion. And we'll talk about more how to manage these problems and complex complications.  Lucas already mentioned potential conflicts. There's nothing that I've ever developed, I gotta be honest, that would gain royalties or anything that would help fix this problem.  I mean, I have some ideas and tried some things over time.  But again, there's a lot to learn. It's interesting because as I put this talk together, I went back to look at some of these  choose wisely recommendations by the Foot and Ankle Society,  I think largely put together by our evidence-based committee. Number one on that list of recommendations was don't undergo surgery for a bunion or hammer toes without symptoms.  And I think that's so true because if somebody has a hammer toe that you want to correct just for the way it looks, they are not gonna be happy.  It gets a little complicated because we know that patients that have a bunion surgery, in general, the results aren't perfect, but...  and I'll even say from my own experience, they tend to be better than somebody you're treating a bunion with hammer toe because the hammer toe is never great.  It creates a toe that's maybe straighter, but it's a little more stiff and patients are never happy. So there's two things to say. One, don't treat a hammer toe unless it's painful.  But if you get in the setting of a bunion, sometimes I think you should actually fix the bunion before the second toe becomes a problem and something else we could talk about.  But it's interesting to see that our evidence-based committee is telling us not to do surgery for hammer toe without symptoms.  This is what I'm getting at. This is a study that we published. Jesse, this is for you. I'll make sure you read this in detail. We'll talk about it later.  What is the influence of concomitant hammer toe correction on post-operative outcomes? And we took a whole group of patients  that had bunions versus those with bunions and hammer toes.  And then we showed that everybody in both groups had improved outcomes, but there was, you know, I put it in a box there on the bottom in red,  but those that had simultaneous hammer toe correction had substantially less improvement in post-operative pain-related outcomes that just had a bunion alone.  So one of the keys may be, let's fix that bunion before the second toe becomes a problem.  You know, again, it's not always the case, but a lot of times when the second or lesser toes become a problem, it's in the setting if somebody has a bunion.  And we looked at, see if there's any demographic parameters that could predict in the setting of a bunion who develops different types of second rate pathology.  Because at the end of the day, it's not just a second hammer toe that occurs with a bunion. Sometimes it's a stress fracture, the second metatarsal, sometimes it's arthritis.  But what we found was that patients that had a worsening bunion, it's in that red box below, had tended to have increased incidents of other second rate pathologies.  One that was interesting is metatarsus adductus and high BMA are associated with midfoot arthritis. Hammer toe itself is obvious, but the longer it's been there,  and the worse the deformity is, the more likely they're going to develop a hammer toe. And this is part of a talk that I put together for a complications course,  but I thought this was clever. And certainly apropos to the, it's not clever because I did it, but certainly apropos to the topic at hand is the toes are like little piggies  and they just make you wanna cry, wee, wee, wee, kind of like the nursery rhyme. And why they make you cry wee, wee, wee, and I'm gonna get to expectations in a little bit  is because all these other problems that happen,  and I'm gonna go briefly over them. I think it's a whole nother talk about what to do with these when they happen. And I think some of our other panelists will get to this,  but you can kill a toe because you stretch it out and the blood supply is not good. You can have a toe that elevates. We see this so often,  it's often blamed on metatarsal shorting osteoarthritis, but not always the case. You fix one hammer toe, but the next one aside to its side starts becoming a problem.  You have a toe that you thought was great and won't play, but starts drifting in varicebalgus. You can have that flail toe, Jason brought up this as we were meeting together  just before the webinar started, where you take some bone, but it feels like some bone resorb, and then you can have transfer metatarsalgia. Just some examples of these,  this is a patient I did a hammer toe as part of a bunion. This is somewhat early in practice and I pinned that toe down. I probably pinned it too far down  and I didn't realize, but the blood flow to the toe is not good and the toe went black. Luckily I pulled that and that pin was across the MTP joint, by the way,  and I ended up seeing the patient emergently the day after surgery, pulled the pin and thank God the toe survived, but this is a real problem.  It almost makes me look like I don't know what I'm doing. I mean, this is the x-ray. You think, well, that's pretty good. Corrected a bunion, shortened the metatarsal,  pinned across the MTP, but it was just too much for that toe. Here's some other problems. You have a toe, which you take a little PIP resection.  This is not my primary bunion procedure because I tend to do a lapidus, but I fixed the second hammer toe subsequently and look on that left side, that second toe is floating  and patients can't stand it, at least in balance.  I kind of say jokingly, sometimes you correct a hammer toe and the ones aside get jealous. I had what I felt like was a really good bunion correction  and fixed a hammer toe, but then the second hammer toe and the third one started drifting over it.  And here it is. I mean, great bunion correction with the lapidus, I think. Shorting metatarsal osteotomy. I don't show the pictures, but it was a pinning of the second MTP,  but here's what happens. You just can't win, right?  Here's a problem that I think all of us recognize now as a ductus, which has its own issues. I think, Jesse, you were mentioning as we started just before the session, too,  how this can be a problem, but you see that significant valgus before, and despite me getting a good IM angle correction, those toes keep drifting over.  I had pinned across the MTP and took a little chunk out of the metatarsal head, which became a problem later, too, but those toes keep drifting. Patient not happy.  Here's the one, Jason, that we were talking about where somebody had taken probably what was not as much bone as you think out of that second PIP,  but then it just resorbed over time. And they had a flail toe that seemed floppy and short and it didn't work so much. There's ways to fix that we can talk about later,  but these are all the problems that we see. And the other one that's awesome is when you have a patient that you shorten one metatarsal  or picks a hammer toe, and that leads to metatarsalgia if you didn't have it already done the third, and I've had one on the fourth, so it just, it goes on and on.  So all this makes us take a step back, reconsider, and how do we define success after foot and ankle surgery, and how are we gonna define expectations, which I'm gonna get at?  So some of the success might be the x-rays. I showed you some good x-rays, but that doesn't mean the outcome is good. We have all these legacy reports of outcomes.  There's concepts of, and by the way, more novel or modern ones include computer adaptive tests or measures of satisfaction, how happy somebody is. But there's also expectations,  and we've done a lot of work in my institution on understanding what expectations are. Expectations is not the same as satisfaction. It's not how happy they are,  it's what they expect to gain or how they expect to be after surgery. And there's so many factors that go into this, including the discussion a patient has with their surgeon,  maybe the previous experience a patient has had themselves or somebody they know that's had bunion and hammer toe surgery. There's general knowledge you might glean  from the internet, social media. There's a lot that goes into it. It's, I think, very unique within foot and ankle, particularly unique, I think, within hammer toe.  As surgeons, we tend to focus on what we can help patients in terms of pain.  That's not what a patient's always thinking about. A lot of this is shaped by these long recoveries and some unique circumstances that are particular to foot and ankle surgery,  such as shoe wear and appearances of activities, not to mention nerve pain, which can ruin any surgery. So we started, we have a series of publications,  but basically developed this expectation survey, trying to understand the factors that were associated with preoperative expectations. We went on later to look at,  based on this expectation survey, whether people's expectations were fulfilled. A number of things we looked at later were how expectations are related to diagnosis,  anxiety, and depression. And by the way, it's very interesting to look at how surgeons' expectations may compare to patients. I'm gonna go into some of the studies.  It's interesting, if you look at our studies, we don't have diagnosis often honing down just on hammer toe because it's often part, as I said from the beginning,  and part of other issues. But you can learn a lot if you start looking at the data. So the first study we did was to look at and how to develop expectations. My colleague, Liz Cody,  who was at Duke for fellowship now at HSS, did an open-ended survey.  It just had a wide variety of foot and ankle patients, including hammer toe patients, talk about what they expected after surgery. And we took their answers in an open-ended fashion  and took the ones that were most cited, more than 5% of the time, and then brought them together. It came up with 29 total expectations, re-administered that twice to 63 patients,  and we kept the ones that were reliable. In other words, the ones that were repeatable and came up at the end of the day with a survey of 23 patients.  Now this is a eyeful, if you will, but here's the survey, if anybody's ever interested and wants to use it or look at it with your patients.  The ones that I put a little arrow next to, I think are probably more particular to second toe, but patients expect after these surgeries to increase a variety of shoe options  in the appearance of their foot. And they can rate expectations from going back to normal to a little improvement or none, or maybe they'll say it doesn't apply.  There's a scoring of the survey that you can do by taking all the expectations that they list, seeing what the amount of expectations they have,  you sum them up and then transfer it to percentile.  So the higher that expectation is, the more expectations and the more full expectations they have. In our initial cohort, expectation scores were around 65  and there was good reliability. We looked later to see what factors were associated with expectations and looked at all these different outcomes,  including legacy outcomes, et cetera, and took a huge group of 352 patients, also correlated them with demographic factors. Age, as we looked at the results, was not a factor.  Women expected more expectations or had a higher expectation score and had more expectations of complete improvement than men. Higher expectations were based on race.  Interestingly, use of assistive device in some of the medical core mobility. So people that were using a cane or crutches and were sicker often had more expectations.  And here's a whole summary of the scores. I don't have time to go into detail, really. We correlated the legacy scores with expectations  and found that the worst that they did clinically, the more expectations, the worst that they were pre-op, the more expectations they have, which actually stacks the deck  greatly against you from the beginning. And by the way, the more depression and anxiety they had, the more expectations they have.  So you start combining these levels of depression, anxiety, and then they want more and it just gets to be even harder and none could be more true, I think, than hammer toes.  It was interesting that people that had previous orthopedic surgery were less likely to expect complete improvement. I think that's because somebody  who's had orthopedic surgery realizes it's not gonna be perfect.  And people that did sports had fewer expectations. And my guess there is that people who've had injuries, they learned to tough it out  and just are able to understand that there's limitations. Patients that were on narcotics, interestingly, had more expectations. Diagnosis definitely played a role.  Now we didn't look specifically, like I said, at second toe, but we took in a later study, 270 patients and honed these down to seven common diagnoses,  previous demographic factors as well. But diagnosis often accounted for a huge amount of the variability in the outcomes, up to 10% of the outcomes. Interestingly, in that cohort,  the highest correlation between pathology or diagnosis now goes to ankle instability or OCD. They expected higher outcomes post-op,  probably because their height functioned to begin with. The people that expected the lowest were midfoot and hindfoot arthritis, probably because they were doing the worst before.  We did find that people that had certain pathology, like Alex Rigis or Alex Valgas, had the most expectations for shoe wear. For appearance, it was Alex Valgas.  We didn't hone down on second hammer toe, but I have a feeling that's where they fit. And for running and sports, people expected the most in ankle instability.  There were some absurd expectations. For example, people with OA that had an ankle replacement in general expected to run 20% of the time, even though we told them they wouldn't.  And patients with neuroma often expected complete relief. So take-homes from a lot of this research is that the worse you are, the more you expect.  The more depression, anxiety, the more you expect. A lot of this is timing. You really have to look out for the warning signs, and that is so true with hammer toe,  and you have to counsel your patients. We did go to see who had their expectations fulfilled, meaning did they meet the expectations that those particular patients cited?  And so it was a follow-up study from the original patients. We had a way that we scored expectations, but basically asked them only about those scores  that they had cited before survey that they expected, not all the 23 factors, and we only scored the ones where they had listed something pre-op.  And basically you see what they expected pre-op, what they achieved post-op, and see what the ratio was. And one would be if patients completely had their expectations fulfilled.  And what we found in that huge cohort is that in general, the fulfillment was about 84%. So 84% of patients' expectations were fulfilled. That means we do not reach in general,  at least in my practice, what patients fulfilled. Only on rare occasion was it more than they expected. A lot of times it was less.  I'm not gonna go through this, but basically using this allows you to assess for expectation fulfillment over time, and every patient I can tell you is different.  And in general, not all of expectations were fulfilled. Some of them were, but not all of them. And it doesn't mean they weren't happy,  but they just didn't have all their expectations fulfilled. So part of this makes me wonder whether we should screen for psychiatric disorders, counsel patients pre-op.  We specifically have to counsel them about what we expect for normal in terms of shoe wear, and let them know that they're not gonna achieve all their expectations.  Pre-operative depression, anxiety, and particularly the setting of hemorrhage that I think are important. There's those patients we all know that catastrophize too  with their catastrophizing about their toe. It's a warning side.  But I think as it comes to little piggies to round this out, we have to be cautious about what we can achieve. You have to think about some of those complications that I presented.  I would say based on what I originally said, if they have a bunion, fix the bunion if you're going to do the hammer toes, because you know that's going to lead to it again.  It's only for pain. Maybe there's a role to fix a bunion earlier before a hammer toe occurs. Set the expectations early, and if you're honest and critical about the results early  and pre-op with yourself and the patient, I think it's going to have better success. I haven't shown you what the key to success is,  but all I'm saying and showing you is that we don't fulfill expectations in general. Patients have a lot of expectations. There's a lot that can go wrong with hammer toe,  and just be open and honest early. Jason, I'll turn it back over to you and the rest of the panel. Scott, that's a great talk. One quick question just before you go.  Do you think of hammer toes in isolation if they don't have a bunion? Address it like the expectations of a bunion in that it's shoe wear,  it's fitting, and then with bunions often they don't lose motion. With hammer toes, they do. Is that something we have to educate? Is that, I think, you think a factor?  Because I think of hammer toes as a stiff straight toe when they're done. Bunions, they don't think of it stiff most of the time with a good lapidus  or a good minimally invasive, that kind of thing. What do you think? Yeah, OK. So you're right. And I said it's much more rare to have a second toe in isolation  or second or lesser toes. But even in that setting, they just don't do as well. In fact, they might even do more poorly because in the setting of a bunion,  at least they have the bunion that goes well. So you have to really set the expectations early about what you can achieve. And my experience is just like yours.  I mean, I've tried everything. We talked before we came on live here about plantar plate.  That's not perfect. The toe can be straighter, like you said, but it doesn't. My mom had one, and she says it's fine, but it just doesn't move much.  They don't grab much with their toe. It tends to elevate. So I mean, these are all things you have to tell the patient to expect after.  And they may not be happy with it, but they'll be more satisfied if you tell them at least that's a possibility. Awesome. Well, thanks, Scott. Let's move on to our next speaker.  Next up is Paul Toulousan. He's going to talk to us about hammer toes in complex patients, rheumatoid, diabetes, geriatrics. Should I change my plan?  All right. Thanks for having me. It's an honor to be up here with my fellow panelists. It's like they're like the Mount Rushmore of hammer toes.  And so I'm going to talk about the hammer toe in the complex patient. And here are my disclosures. So the hammer toe, I mean, we're hearing about hammer toes a lot here.  So I'm not going to really go. I don't think addressing the actual deformity is all that different in this patient population. And these hammer toes are still hammer toes.  But the thing to really consider is the patient protoplasm. And then with certain patients, you got to, especially the older ones,  you got to talk to them about, you know, your expected recovery time and sort of in the back of your mind.  And you never really mention it is like kind of what's your life expectancy and how much of that time you got left. Do you want to recover from something?  And then also you got to think about things like, you know, they're going to survive anesthesia.  Are they at risk for wound issues and infections and non unions and things like that?  So kind of going into the geriatric population first  and Dr. Baratos published a bit on this.  But this study looked at patients that were younger than 65 and older than 65. And so in the young group of patients, they had like 13 percent complications.  And in the older group was like 10 percent complications. So basically, both the old and young groups had significant increases in their pain scores and in their outcome scores.  And if you compare the two, the old versus young, there was really no significant difference, meaning they both they both did well.  And there's really no no differences between the two and also no increase in complications for the older patients.  When you look at the patients who did have complications  and look at the different comorbidities associated with that,  these these are the ones that this group looked at smoking,  blood thinners, rheumatoid arthritis, diabetics, peripheral artery disease, COPD, cardiac disease and osteoporosis. So when you take these comorbidities  and they looked at the patients who had complications, so the average age of their patients was about 70 and about two thirds  of the patients had  like zero or one comorbidities  and then 32 percent had two or more comorbidities.  And then looking at their outcomes, so their pain scores  kind of went from four before surgery to a one point five after surgery. So they all improved. And then again, comparing the two with their pain scores and  outcome scores, there's no significant difference. One thing that they saw was that if you had two or more comorbidities,  then you had a higher risk of superficial wound infections and then recurrences that required revision. The way I approach it in practice, though, is I kind of think of the patient  and I group you into one of three groups.  I guess the best group would be the old and healthy.  So those are the folks who, you know, they might be 80, 85,  but they don't look a day over 70. They drive. They live independently. You know, they're still sharp as a tack.  And in those folks, I mean, I sort of talk to them.  I'm about the traditional surgery that I would do,  you know, whether it's implants or pins in the toe.  And and then really it's the recovery time, I think, that kind of scares people out of it or out of, you know, having to go through all of that stuff.  And then not driving is a big one for for a lot of them, too.  After I try to tell them how awful the surgery and the recovery is, usually they'll say, like, well, can you just cut it off? And then I say, of course we can.  And then that's what I do, because, you know, in my hands, anyway, the recovery time from amputating a toe is like three, four weeks,  whereas doing a hammer toe or something like that, you know, much longer or at least lingers for much longer.  And a lot of these folks, they just want to get back on the golf course, you know, or getting back to the gym and all that stuff.  And, you know, if they don't bring up an amputation, I will bring it up in the conversation. Here's the pinning and all that stuff. And then I'm like, or you could do an amputation.  And if they want to do it, great. And if they don't, you know, then they can choose.  The next group, though, I call them sort of the old and controlled. So those are the folks who, you know, you look at their medical history  and it's like looking at the table of contents in like Robin's book of pathology, and they just got every disease.  And then you go into the exam room and, you know, they look like  people in these pictures where you're like, whoa, you actually look  pretty good and healthy and all that stuff. You just have a really extensive medical history. So in the case where they have really controlled  medical problems, even though there's a bunch of them, I'll have the same conversation as I would with the old and healthy person.  The third group of the geriatric population are like sort of the never evers where you really should think twice about doing surgery.  They're the people who are sick. And really, the only time I'm talking about surgery for them, it's definitely not or usually not something elective.  It's more like if they have a wound. And we're trying to protect like protect their total knee or their artificial valves or something like that.  And we just don't want that person having a wound. So typically, in that sense, you know, if there's a wound on a hammer toe, like I'll do a toe amputation for the most part.  And then the other reason where I might really think about surgery is if like, you know, they have a hammer toe and it's really in a bad place,  you know, it's curled under or whatever, and they just can't walk. And and that's the only thing that's like really  you're fixing the hammer toe would give them the ability to gain some independence by giving them the ability to transfer or ambulate.  So moving on to diabetes and, you know, kind of like with the with the geriatric population, you got to sort of think about the particular diabetic that you're working with.  But this paper looked at hemoglobin A1C and its relation to surgical complications.  In foot surgery, not specifically hammer toes, but just foot surgery. But so this was a V.A. database, 20,000 patients looking at complications within 30 days.  The overall complication rate was three point two percent. But that's sort of all comers. And then the complications that we're looking at were mostly infections  and then mechanical failures of hardware,  you know, cardiovascular events and some wound healing issues.  The biggest thing that I take away from this study is that for every one percent increase in the hemoglobin A1C,  you give a five percent increase in the odds of having a complication. So A1C control is important.  In patients who have neuropathy, they have a one point seven eight or two times risk  of having a complication compared to people who don't have neuropathy. And then if you have neuropathy plus two or three comorbid conditions,  as listed here, you have a three times higher risk of having a complication.  But but but, you know, but again, I group these patients into like the well-controlled diabetics. And those are the folks who like, you know, they take care of it.  They are A1Cs under seven. They're active. And I pretty much proceed as I would if they didn't have diabetes.  Occasionally, I'll think about using like an expensive intramedullary implant rather than a pin or a K wire coming out of the toe.  Sometimes it really just depends on my mood, to be honest with you. But at least think about maybe avoiding pins in in some of the diabetics.  The poorly controlled diabetics, different, different animal. It's, you know, unless there's an infection, if we're talking about an elective hammer toe,  I mean, you just have to get their A1C down to under seven.  And patients sometimes they're like, well, I can't do this or that. And then I tell them, you know, for every point above seven on your A1C, your your risk of infection goes up.  So usually that gets them to take it seriously.  Sometimes you have to reach out to the the primary care or the endocrinologist, like if you really think the patient is doing their part  and maybe they need a med change or something like that.  But that being said, the majority of the time the patient has to do their part.  And, you know, patients where I will operate is basically if there is a wound.  Mostly I'm doing a toe amputation.  Now, I don't know how many of you all have been affected by this, but this is something I've been dealing with recently.  And we call it the the Ozempic cancelectomy, where, you know, I'm all ready to go. And then the anesthesia folks say we got to cancel this case.  They took their Ozempic within seven days and  they have a risk of aspirating. So Ozempic is it's semaglutide. And it's a glucagon like peptide receptor agonist,  which basically it increases your insulin production when your glucose is elevated. And it suppresses appetite.  And also it slows gastric emptying, which is good, I guess, because it prolongs people's like a feeling full.  But the ways it affects us, that's that's kind of what anesthesia will cite. They'll say that because of the slow gastric emptying, the patient has a risk of aspirating.  So they want at least at our institution, they want us to stop  semaglutide seven days before surgery, unless it's an emergency or something.  Moving on to rheumatoid arthritis. So, I mean, I'm not going to go through the whole pathophysiology, mostly because I don't understand it.  And I really just know enough so I could pass the test in med school. But the gist of it is that it's an autoimmune issue and you form.  These antibodies, which then form immune complexes, which then bind to rheumatoid factor and leads to the activation of complement and the inflammatory cascade,  which then leads to like synovial inflammation. And then it starts breaking down the cartilage and things in your joints  and leading to a lot of painful inflammation.  More pertinent to us is the medications that people are taking. So the DMARDs are defined as the drugs that target inflammation  and then also reduce progression of damage of cartilage.  So NSAIDs are not technically DMARDs because they don't reduce damage progression, but they do reduce inflammation.  A lot of these patients would be taking glucocorticoids as well. And there's a lot of long term side effects. But so quickly, the mechanism of action.  Oh, then there's the biologics, too. So those are your like monoclonal antibodies and whatnot to have really long name.  And I'll bring up a list of it later. So, you know, the big thing is, I think for us is, you know, what what medicines do you hold? What medicines do you continue?  When do you restart the medicines? I am always in touch with whoever's giving these medicines, whether it's primary care or rheumatology, because I want them on record  as sort of giving me a guideline. But because we didn't really know, our group actually wrote a review article on this, most of the guidelines are from total joint literature.  And some of the things to consider is like, you know, patients with rheumatoid arthritis, it doesn't just affect joints. It also affects multiple organ systems.  So, you know, these are people who you actually want to check like their renal function and things like that.  And then, you know, withholding meds, we always risk having a disease flare. So here are some of the DMARDs and some of their mechanisms of actions.  I'm not going to like read through it, but it's in the paper. I'm happy to share this slide with you. But the thing about DMARDs is that you continue them. We don't stop them.  Methotrexate is probably the most like the best studied one. And in elective orthopedic surgery, there's actually less infections  if you continue methotrexate compared to if you stop it.  And so that was looked at in just general elective surgery. It was the same findings in hand surgery, in elective foot surgery. There's no increase in wound healing or infections.  And then stopping methotrexate, you run the risk of  of flaring up their disease.  So glucocorticoids. So we don't really do stress doses anymore. I think when I was training, we were, but like we really don't anymore.  So that you just take your daily dose of your of your glucocorticoids. And we don't typically worry about stress doses as much.  If someone's on prednisone, you try to taper them down to less than 20 milligrams a day, but don't taper for if they're taking the steroids for like adrenal or pituitary issues.  The biologics are the ones that you do want to withhold.  There's different times of when to withhold them, but pretty much we want to restart them two weeks after surgery, as long as they're not showing any signs of infections.  The reason we wrote this review article is because I was like, can someone just find a table for me that has all the meds and when to start, when to stop? And it didn't exist.  And so I was like, I found a med student and we banged it out.  And now we have copies of this list, like all around our clinic for us to refer to.  And in conclusion, when it comes to geriatrics, you know, consider their health in addition to just their numerical age.  For diabetics, get their A1Cs under seven.  For the rheumatoid arthritis, you want to continue the DMARDs and then biologics, those are all held at different times.  And you typically want to restart them about 14 days after surgery.  Now, references, thank you very much.  Awesome, Paul, that's a great talk. One quick question for you, you know, the classic teaching for hammer toes in a rheumatoid patient is a modified Hoffman to get them stable  because they're often very unstable. You think with the new DMARDs and the biologics, treat them as a as a traditional patient, or do you still sort of follow that old guideline of,  you know, PIP joint fusion and cut out the metatarsal head and get all their toes just straight and stiff?  Yeah, I I treat them as I would any other. I think that, you know, our generation kind of came up through the like we're the ones who don't really know how to do the rheumatoid  reconstructions as much, you know.  So, no, I mean, I typically will just go  with like my typical like MTP and hammer toe surgeries. And I don't think you really burned bridges for, you know, doing the resection arthroplasties after that. Awesome.  All right, great talk. Next up is Jesse.  Jesse Doty's from the University of Tennessee College of Medicine in Chattanooga.  He's going to talk to us about hammer toes with metatarsal phalangeal joint instability.  Hey, thanks, guys.  Thanks, Paul. That was a that's a great article. Well, that was a that's a great article to fall back on because I get that question  all the time internally, and I'm not sure if I'm doing the right thing with the with the rheumatologics. And also, Scott, thank you for  publishing and being honest with us about how you always disappoint your patients. And so I'm going to go ahead and get started here. I think that this is probably one  of the most difficult things, and it's actually an easy topic to talk about, if you're honest, because there are a lot of cases and complications you can show.  And you can, just like Scott showed, and in all honesty, I was glad he published those studies. I thought they were great to fall back on and help us with patient selection.  And so MTP instability, certainly this is one of the least predictable things when you're dealing with a hammer toe. And they've covered our disclosures,  but this is definitely, most honestly, my biggest disclosure. This is the only predictable operation for lesser toes in my hands.  So really to understand where we're at with lesser toes, you have to understand where we came from. And much of what we do now has been developed over the last 20 to 30 years.  And this was largely a territory that was unsettled and unclaimed. And this is one of the early articles from 1956, and it's not very scientific. In fact, this first article,  they simply queried seasoned surgeons, Mel Joss and Dr. Mann, and just determined that, hey, we don't really know the cause for this. There's no real good treatment algorithm.  And they mentioned soft tissue releases and flexor tendon transfers that could be beneficial. And initially it was felt that these were all from a neuroma  and that there was deviation of the toe from a neuroma. And really Dr. Coughlin, when he started practicing in 79 and 80, back in Boise, Idaho,  he told me that he would see these farmers come in from all these surrounding states with their neglected forefeet that hadn't been treated.  And he would go in to take out the, quote, neuroma. And he had a case where he noted that the lateral collateral ligament looked attenuated, but the toe was straight.  And so he took out the, again, the neuroma per se, and he watched the toe. And sure enough, over the next year, the toe began to drift. And so this was an epiphany.  And there were a lot of people around the country, really, who started to note the same things. And so in the 80s, it was a trial and error process.  And there were a litany of procedures that we tried and tried to figure out, hey, what's working. And it was around this same time that we really documented the etiology  and the causes for the deviation of the toes. And so for mild deviation, it was popular to do capsulotomies, capsular reefing, more moderate deviation,  more aggressive plantar capsular releases, extensor tendon transfers or lengthening, or flexor tendon transfers.  And really, if you fast forward in 1987, that's when a conglomerate and a case series of these patients was published. And that's when the AOFAS, and then subsequently JBJS,  there was an ICL that was published. And really, it's the first that you started to see a major interest in these areas amongst orthopedic surgeons.  And this was an article from 1993, really where they coined the crossover toe, and it was a second crossover toe as it was labeled. And so I think they kind of regretted  that they tied the second toe, because certainly we now know that it can affect all the toes, but that's when we developed the ICD-9 and 10 codes.  And so concomitantly, the podiatry groups, Dr. Lowell Senior was doing, in the 90s, doing wild osteotomies, and he presented this in 1998 at the AOFAS.  And so the orthopedic surgeons were interested, and this became a tool that we added to our soft tissue releases, trying to decompress the joint.  And so this sparked a lot of interest with the addition of the so-called wild osteotomy. And I know it's controversial, but I still use this, and I've had some success.  And this is a patient, for me, that has metatarsalgia, but no real severe sagittal plane deformity at the MTP joints, and no significant instability or door testing,  but just tight joints with metatarsalgia. And so wild osteotomies, I think, can be beneficial. And so the techniques didn't change much over those decades  as you look through the textbooks. And I do remember trying to memorize this as a resident and thinking, gosh, this is so convoluted, and I'd get so confused.  And the reason, it's so funny now, but the reason it was confusing is because even the guys who wrote this were confused, and we still are. And I watched Dr. Coughlin,  even later in his career, change a little bit of how he was doing things. And so we continued to evolve. This was around 2000. John DeLand published this,  and he had a single cadaver where they looked at a crossover toe and noted capsular instability. And so there was an interest there, but it was very difficult to find these cadavers  that had crossover toes. And so just based on his interest in hypermobility,  Dr. Coughlin had been to Barcelona with some of his fellows 10 years prior. He talked to Paolo Galano, who's an anatomist down in Barcelona, and said, hey, if you can collect  some of these specimens in Spain, we'll come over and we'd like to look at these crossover toe deformities. And from that, really, you had a litany of publications,  now 10 or 12 years ago, where Caio Neri was working on this and Lowell Wilde Jr. concomitantly with the podiatrist groups, but they got together with the orthopedic surgeons  so he could avoid two classification systems and have more of a universal system to look at plantar plate tears. And so, as you'll recall,  the plantar plate was kind of implicated around that time, and that came from those cadaver studies over in Spain. Subsequently, over the next five years,  there was a lot of interest in the need of a wild osteotomy versus not, and the different exposures and the different surgical instruments to appropriately pass suture.  And so that became really popular. And this is one of those patients where I think is probably still a good candidate for a plantar plate repair. She's generally young  and can have pretty good quality tissue expected, and you can see how she had the drawer testing there, but not a horrible deformity.  And so someone who certainly I agree with the panel is gonna have some stiffness, but if you can control the dislocation or give her more stability,  then perhaps a little bit of stiffness, but more stability is worth the trade-off for that patient as long as you appropriately set expectations.  And so that's what we did, and she did okay. But what we found as we did this more and more, there were certain patients that didn't do well with plantar plate repairs,  and this is a 48-year-old male of mine. He had grade four tears, no real good tissue, had to do pretty significant shortening osteotomies, obviously, to get him relocated.  And as you would expect, some degree of stiffness. And he did okay, but he didn't have good toe purchase, much like the case you saw earlier from Scott. And it's just not,  there's not a lot of good toe paper pull-out tests. The toes are still kind of non-functional. They're a little stiffer. I still think you can have satisfied patients  as long as you explain that, and their toes aren't rubbing on the shoe. But certainly you wanna do this only for pain or if it's symptomatic.  What else we found as we did more and more plantar plates, it's very difficult to control transverse plane deformities. And so it's a 65-year-old patient of mine,  and he had actually great, he's an attorney, a local attorney, but he actually has very fair expectations. And he had even said, hey, do you wanna just take this thing off?  And I said, well, let's try some other things. And so did a shortening osteotomy. You can see his toes swelled up pretty bad, made me a little nervous. And he did okay.  You can see how, again, I didn't have a lot of control in the transverse plane, but you can see what his sagittal plane deformity was pre-op  and then what we're able to correct that to. And so he was actually satisfied.  But again, with those cases, I learned, or at least I felt, and I either evolved or devolved, who knows, but I did and do less plantar plate repairs. And I think a lot of it stemmed  from the transverse plane deformities. And I felt like those were different and really had to try to employ some other things. This is a case where the significant adduction drift,  anytime I see severe abduction or adduction of the toes,  I always am intimidated. And I think you can help these people, but these are the cases where I just tell the patients, I'm like, this is gonna be really tough and I'll do my best.  And here's what I'm hoping for. And so in this one, correcting, you have to correct the midfoot as well, doing lateral capsule releases, which is a little less intuitive,  and then trying to correct the deformity. And that patient did okay. Here's another one. And this is something that I found very useful that I didn't do very much early on,  but it had been done for years. And doing this EDB transfer, this can be really powerful. And I started doing this sometimes in lieu of a plantar plate repair.  And if you haven't done this, it's easy just to, there's some sutures where you can tubularize it with a loop suture and really just using cannulated drill bits to pass the tendon.  And you can pass the tendon lateral to the MTP joint to regain that stability. And certainly this tendon is much more robust than just repairing the lateral collateral ligaments.  And you can pass it more plantar as well, if you feel like there's dorsal instability in addition to your transverse plane deviation. And so this is a patient with,  where I did EDB transfer of the second and a capsulotomy.  It's quite frequently, especially now that minimally invasive surgery has become more popular, that I have a pretty low threshold to do capsulotomies  if I suspect or I see some early drift of the MTP joints. And so doing medial capsulotomies is pretty common for me. And you can do that percutaneously by palpation.  This is, if you haven't done the EDB transfer again, you're kind of rerouting it like I've highlighted here. And there's some studies out there.  I know Steve Haddad's got another study that may have been earlier than this one, but you can see how powerful that is when I use the hemostat to pull the tendon  where I transferred the tendon. You can really see the second toe if you watch. It's kind of neat. So I kind of like doing this sometimes. You can do it with wild osteotomies.  You just have to be really careful. Do the wild osteotomy first and put your fixation in and then be super careful when you drill your tunnels. And so here's a patient  with probably a severe adduction drift deformity, but also a sagittal plane deformity, you can see. And we're gonna do a hammer toe repair on that. But at the same time,  I know one of the panelists mentioned when we were prepped before we started the talk,  we were all just being honest with our shortcomings. And Jason, I think, said he likes to pin a lot. And I don't pin a ton across the MTP joints, but I think there are some cases  where it can be beneficial. You can see I've shifted the wild osteotomy a bit medial on this one, trying to control rotation of the toe.  And I must've had some instability or something in this case, I don't recall, but I ended up pinning across the MTP joints. I've gotten to where I leave those pins a bit longer.  It used to just be four weeks, but now I generally try to leave those pins six weeks. And I do agree in diabetics, I try not to pin because I've been burnt with infections,  but primarily only in diabetics. And so here's a look at post-op. And that's one where again, on the lateral sagittal plane deformity, and I got away with this on the patient heel.  And I did, she did fair, even though I had pretty tenuous fixation in my wild osteotomy. I do believe even though it's not popular anymore to admit it,  I think there are patients that really a metatarsal heterosection is gonna be the most predictable thing. And I'd say it's a very vast minority of my patients,  but when you have a severe long-term chronic dislocation, I don't believe there's anything predictable you can do to maintain the MTP joint reduced,  unless you do metatarsal heterosections. And I've had some patients with some very severe deformities who've done quite well, just because they can finally wear a standard shoe.  And certainly in those patients, you wanna pin across the joint and leave those pins as long as you can, at least six weeks. And certainly you wanna correct the hammer toes  concomitantly so they don't continue to drive the MTP joints dorsally. The other option besides resecting the metatarsal heads is if you do these aggressive shortening  osteotomies of the metatarsals. And I'll be honest, I've done more metatarsal heterosections because they're easier and they're faster,  but I've had good success with this in a few patients where I thought, hey, maybe if you go back and look, maybe there's some justification for trying to preserve these joints.  They're not a hundred percent shortened and translated at the joint. So if I can shorten them enough and pin them, maybe I can get some stability  and avoid trying to resect the metatarsals.  I showed a lot of pins and to be fully transparent, I don't use the K-wire pins as much anymore because I started to see things like this now that I've been in practice 10 years.  A couple of times I've been in clinic and I've seen these patients and I go in the room and I can't remember my patients anymore if I've met them or not.  And I'll introduce myself and then I'll look at their toes and I see their toes look awful. And I just think, my God, who did this?  And then I look and it was me like in 2014 or 2015. And I started seeing this with these toes where I'd done pins and I thought they looked great at the time.  And then they come in and they look awful. And this is another one that I did myself and I left these pins for six weeks and I had to go back and revise with a permanent implant.  I do have a lower threshold now to do permanent implants. And I usually just with the patient, the discussion is pretty quick, but I ask them, do you have a preference?  I'm gonna use a permanent screw. Your toe is gonna be stiff, but it's gonna be straight and stiff. Would you rather have a stiff straight toe or a stiff crooked toe?  And that usually kind of sets the precedent and the expectations. I am interested in the minimally invasive stuff. I do believe there's merit to this  and it's not necessary for everybody, but certainly I do think that there's more mobility that can be maintained and less wound problems. And I've lost a toe as well, Scott.  And I've even had a couple of toes that I was super scared and the toe sloughed kind of like snake skin off the end. And I just thought, gosh, I'm so glad that toe survived.  But I haven't seen that as much when I've employed the less invasive techniques. And so I do think there are those patients where that can be beneficial. It's quicker.  I think I've seen less infection. I think you have to be a little more careful with the accuracy of your joint prep and implantation of your orthopedic implants.  But other than that, I've had good success with that. And I do think it can be a game changer in certain patients. This is a patient who had horrible skin  and otherwise not good pulses, but he had a severe callus with impending ulceration under second metatarsal head. And so did a percutaneous DMMO  and then did percutaneous hammer toes. And you can get an appreciation in this picture, just the quality of tissue. And he probably wasn't a good candidate for open surgery,  but he ended up doing okay. And so I think that's been neat to see in my career how those techniques have evolved in the United States.  If you're like me, when you see this, I used to hate this. I would have much rather done an ankle replacement or a pilon fracture early in my career. And I hated toes.  And I still hate sometimes when I see this come in.  But I think there are some things that don't write off all these patients. Some of them, there's nothing to do. Some of them, in this patient,  I just did plantar exostectomies over a second. She had these severe, wicked, protruding exostosis over plantar metatarsals. And so just smoothing that out.  And you can, I rarely go plantar, but sometimes in these scenarios, you can go plantar and remove large prominent exostectomies.  And so I just want you to know that you're not alone. And this used to be what I saw when I looked at every forefoot. And I've gotten to where I actually like  forefoot surgery a little bit, just because I've learned to manage my own and my patient's expectations a little bit better. And I've learned that I'm not in this alone  as I've watched some people that I really respect continue to change the things they do and employ new techniques over the course of their careers.  And so thank you guys, and likewise, I look forward to seeing and learning from your cases.  Jesse, that's awesome talk. Those were great cases. In an abundance of time, I'm gonna just go right to my talk just to try to get that done.  And so,  I'm gonna share my screen just to talk about arthritis quick, and then,  you see that everybody?  So, so now we're thinking about  hammer toes with MTP arthritis, you know, and Freiburg's, what are the options?  So I'm a consultant for, here are my disclosures. I have no relationships with this talk.  This talk, I want you to understand the different types of MTP arthritis, think about the conservative  and surgical treatment options when arthritis is present with those hammer toes, and talk about some techniques and pitfalls.  So we're going to talk about a couple cases, 55-year-old female, painful second hammer toe with pain and arthritis at that second MTP joint, failed conservative care.  When you're doing her hammer toe, what do you have to consider here?  This is a 48-year-old with a previous complex hammer toe correction, short and painful. How do you address this MTP joint and arthritis here?  And the third case is an avid runner with pain at the base of the second toe, mild second hammer toe, but how do you address this issue coming into your office?  And so you got to understand what Freiburg's infarction is. It's a bad osteochondrosis that can occur. There are significant risk factors, including diabetes, hypercoagulable state.  It's thought to be related to rigidness of the second metatarsal. Some gastroc tightness has been postulated as well.  And then there's a pathophysiology, which basically leads to a loss of blood supply to that second metatarsal, which leads to fissuring of the epiphysis, collapse over  time and loss as it progresses. And then at these stages, you often get hammering of the toe, which has to be addressed as well.  The other thought is that primary osteoarthritis, which isn't Freiburg's, but it is often related  to what Jesse showed, which is chronic MTP instability, where they get wear along the dorsal aspect, can occur after a shortening osteotomy, which can be seen in those instability  repairs. Are these instability repairs sometimes too tight? Or does like Jesse talked about before, sometimes pinning the MTP joint play a role?  I am an aggressive pinner of the MTP joint. And then like Paul mentioned, you know, inflammatory arthritis can lead to cartilage wear and instability.  And how do you address that? Often there's pain over that MTP joint when they present. They get focal pain underneath if there's instability.  I think the toe deformity or the hammering is a late finding in Freiburg's, but in primary arthritis is often the underlying cause.  And so does this affect outcomes and does the preoperative arthritis affect it? We looked at this a few years ago and presented it at the AOFAS.  Patients with preoperative arthritis had longer OR times, longer tourniquet times. They had trended toward a better improvement in pain.  As you can see, they had dropped four points on their VAS, where the no preop OA only dropped about two to two and a half.  These weren't statistically significant, but certainly probably having more pain and a better improvement.  But as Scott mentioned, with some of these complex issues, they may not have the right expectations.  In standard view, when you're working them up, always want to get an MRI if they have arthritis of the MTP joints to differentiate Freiburg's versus primary OA.  And think about that rheumatoid workup so that you can determine the significant synovitis that occurs at those joints.  And so I might have a low threshold to order labs to make sure they don't have a rheumatoid. Conservative options are all the things we talk about for that arthritis, offloading,  a four-foot rocker. I tend to use a bone stimulator for Freiburg's. I think it anecdotally helps, but I have no data to prove that.  You can try steroid injections, but be very cautious for patients with steroid injections as you can worsen their instability.  And stem cells and PRP, no clear studies yet that prove that it works. When the patient has isolated OA and a hammer toe is present, you want to stabilize the hammer toe.  I often use a boot and splint to bring them down. Often want to think about is the hallux contributing and how much is the bunion playing a role to that arthritis.  From surgical treatment options for these patients with a hammer toe and arthritis, you want to think about joint sparing versus joint sacrificing techniques.  You can do a debridement and microfracture. You can do a realignment osteotomy. Cartilage restoration procedures are possible.  There's interpositional arthroplasties from the patient themselves, a dermal matrix, implant arthroplasties with partiva.  I do think modified Hoffman metatarsal head resections, especially in patients with severe deformity or rheumatoid arthritis definitely plays a role.  And I completely agree with Jesse's talk. When thinking about Freiberg's, you want to know is the second metatarsal long? Think about an osteotomy.  If not, is there a role for an interposition? How much of the metatarsal head is left?  If you can do a local interposition and realignment, do you need to progress to a joint sparing option? In primary OA, you have to address the bunion and the hammer toe deformity.  And thinking about instability and, you know, will it decompress with a while and reduce the arthritic pain? And so what does the literature show us?  This is a study that can show 15 consecutive patients with arthritis in the Freiberg's component did very well with just the debridement. So how do you do that?  You expose the joint really well. This is a 50-ish year old patient of mine who really had more dorsal arthritis.  We cleaned up the dorsal spur and removed it and then just poked some holes in the bone. And she had an excellent result.  She's one of the oncology partners, wives from our general surgeons, and she's doing excellent.  You can do an interposition with the Accenture Digitorum Brevis sort of as Jesse talked about, but instead of using it as a ligament, you can use it sort of as an interposition and  ball it up between a collapsed metatarsal head. And they showed good results. There's a couple prospective studies that looked at osteochondral allograft transplantation  versus closing wedge. Both had good results, a little bit more range of motion and a little less complications with the osteochondral allografts for these more severe Freibergs.  And this was shown again in another prospective study by a different group with three years of follow-up, quicker return to sport with the OATs, and some significant improvement  in their postoperative scores at one year. The most recent systematic review for arthritis when thinking about Freibergs, which I think  when we treat MTP arthritis with a hammer toe, we have to derive it from this because this gives us the best information.  Only two studies with level three evidence, poor evidence for all types of procedures. So you basically got to sort of go with what you know and what you think is best.  But unable to differentiate between joint sparing and joint sacrificing procedures. You can think about using a CARTIVA implant.  This is a study of five patients, no complications, significant improvement in pain. However, the group in Canada sort of did this for 13 patients, five with Freibergs, six  with primary OA, and two for osteochondral defects. All had significant improvement in pain, but had five out of 13 with complications and three required surgery.  So this implant is not a panacea, but certainly is a tool for the surgeon to use. When thinking about how to do this with a CARTIVA, you got to make sure that your metatarsal  head is big enough to have the implant. You need to have a good rim of bone all the way around, and the implant should be out of the end a little bit.  And you want to do this with a toe that is not significantly issue in the coronal plane. So going back to our cases, 55-year-old, painful second hammer toe, pain at the MTP.  MRI didn't demonstrate Freibergs, but some significant arthritis throughout the joint. So we took her to surgery, opened it up, did a hammer toe correction, and placed a CARTIVA  implant. And you can see in her postoperative x-ray, patient did very well, really liked the result, and recovered nicely. This was a little bit more complex.  Previous while osteotomy, significant pain. If you measured the width of her metatarsal head here, I didn't think it was big enough  for a CARTIVA type implant, so we used a dermal type matrix. This is just an MRI showing the amount of arthritis and wear from an outside facility.  We removed her implant, put a dermal matrix in, and revised the second hammer toe, and she returned to sports and exercise.  She's still a little bit shortened, but now the toe touches the floor, it doesn't float anymore, and is appropriate in the sagittal plane.  This is a 45-year-old runner that we talked about before. Significant arthritis. When we got in there, primarily the arthritis was in the dorsal aspect, so we did a dorsal  closing wedge osteotomy, and a dorsal interposition with some local tissue. Significant improvement in pain in the patients back to running, and recently saw them now  eight years out. But a word of caution, not everything works well. This is a 65-year-old female who came in to see me terribly unhappy with her forefoot,  had bad arthritis pain at her first and second. We tried to use CARTIVA implants for the first and second.  She got no improvement, has severe pain, hates it, probably now needs an MTP fusion and a second hammer toe with a met head resection, but isn't sure she wants to proceed.  So I would say nothing is perfect, and certainly this patient has lots of the things, when I look back and think about her case, that Scott mentioned, sort of catastrophizing,  psychiatric issues, that type of thing, and maybe I should have recognized those things before proceeding.  When thinking about an algorithm of how to manage S or MTPOA, if it's Freiburg's, you want to think about if there's a long lesser metatarsal using an osteotomy and an interposition  if needed. If it's shortened or collapsed, either a CARTIVA or some type of dermal matrix.  If it's post-traumatic or related to instability and there's OA and they've had no previous surgery, have to address the hammer toe, have to address the instability, and then follow  this chart based on where they are. And then if it's a revision setting, you've got to get the toe straight, and then think about a modified Hoffman versus other options.  Key tips, so I'm sort of opposite of Jesse and Paul, I love pins, I pin everybody. I use a dorsal incision, I worry about the dorsal incision, so I always pin the MTP down  in about 10 degrees because I worry about a floating toe more than anything else. In revision settings in inflammatory arthritis, really consider a modified Hoffman.  Always need to address the hallux and really want to educate your patients that they'll never be normal. Be very careful with these procedures with runners and high-level athletes.  So important to recognize the arthritis and the AVN at the lesser MTP joints. It has a significant impact on patient outcomes.  There's lots of surgical options, we don't know which one is best, and we need larger studies to figure that out.  So I'm going to stop sharing and see what about our questions, if there's any questions. The one question was, and I'm going to ask Jesse about this, a few of the mentions ad  ductus contributing to MTP instability, is anyone doing proximal minimally invasive metatarsal  osteotomies to correct the ad ductus and hammer toes and MTP instability? Jesse, any thoughts on sort of MIS for the proximal for ad ductus?  I don't have a lot of experience with it. I've seen some really cool looking x-rays and some guys that I trust that are employing those techniques with good success.  I think definitely you can accomplish some of the correction with your fusions by shortening  and if you can do that in a minimally invasive manner, then I think that's even better.  I will say what I've learned in those deformities, and I failed to mention it in my talk, particularly  those with transverse plane deformities, I've found that I feel like even though it's an old technique, I almost always have to lengthen the extensor tendons at the same time, even  if I'm shortening osteotomies or even if I'm doing a shortening midfoot fusion. And so just keep that in mind and don't be afraid to lengthen the extensors if you need to.  And you can do that minimally invasive as well if need be. Jesse, you showed a case where it looked like there were staples in the midfoot that you corrected ad ductus.  Did you get that through the TMT fusion? Did I do that for a TMT fusion? Yeah, it looked like you fused the TMTs to correct ad ductus. Yes, I did.  I shortened and you got to be careful. You have to make sure you use a ronger to separate the transmetatarsal ligaments.  You can do an aggressive shortening midfoot fusion if you resect a little bit more of the bases of the metatarsals and decompress the entire metatarsal length.  You just have to know sometimes it's difficult to get that metatarsal to shorten and get good compression, but that's what I did in that case.  If you're doing a single metatarsal, it's more difficult than if you're doing two and three or two and three and four.  You have to use a bone clamp to really compress to grasp the metatarsal and the cuneiform.  Another question from the audience, what does the group think of how to fix a floating second  toe with the third toe after previous shortening osteotomy and the third toes curling under it? I've definitely seen this case.  This for me, I'd have to do the third toe and then redo the second toe and pin it down, but I'm curious what the group's thoughts are, a floating second toe now with the third  toe curling under it in a revision setting. There's no great answer for that. I think we all see that and I'll have that in our practices.  That's when I'll get very aggressive about doing a plantar plate repair. You can't always trust the plantar plate in that situation, so sometimes I'll get creative  I've used various synthetic suture tape things and whatnot to try to run in the vector of the plantar plate to try to address floating toe, but then sometimes you address the second  toe. The reason the third toe is curling under it is because it was under-treated, so sometimes you have to do whatever you have to do on the third toe, whether it's hammer toe plus  metatarsal shortening osteotomy or something like that, but sometimes you have to go after the third toe. Yeah, I agree with that too, Paul.  It's so often when you lengthen one extensor tendon, the one next to it's pulling up relatively speaking, I think because they all come from a common extensor.  I feel like a lot of times I should probably lengthen the other extensor tendon, so certainly like you said, Jason, address the third hammer toe by lengthening extensor tendons.  I often shorten the third also. I don't do the plantar plate either for the reasons you guys said, and I'll pin, like you said, across the joint to try to get the scar down longer.  Another question from the audience. Sorry, Jesse, go ahead. I was just going to tell Scott, I've seen that too, where you have an uneven sagittal  plane alignment if one extensor tendon's looser and tighter than the others. I don't know, Scott, you may know if there's any literature on it, but sometimes I'll sew  the extensor tendons of multiple toes together so they have the same tension. I'll kind of sew those together and then set my tension to the main extensor more proximal.  I can agree where I've done too. To me, it makes a lot more sense than syndactylization.  I don't know if any of you guys do syndactylization, but I've never seen a happy patient with that. Nope. Agreed. Yeah.  Another question, does anyone here avoid calf tourniquets with forefoot surgery? Does it matter in the panel's opinion? I don't use calf tourniquets.  Does anyone use a calf tourniquet? I'm not a calf tourniquet person, but yeah, I think that if you put a calf tourniquet  on, you basically tether the long flexors and extensors in whatever position the foot was when the tourniquet went up. I will typically do a calf tourniquet.  In patients who they're under sedation with a block or something, they won't tolerate a calf tourniquet, so oftentimes I'll go without a tourniquet at all for some of them.  I use an ankle tourniquet a lot if they're doing a sedation with an ankle block, but I have that theoretical concern, just what you guys said, because it could throw off  your judgment of extensor balance, although I can't really say I've ever seen a problem.  It seems almost hard to squeeze the tendon so hard that it affects what's happening distally. Last question, what's everyone's protocol with pins? We mentioned up to six weeks.  I know I do six weeks with my pins. Jesse mentioned six weeks sometimes. Scott and Paul, what's your protocol for pins in a hammer toe? Typically I let them heal weight bear.  I won't really let people drive until the pins are out. I don't really do anything for pin care.  If it gets real nasty, then clean them off with a Q-tip and some peroxide or something, but I don't typically have any pin care protocol.  For me, a lot of it's driven by what else you're doing and what the recovery is. It gets something that makes it easier when it's a bigger surgery and you're going to  keep them off the foot anyhow. I tend to pin the ... I guess we're talking about different lengths of pins. Across the PIP, I'll leave that routinely for five or six weeks.  I notice when I get pin tract infections, it's right around five weeks or so, so I'm a little nervous about that.  I found, we were talking about before the webinar formally, that if I pin across the MTP, if I leave it real long, it might get stiff on the way down, although the bigger  problem usually is elevation, so I tend to try to take a pin across the MTP out at four weeks.  One thing I'll say for sure, I've had a patient who walked early, and I think it was telling  her to walk heel weight bearing, but I walked her early on an MTP, a pin that I pinned across the MTP, and she broke the pin, and that is a huge deal because I had to go back to the  operating room and take that thing out. If I pin across the MTP, I'm not letting them put weight on it, and I'll do that generally four weeks.  If it's just across PIP, more like six weeks. Watch out for pin tract infection about five. Scott, I had this patient who mowed her grass with her pins on cocaine, and she came in  and her toe was completely elevated and crooked with the pin in it, and I took her an x-ray and just told her, I'm like, hold on. I have different problems.  Well, I think we're about to 1016. I wanted to thank all the panelists for their excellent talks.  I want to thank Lucas from AOFAS for helping organize us, and thank everyone who showed up to listen to us. Hammer toes are a difficult problem.  Hopefully this hour we've spent together will allow you to take better care of your patients.  I think any of us would be willing to answer questions if you have them after the talk, and thanks for joining us tonight.

Video Summary

In a webinar on complex hammer toes, several doctors highlighted key points for managing this condition. Dr. Barreto emphasized the need to manage patient expectations post-surgery. Dr. Ellis discussed the impact of comorbidities on surgical outcomes and advised tailoring approaches based on patient health. Dr. Toulousan highlighted considerations for patients with rheumatoid arthritis. The panel delved into treatment options for hammer toes with MTP arthritis, including surgeries like debridement and realignment osteotomy. Addressing hallux deformities alongside hammer toe corrections was stressed. Surgical techniques and case studies demonstrating successful outcomes were presented. Recommendations on pin usage post-surgery varied, with most agreeing on specific timelines to avoid complications. Managing floating toes and developing individualized treatment plans were also discussed as crucial for successful outcomes in treating complex hammer toe cases.

Asset Subtitle

Moderator: Jason T. Bariteau, MD
Faculty: Jason T. Bariteau, MD; Jesse F. Doty, MD; Scott J. Ellis, MD; Paul G. Talusan, MD

This webinar focuses on the management of complex hammertoe deformities including those with metatarsophalangeal joint arthritis and metatarsophalangeal joint instability. It will also discuss hammertoes in complex medical patients such as rheumatoid arthritis and diabetes. Further, it will assist providers an understanding what are key variables to optimize clinical success in hammertoe corrections.

Course Objectives

At the conclusion of this webinar, you will be able to:

Identify unique issues and different treatment options for patients with hammertoes that have MTP arthritis.
Identify unique issues and different treatment options for patients with hammertoes that have MTP instability.
Understand how complex medical issues (i.e. DM, RA, etc.) effect surgical options for complex hammertoes.
Understand how patient expectations can influence outcomes of hammertoe corrections.

Keywords

complex hammer toes

webinar

doctors

patient expectations

surgical outcomes

comorbidities

rheumatoid arthritis

treatment options

MTP arthritis

surgical techniques

floating toes