On behalf of AOFAS, I want to welcome you to tonight's webinar, Alex Valgas, MIS Open and Other Associated Deformities. Tonight's moderator is Dr. Rebecca Serrato. Joining her are Drs. Samuel Ford, Stephen Newfield, Patrick Maloney, and Elizabeth Cody. 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 on 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 your browser and logging back in the same way you did the first time. 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I'll now turn the program over to Dr. Sarada to begin. Thank you. Thank you, Lucas. Good evening, everybody, or late afternoon for anybody on the West Coast. Again, my name is Rebecca Sarado. I'm a practicing orthopedic foot and ankle surgeon at Mercy Medical Center here in Baltimore. I just finished. I am looking forward to tonight's webinar, and I want to thank the Education Committee for putting together a great list of topics this year, and specifically the Focus webinar group for inviting me and my faculty to be speaking today. We're going to be speaking, and our topic tonight is on Hallux Valgus, MIS, open and associated deformities. Again, I want to thank my four faculty, and I'll introduce each of them individually when they give each of their different lectures. I will be looking through any of the questions that any of you guys may have, and we can see, depending upon the flow of some of the talks that we're giving tonight, maybe we'll see if we can address a couple of them in between each one of those lectures, and we'll certainly try to give some time at the end to address any other lectures. So with that, I'm going to introduce my first speaker, Dr. Samuel Ford, who is at OrthoCarolina, and his talk tonight is going to be on minimally invasive Hallux Valgus correction osteotomy planning and techniques. Sam? Thank you, Dr. Sarado. Hopefully you all can all see my screen sharing. Yeah, so we've got, I'm going to try to be concise and quick, because we've got a lot to cover tonight, and really what I'm doing is setting the stage for hopefully what's a really dynamic discussion. These slides aren't all mine. I've adopted some from Dr. Greg Furnin-Sarado, although all the cases you'll see are mine. Outline. I'm going to talk about principles, planning, and techniques for minimally invasive, when to do it, how to do it. Complications, Dr. Neufeld's going to cover, Dr. Maloney's going to talk about when to open, and then Dr. Cody's going to touch on other associated deformities. It's important to address bunions with the same principles you would whether you're open or MIS. I think that's the biggest groundwork I want to lay. If you have a mild bunion, you need to recognize that. If you have a moderate one, your tool bag may be different depending on your comfort level, and you need to recognize how to look at those things. Is the joint incongruent? How elevated is the HVA? What about the inner metatarsal angle? Of course, that's relative to the position of the second metatarsal, so do you have metatarsal seductus? Is there severe deformity? Is there something else going on with the lesser toes like this second toe here? You really need to be looking at the whole foot holistically when you're planning what to do and how to do it. If someone has arthritis, stop. Don't pass go. There's no minimally invasive bunion for you, at least in my practice. If you see a first MTP, you can't passively correct in the transverse plane because they have arthritis, and they've got a grind test, palpable osteophytes, and their X-lays look arthritic, you need to move to the fusion because you're not going to get predictable pain relief. Pain relief is what predicts long-term function following correction of these deformities. If you see TMT instability, too, on this sagittal CT scan that you can see in the center bottom, you see that vacuum effect and some sagittal plane translation of the first TMT. If you see that, you've got instability of the first TMT. It's harder for me to tell you how to feel instability of the first TMT on exam, but if you feel first TMT on exam, TMT instability on exam relative to the contralateral side, or maybe somebody simply got loose TMT joints, you're going to get a less predictable correction with minimally invasive techniques. Again, look for arthrodesis. MTP fusion does well. As a background, traditional open osteotomies, they do well. You get correction, you get restoration of a congruent joint. Scarf is very powerful. This is what I did when I first started practice because it's what I did in fellowship. You can derotate, you can imprecate the capsule, you can restore congruence to the joint, sesamoid position improves, but you get big incisions, you get loss of range of motion, you get a protracted recovery, your early postoperative pain's worse. Is this really where we need to stop? That's why minimally invasive options really are appealing to me. Lapidus, I think for a lot of people, is the ultimate severe deformity corrector. I do lapidus. If somebody has first TMT instability or first TMT arthritis or severe deformity, I'm worried about bone quality in somebody who's older, a lapidus is something to jump to, but nonunion's a problem. Late failure, between three and six months, getting a little drift as the fusion really matures, that happens. None of these surgeries are perfect, and the panel will go over those downfalls in detail. What I'm going to focus on today is minimally invasive Chevron and Aiken. This is the combination of percutaneous technique with, honestly, improved fixation options. It used to be that you could do percutaneous, but you didn't really have the fixation to match it, or you could do open, but get stuck with the big incision, and now we can combine both. This is not a technology looking for a niche to be used in, right? This is a clinical problem that we're trying to address with more minimally invasive techniques that's now improved. If you look, what equipment do we use? We use burrs to make our osteotomies, right? The typical burr we use for our distal Chevron is, for some reason, it's advancing. Oh, there it goes, sorry. The burrs we use typically for a first metatarsal osteotomy is a two by 20 millimeter burr. You can have wedge burrs for bone resection, and other style burrs for joint prep. There are 12 millimeter burrs for Aiken osteotomies, and as you can see here, you can do Phalanx osteotomy, and really, there's a whole gamut of burrs to be used. The motor is really the most important part of this. If you don't have the right motor setup, and Pramod is what I use, Pramod is what a lot of people use in the United States, but apparently, there's some even better power units out there, but really, what you need is a box that's got a high torque capacity with strong coupling so that you can have effective power, but on low speeds so that you don't generate a lot of heat, and you've got to irrigate. You've got to make sure not to burn your soft tissues and burn your bone. I think this is what makes this a little intimidating to approach and do on your own if you haven't done it before, because you can end up with something like this where you get necrosis of bone from overheating, and you get terrible nonunion and a disaster, really. This is a picture of OR setup courtesy of Dr. Serrato, a left foot. You'll see the mini C-arms coming in from the patient's opposite side. If we were doing a right foot, it would still come in from that side, so OR setup's really critical. You need to be able to access the foot and access the mini C-arm, and as you can see here, this is what facilitates you being able to do your minimally invasive technique, but also get the mini C-arm into the appropriate position. Now, the osteotomy, it's not your open chevron. It's a more shallow osteotomy, and some surgeons have gone to a transverse cut trying to maintain the bony pillar of their lateral cortical wall of the distal metatarsal, and so what you're trying to do is insert your burr percutaneously just below the neck of the first metatarsal head, and in planning for the resection, the 2mm resection of the burr, you know you're going to shorten, but then when you correct the deformity, if you do it at the right angle, you will regain some of that length, right? If your burr is aimed too proximal or intentionally proximal in the setting of a long first ray or some mild arthritis that you want to decompress a little bit, you can definitely shorten the first ray. You can lengthen the first ray, too, or balance the two, and so what you're trying to do is with your burr, you're trying to sweep and translate at the same time so that you are able to do everything through the same keyhole. This avoids the wound complications and maceration of the portal site. You don't want your scars to stick down. You don't want your incisions to get larger as you use them or burn, and so you're irrigating through this whole process, but again, it's rotation and then translation, and you do it in both directions. So here's a case, 41-year-old male. This is not necessarily a typical patient. Obviously, our cohort is female, but we have a 41-year-old male. He's active. He can't play basketball, and he can't wear his dress shoes, and the prominence of his right first metatarsal head is getting larger, so he does not have arthritis. He doesn't have first TMT instability. He's young with good bone. Now, good bone, you got to be patient with the burr. You got to let the burr do the work. You got to pause and clean the flutes. You got to pause and re-irrigate it in the wound. You do this procedure in somebody like this with no tourniquet so that you get the cooling of the bleeding, and you just let the operative worry about the blood on the floor later, because if you end up with dead bone, you end up with nonunion risk, right? And so for this case, intraoperative technique, this is a freehand case. These wires, they have a trajectory that's a little low in the first metatarsal shaft, but because the shaft is a relatively dorsal structure, it ends up being okay. We're planning here to ... Now, I run my wires first. Not everyone does that, but I'm planning to keep the lateral pillar of bone intact on either side of my screw, so I have wires run for my screws. My proximal wire is very proximal. It starts at the proximal base of the first metatarsal. You can see that the burr is angled essentially perpendicular to the long axis of the first metatarsal shaft. If you aim it flatter, it'll shorten. If you aim it more distal, it will lengthen, and you'll also lose a little bit more of the lateral head in your distal segment and leave it with the proximal segment, which can make fixation a little difficult. So this is a good starting angle. You bring the burr across. You execute your osteotomy. The translator's not pictured here. There are all sorts of translators on the market. You can see how these wires are on either side of that intact lateral pillar. We check on the lateral view. Now, these wires are a little plantar, but they're in the first metatarsal head. I don't mind being a little plantar because to me, that's going to resist dorsal subluxation of the first metatarsal head. We just need to make sure that the first metatarsal is still in line from proximal to distal on the lateral radiograph. We can't allow for too much dorsal to plantar translation. So here are our finals before we resect our imminence. You can see that we've got good translation. We added an acon. Our deformity is well-corrected. Our sesamoids didn't quite come over like we wanted them to, but here he is six weeks post-op. These are what the scars look like at six weeks. Sometimes the skin's a little flaky, a little macerated. You've got your standard five poke holes, but this does not look all that bad. It's a little dorsiflexed. It's a little dorsally translated. He loves it. And at three and a half months, he has no pain, 50 degrees of motion, literally asked me if he can go play basketball. So that's our goal, a faster recovery, less early pain, less concerns about infection because of a big incision and less stiffness. Here's another freehand example quick, just to show you florals. This is from a couple of weeks ago. I saved more florals on this one. So plan your wires, get ready to advance your wires, make sure they're in a good position on the lateral, execute your osteotomy, and then translate, hold the wires in place. You can see we've got a wire on either side of that lateral cortical pillar because the proximal screw needs to give you good fixation. You want to get quote-unquote tricortical fixation if you can with the proximal or lateral screw. Here are wires advanced across the osteotomy. Again, that inferior wire is a little low, but it gives me better spread. So I don't necessarily mind that. You can see while I'm drilling, I hold the translator back in place. I hold the hallux into varus. We get our screws placed, take off. Then I, through the distal of the screw holes, I reintroduce the 2x20 burr and make a small pilot hole into the remaining first metatarsal and then cut the prominence from inside out. So then I'm not using a wedge burr in between bone and subcutaneous tissues. I'm trying to minimize wrapping up the dorsal mediacutaneous nerve. And then really we just need to make sure the soft tissue is decompressed. So in this case, I did burr off the actual medial eminence of the first metatarsal head a little bit. I don't always do that. And then added the acan. So at the end of the day, I'm fairly satisfied with how this case went. There's fantastic evidence basis to support you doing this. If you're a surgeon who just went out and out in practice and you didn't do this much in fellowship, but you want to learn, this is no longer something that's controversial in boards, at least in my opinion. You can see we've got Dr. Neufeld referenced here, some of our British colleagues. There are learning curves and issues, and we're going to cover this a little bit more. You can have fixation failure, overcorrection into varus a little bit if you're not careful. But in summary, it's a moderate learning curve. The pain profile and the wound complication profile is worth it if you can master this. And it's difficult to teach. And so there's a little bit on here bled over from another talk in the cons of this. Calcaneal osteotomies take longer, but bunions, you know, higher upfront surgical costs, there's a moderate learning curve and it's difficult to teach residents and fellows. But if you go to a place where there's a surgeon who does a lot of this, usually they're comfortable teaching. So anyways, thank you. I'll hand it over to the rest of the rest of the group. 14 minutes. Not too long. Thank you, Sam. I really appreciate it. So there's, I see two questions that got brought forward by some of the attendees today and so one of the first questions one of them was that and anybody else feel free to jump in and if you want to put your opinions as well but the first one was what size are the K wires that you use in the beginning do you drill after for your screws yes so the K wires in the beginning I think are one fours I like to use two four oh screws if the foot can accommodate it I think it gives you better fix it your distal screws better fixation I just I've had a couple times where the three O's because they need a smaller wire they're harder to get the wire where you want it number one and then number two I just I've had I felt like the fixation wasn't that great with my more distal screw so if I can if I can get two four O's I do that affords you a bigger K wire a few companies have an anti-skive wire it's a little bit differ and tries to stay on track a little bit more I'm really careful about not penetrating the I don't with my proximal wire I don't penetrate the lateral cortex until I know it's going to be well positioned when I translate and then I only drill one at a time so you get both wires in position drill one while you're holding the reduction put that screw in and then drill the other yeah I would say the same for me I usually use and again different companies have different size slight variations to not just the size of the screw but maybe the size of the K wire with what the one I use I use a 4o and a 3o screw I always put the guide pins for two 4o screws because it's a much stouter K wire and it doesn't flex or bend for the more distal one so I save myself tremendous amount of time I always put that in before I am measuring drilling for the first screw but you're right I still have the translator in there and I'm kind of holding the position of my head but I also like to have that second guide pin in there sort of holding the position that I like before I've placed that first screw and then all I do is exchange the larger guide pin for a smaller one to get my my smaller screw all right and then we're gonna go to to the next one so this was another question a little bit earlier and anybody on the panel again can answer this what do you do with non-union after overzealous translation meaning greater than a hundred percent that has gone on to a non-union now has failed revision ORIF with dorsal plate and bone graft it sounds like yeah and that's the expert case stay tuned stay tuned for the next for the complications up yes well let's tackle that with some of the complications and and again I think at the end some of the panelists we can talk to you guys about you know third time revisions and what we may have done and stuff like that I'm gonna hold some of the other questions so that we can keep moving on so we're gonna move on to our next speaker and this is my partner dr. Patrick Maloney and dr. Patrick Maloney is my partner here at Mercy Medical Center in Baltimore and he's gonna speak on when I still open Pat all right thanks Becky here I see my screen okay yes all right so here are my relevant disclosures and I thought also be worthwhile mentioning that you know usually I'm on the MIS side of these talks so MIS certainly is my go-to for the vast majority of my hox values corrections and I don't want to kind of skew the audience into thinking that I'm anti MIS personally I began doing these in 2018 and this is by far the majority of my practice I certainly acknowledge there's a learning curve I'll point to Steve's article about his first 94 experience for somebody who wants to read about that and just as a quick plug several of us on the panel here are part of the me fast faculty and for any of those who may be interested especially now on the west coast for the first time we have a course upcoming this fall that I'll encourage you to potentially look into but with that being said when do I still open so same kind of perfectly laid the groundwork for me and we did not discuss this ahead of time but I'll go through at least in my opinion when it's reasonable and when I still open so the main indication for me is when I am considering an arthrodesis lapidus I'll touch briefly on a ductus but I don't want to steal Liz's thunder on that and then also revisions and I just kind of note certainly traumatic hox valgus any kind of collateral ligament injury maybe an avulsion fracture is probably still an open case in my hands as well but that's outside of the scope of this talk for tonight so I think the easiest instance that you have to consider is when there really is both combination of symptoms of valgus and rigidus and to Sam's point if they've got dorsal osteophytes if they've got grinding if they've got pain kind of immediately as well as dorsally to me this is kind of a no-brainer to consider first MTP fusion I would argue you know technique can kind of vary depending upon what your preference is but for the most part these can at least be partial weight bearing immediately which has the advantage over certain other procedures and techniques here's just kind of a case example of mine who by six months was quite satisfied and I thought kind of worthwhile at least noting on the clinical pictures how there is a decent amount of motion through that IP joint so I try and counsel my patients that you know certainly by three months they should be doing most day-to-day activities and by six months really returning to just about anything now just one kind of technical point and I would be interested to see what the other panels think on this I trained almost all the time on a five degree dorsal angulation plate and it really migrated through my practice to really going to a zero degree plate I found that of the patients who are dissatisfied after this surgery they tended to be kind of two dorsiflexed up and now I've been pretty pleased over the past several years of that neutral zero degree plate and found that they can still dorsiflex adequately through the IP joint to get into most shoes but feel just more comfortable and stable with push-off with that how it's pointed kind of more down towards the ground than I was initially trained on here's another instance that at least in my hands kind of screams for a first MTP fusion you know real significant joint incongruity again to Sam's point if you cannot passively correct this in the clinic preoperatively I have a low level of confidence that I'll be able to correct it and keep it there long term with any kind of how it's balanced correction the other thing that I encourage the fellows to look at all the times is a significant rotation the pronation you can almost see sometimes those nails that are pointed straight medially do the significant deviation rotation and in my hands this is just something that I think much more confidently I'll get a good outcome and have a greater patient satisfaction with an arthrodesis so again here's another case example six weeks post-op and by six months you know I would be you know astonished and and you know high-fiving if my bunny correction with that severe deformity was whenever close to that at six months and here this patient is cruising it back to her normal activity well and then I think the most controversial least in my mind is do you have somebody who's kind of got pure valgus and a pure bunion and is it really pure this is somebody who I think I would encourage you to spend a little extra time on your physical exam really try and suss out where are their symptoms is it truly over the medial eminence is it passively correctable and can you almost force them into a positive grind test and this is somebody who I might kind of mash on my range of motion exam a little more rigorously to almost kind of convince myself and convince them is there any wear in that joint that would point me towards doing a first MTP fusion rather than considering a lapidus or a scar for some other correction and I've been kind of astonished through the years and here's just a case example of those pre-op x-rays I showed you that a lot of these have some pretty weird and asymmetric wear through the first minute tarsal head and this is somebody if we had considered doing a lapidus and even if you're really aggressive on your eminence resection I'll be worried that with that degree of degeneration and changes within the first metatarsal head that you're setting yourself up either for pain postoperatively and or recurrence now you could certainly consider an MRI to really evaluate your articular surface before kind of making that decision interoperably but through the years seeing more and more of these has just kind of reinforced my mind and my idea that an MTP fusion really can generate a good outcome and here's that same patient at three months. A couple articles kind of support this that you know there's plenty of literature out there on MTP fusion in general but there are several touching on Hallux valgus in particular one out of Coughlin's group from 06 was mainly talking about revisions but there are several on primaries for Hallux valgus. Another more recent article by Chris Gross and his group down in Charleston I thought was kind of interesting they split their 136 patients into pure rigidus pure valgus and then kind of combination of the three or excuse me of the two with a minimum of three month follow-up but average well over a year and in all of their cohorts they did note improve patient report outcome scores but did note that the Hallux valgus pure group improved the least of the three. They had no major differences in complication reoperation rate or anything else. So let's switch gears a little bit and go on to Lapidus you know the topic of Lapidus could be an hour-long webinar discussion in of itself. TMT hypermobility I would tend to agree with Sam I think it exists there are obviously people who would beg to differ on that I think your physical exam is important so I would encourage you and certainly encourage the fellows and residents you know take the opportunity even if you're seeing somebody for something not at all related to the midfoot try and examine the first TMT joint to note hypermobility same kind of concept as an air interior drawer for ankle instability. Personally I like to do both kind of a dorsal to plantar translation I'll try and stabilize the medial cuneiform and kind of shuck that metatarsal up and down and then I also try and examine the kind of rotational deformity so again kind of grasping the metatarsal more distantly really trying to rotate and see if there's some clear instability and I would argue that it does exist. In today's day and age of weight-bearing CT scans there's also a couple studies reviewing the concept of the hypermobility on weight-bearing CT now that might not be available to everyone at their institution and I still think this is a topic kind of being researched today. As far as open versus MIS Lapidus you know that is a conversation there's an article published a couple years ago in FAI by Alistair Younger in the Vancouver group kind of comparing 40 open versus 40 MIS and I would strongly encourage if any of you have the opportunity to kind of chat and curbside Alistair I would argue he's kind of the king of the MIS Lapidus and just kind of pick his brain for thoughts and ideas as I have. My personal concerns and this is after you know full disclosure doing a couple of these MIS myself I worry about adequate joint prep even if you are pretty comfortable and confident with the burr I think it can be difficult to make sure you've got the full joint prepared. Now there are other shaped and sized burrs coming out to try and help really deal especially with that concavity within the first metatarsal base. I would also encourage you if you are doing this MIS to go ahead and stick a scope in there afterwards as I have done it as Alistair encouraged you to do both to kind of flush out the cartilage and then also to assess your degree of bone prep. I also really worry about shortening again I just kind of am concerned about my level or the fellows level of adequate bone prep without significantly shortening. I think it does take more time at least in my hands and this may not be the case for everyone but trying to do these MIS just adds even at least another hour or so to the procedure if not more and then you do have to consider the equipment you know the burrs are not cheap and if you're using multiple burrs and then you have to go down and do your aching that could be three plus burrs for one procedure where you could just be doing it with a simple saw blade. So just to run through a couple cases again this was somebody who had some clinical instability on examination you know without that TMT instability I think this could be a very good candidate for amica but given that instability I chose to do a lapidus here they were at a year and pretty satisfied with the result. Another case example where you know maybe a little bit increasing congruity at that first TMT but also in the setting of 2-3 TMT arthritis as well some subtalar arthritis and subfibular impingement we kind of went full bore and did lapidus as well as 2-3 TMT fusions. The other thing I do in almost all of mine just to kind of keep the MIS train rolling is add an MIS aching and I think you know that's a nice way to kind of dip your toe into the MIS world if you're not ready to go full bore. Another topic where at least in my practice I'm going to still open is a ductus and again I don't want to jump on Liz's bandwagon too much but my concern here is is there enough room to shift this with an MIS technique if you're not going to address the lessors and then how are you going to address the lessors. I think there are still people or people who are kind of advocating now to do these MIS collusion wedge osteotomies approximately at the metatarsal bases. I think it's great conceptually. I think in actual practice this is a very challenging procedure to do so even though I'm still making my cut with the burr as is demonstrated in these floors here I'm still doing those lessors open. I just find both the cut is difficult I think the closure is difficult and if you're going to fix these which I would assume most of us are I think if you're going to try and perk a screw that angle is very very challenging. So in my hands I'm still doing these collusion wedge osteotomies open. I think again doing it with the burr is a great idea but I have not jumped on doing these in an MIS technique. And then sort of a more extreme example of kind of combination of the both adductus and arthritis plus some instability through that first TMT joint and again for me this is kind of a lapidus with closing wedge through your arthrodesis sites of two and three. Shifting gears to revisions and again I'd be interested to pick the panel's brain on this. I've done a couple of revisions through a MECA technique. I haven't been too thrilled to be honest. Now there's not really any great literature out there on case reports or even case series on this. I personally am a little convinced that the scarring through the capsule the degree of eminence resection I think can limit your ability to correct this as opposed to an altered and a kind of a native joint capsule. But here's one of mine where I thought you know prior eminence resection was done well over 20 years ago should have good vascularity to the head let's go ahead and try this in a MECA technique. And I thought my initial fixation was pretty decent but as with anything nothing ruins good results like long-term follow-up and here she was at a year and to be honest I'm she was never really happy aside from kind of the recurrence of the deformity the joint was stiff her joint was kind of painful I probably in retrospect should have just talked her into a first MTP fusion and my success has been pretty lacking to try and do a revision through a MECA technique. Trying to learn from my mistakes here's another revision case and this one has kind of a lot going on between the DMAA kind of a weird morphological spin however they fix their prior open chevron there's a lot with regards to this metatarsal positioning and deformity. So in my hands nowadays I'm still doing this open in this case it was a lapidus this is a relatively recent case so I don't have really long-term follow-up x-rays but I think for revisions again at least in my hands opening up the capsule freeing up that scarred down tissue maybe revising your eminence or maybe not revising your eminence but going to a lapidus I think just going to get you a more reliable correction. In conclusion again just to kind of still be in favor of I certainly think MIS is here to stay and there are people doing all these cases and all these indications I just went through MIS including MTP fusion so it certainly is doable but I would encourage everyone in the audience do what works best in your hands this is by no means expert opinion but just trying to kind of combine a little bit of the recent literature with my own personal opinion and experiences. Thank you for your time. Thank you Pat. Real quick question as far as some other indications for maybe considering open what about bone density how do you do you ever get nervous about doing a distal metatarsal PERC osteotomy MECA PICA whatever you want to call it and this patient you know they come in they're 72 years old they don't have arthritis they have a flexible deformity but they're treated for osteoporosis. I would say nervous yes has it stopped me no now I put everybody on vitamin D whether they you know osteoporotic or not but certainly the osteoporotic lady or male maybe I'll delay their case and actually check the vitamin D level to see if they are adequate and have the capacity to heal bone. I also think you have to be really critical on your screw placement and make sure you're through that good kind of diaphysial cortex before going out into the head maybe be a little bit more critical on where your screw is ending in the head kind of try and get into that slightly more dense subchondral bone but no I would say in terms of a contra indication I don't think for bone density registers at least at least in my practice. Okay I would also say the other pearl that I teach the fellows is looking at the AP foot x-ray look at the thickness of that lateral cortex because that usually can tell you if that patient you know if they're going to be pretty safe to be able to weight bear pretty quickly afterwards when you get that screw across that lateral cortex into the head and so sometimes I've had patients I just did one day she's 70 bone was actually very good but I felt comfortable with that because of her x-rays I could see that cortical thickness and I felt she had sufficient enough strength to be able to withstand this type of technique. Yeah and the other thing you can try and kind of sneak and get away with is not drilling too far into the head especially with that lateral screw and just trying to leave more bone for the screw itself to bite and purchase. Now you risk a little bit losing your positioning of your wire but you could even if the screw is loud or excuse me if the wire is loud enough in the head you can drive the wire right out as long as you're not piercing through the articular surface and then that way you kind of have a post for that screw to bite into and again kind of really trust your your measurement or maybe even double check your screw before you finally bury it down and make sure your life is good and you're getting into whatever subchondral bone they might have left helpful well thank you all right so for time sake we're going to move on thank you pat and we're going to go to our third lecture and this is going to be given to us by dr steven newfeld dr newfeld is practicing down in northern virginia in the orthopedic foot and ankle center of washington and he's going to be speaking to us on our favorite topic managing complications after m.i.s talix valgus correction steve thank you becky this is a fun one this is where we get to uh uh air our laundry so let's see if you guys could can you see my screen that's showing up let's see yeah you guys can see it oh good all right so let's get this going okay um so managing complications so this is the best part of the night right where everybody gets to see all the different scripts and feel better about themselves so here we go i will start say by saying this these are not all my complications uh my disclosures i do some uh consulting and some i get some royalties for different companies uh the first thing i just want to say is that complications can occur with m.i.s surgery just like they can occur with open surgery but i will tell you that there are way less complications in my hands and most of our hands when you do m.i.s surgery than open surgery in terms of infections what have you but you can see non-unions and malunions you can undercorrect you can overcorrect there's joint damage that could occur there's hardware problems or infections and recurrence and damaging structure so we're going to try to go through this um and and sort of sort this out um when i started my ms journey a while ago um i was curious and see how my patients would do and were there complications and what was the learning curve what have you and uh i looked at the first 94 consecutive cases and i did have some complications now they fortunately none of them were were uh terrible i had some hard removals and little lady bone that was osteopenic i had neuritis uh that needed neurolysis i had one infection i had some paresthesias and i really had one scar sensitivity but in reality though the complication rate was much less than i would have expected there's always a question about the learning curve there's definitely a learning curve as we mentioned earlier in an earlier talk there was this couple studies out there that talk about learning curves uh this study showed the first 53 the second 53 and they had twice as many complications in the first group uh as the second year so some some authors have shown a very steep learning curve i would say that as you're as we're getting more and more exposed and more and more surgeons are learning this the learning curve i would say is not as steep as uh it was in the past there's many more option opportunities to learn now there's definitely some unique aspects of m.i.o. spinal surgery compared to open surgery that um that you need to keep in mind as long as you understand these aspects uh then your complication rate will be lower this is a different surgical skill set you're you're different using different muscles using different skills most of us as residents and fellows learn how to use open how to use saws and how to use burrs in an open setting but this is a very very different type of muscle memory that you need to train yourself it's really it's a it's very humbling because you're learning a very different set of techniques you're using a burr instead of a saw as we talked about earlier uh this burr has to be a high torque low speed high speed burrs you're going to get lots of burning and joint and soft tissue damage the other thing you have to remember is you can't visualize the anatomy so you need a really good fluoroscopy you can't do these blind you need to you have an x-ray in all your cases you're relying on the soft tissues for stability so we have open cases you do lots of soft tissue stripping theoretically and in these cases you're not relying on your open visualization you're relying on your tendons and your ligaments to stabilize your osteotomies and again the positioning as we talked about earlier is very important so these are just some interesting aspects you got to keep in mind um what i want to do is is break down the complications and and these aren't hard and fast truths but it's just some way nice a nice way to think about it i think there's some preventable complications i think there's some unavoidable complications and then there's complications that i would not consider a complication at all we'll go through some of these so preventable complications is really related to the surgeon's skill and learning curves and the techniques like i said this is a different set of muscles a different set of techniques that you need to really practice and the preventable ones are burning of the skin and the bone lots of correction uh many times you can prevent those malposition as long as you have a good x-ray and you're looking at the the right views you should be able to avoid malposition joint damage really comes down to your skills injury to surrounding tissues and painful hard work again these are closed cases you don't you're not looking at the anatomy so you really need to use your skills to prevent these complications let's go through some of these uh briefly uh skin burns are something that can be prevented it's a frequent problem when you're first learning the MIS techniques and they can lead to disasters nerve injuries painful scars infections the key to preventing burns is to use the proper technique low speed and high torque every case should get a new burr i know it's tempting especially when you're in a surgery center let's just reuse the burr you don't use it for five minutes but those burrs do get dull and a dull burr will require much more power next time and that's going to cause burning of the bone i would also encourage you to limit the amount of burring you're doing in a row so you should start you should stop you should start you should stop we frequently take the burr out of the bone and clean the burr it's very important to use fluid to cool the burr if you're using a tourniquet that's especially important if you don't use a tourniquet the blood can cool the burr sometimes adequately the other thing is don't put excess tension on the skin you let the burr do the work as we talked about earlier the technique in the first lecture and the other rule that i kind of have and i teach my fellows also is one incision one procedure so don't push the indications don't stretch your burr into another part of the foot you it's only poke minimally invasive incisions so just be careful where you're going now if you get a skin burn the way to manage it obviously number one is prevent them the number two it's basically local wound care you minimize the motion until healed so basically you're the typical stuff you do for any other burn sylvedine put the split put a splint on the foot let let the soft tissue calm down and hopefully it won't turn into a disaster how about osteonecrosis and bone burning again how to avoid this low speed you want to listen and feel for the bone you're again you're not seeing it you're feeling it it takes muscle memory takes skill you want to take breaks you want to clean you want to clean the burr you want to cool the burr and you'll avoid osteonecrosis and bone burning bone burning if the bone burns how do you manage it well first of all you hope that it heals uh most of the time it does heal you're not violating the soft tissues as you do in an open case so usually the soft tissues are fine and it will heal rigid fixation is important so if your fixation is poor you would want to switch that for a larger screw or an extra screw and you have to wait and wait and wait and wait uh if the dead bone doesn't heal by itself you can always go back later and add biologics i've had cases where i just will go back inject some b-mac or some biologics and that bone will will eventually heal so i would just wait and wait and wait and wait and many times it's it's not painful anyway all right let's talk about another preventable um complication loss of correction now sometimes you can avoid it but most of the time uh there are cases like this where here's a here's a very straightforward mica potentially but post-op look what happened we lost the correction and the reason we lost the correction is because that screw uh missed the metatarsal head uh we didn't get a good oblique view and a good lateral and then it healed and we lost the correction so that is something that could have been prevented right at the onset here's another one again missing the lateral cortex first post-op the extra look pretty decent looks like a good correction but if you notice carefully that first screw really missed that lateral cortex and the head slid back uh and we lost correction so this is one that could be prevented if we spent enough time making sure that screw came out the lateral cortex here's another loss of correction that could be prevented if you over strap and over tape your toe that can turn into a virus or if you have poor technique you do too much in release i would say that out of uh every hundred micas that i do i probably only do a lateral release two or three times um most of the time by translating the head over by rotating it appropriately you don't need to do a lot of release and if you're going to do a lot of release you need to be careful not to over strap it because that will lead potentially to a malreduction or a hallux varus here's another one preventable poor technique uh this is just too much correction uh and we lost we lost it and went on to a varus some other preventable malunions poor strapping on the one on the bottom led to a dorsiflexion malunion of the proximal phalanx this would be easily preventable if you catch it early enough here's another case on the right where the planet the first metatarsal was to plantar flex and they ended up with sesamoiditis and this is preventable also by just checking a good lateral x-ray intra-op um you'll avoid this complication here's an interesting case unfortunately one of mine this is the pre-op kind of a standard uh approach from mika where we did a nice reduction but look what happened um the first metatarsal was dorsiflexed on the ap it looked terrific but on the lateral notice that first met head is dorsiflexed slightly leading to a mal position and they essentially had a hallux rigidus a functional attrition that patient was not very happy with that here's another one that i think is preventable mika it broke through the medial wall with one screw lost correction at eight weeks post-op so how do you prevent uh or how do you handle a loss of correction or malposition well if you've over corrected it and you catch it early enough you can tape it back into position um use proper fixation use a rigid fixation and if it's over corrected you can always re redo it with an osteotomy using ms techniques now if it's under corrected or it's malposition position you can tape it back in position and sometimes you can always add an ache and revise the surgery so most of these are not uh horrible complications but you know occasionally they begin to shrivels and you just have to watch them carefully so i always see my patients one week post-op and three weeks post-op because we let them walk right away and many times you can you can catch these early enough here's another preventable complication joint damage the burr is a great tool it is your friend but it is also very dangerous you're not looking at the joint itself you're needing c-arm for this so um you need to use c-arm and every time you're going to use that burr it's like our eyes so here's the example unfortunately that went right into the proximal phalanx and you know destroyed the metatarsal head this is preventable how about injury to surrounding structures uh that is preventable if you use safe techniques and you know the anatomy and you look at the fluoroscopy you should be able to prevent those that burr should be inside the bone you should be cutting from inside out as soon as that burr leaves the bone you'll be able to hear and feel the sound of that burr it changes so once it's going through the soft tissue you need to stop cutting the burr now fortunately the shannon burr that we use is fairly safe on soft tissues but if there's tension on that burr it will cut through a tendon it will cut through a nerve so therefore never place tendons and nerves on tension so if you're burring the bone you want to not put your hand on top of that bone and put tension on the soft tissues because if your burr leaves the bone it could potentially do some damage shannon burrs typically don't harm tissues but if you use wedge burrs which we do many times that could damage soft tissues very easily and the surrounding tissues so just be careful and know your tools and really get good at that here's some examples of injury surrounding structures there's a fairly straightforward bunion pre-op on the left post-op on the right it looks pretty good on these on this view but post-op she came in the office and she had some some discomfort she had weakness of her gray toe she had difficulty walking and if you look at the ct skin the mri you can tell that that screw was malpositioned down into the sesamoids and it cut right through the ehl tendon i'm sorry fhl tendon and she was not very happy with that so that's a complication that could have been prevented if there was adequate fluoroscopy and adequate visualization preventable nerve injuries the technique is very important so when you make percutaneous incisions with your beaver blade which always be parallel to the anatomy parallel the tendons parallel the nerves when you're underneath the skin inside the joint then you could rotate it but you don't want to go in at 90 degrees to a nerve 90 degrees to a tendon that would be avoidable if you do it correctly there has been a fairly recent study uh from the group uh the knee fast group we talked about there's a terrific paper i would recommend you be looking at it where he talked about the clock method the safe zone around the first mtp joint i think dr serrato also published a paper on the safe zone around the first mtp joint where the nerves are so i'll encourage you guys to get this paper look at it before you embark on m.i.s bunion surgery but it is uh there is a very large safe zone that is that um you could easily avoid injuries the other thing that's preventable is painful hardware so make sure you use the proper screws you know m.i.s surgery uh the tools are created for m.i.s surgery so the screws we use are typically beveled screws they're uh they're we don't use washers they're not sticking on the bone because those will be prominent and they will be painful so make sure you bury the hardware and ideally use beveled screws if you can so let's go over some unavoidable complications and adverse events and these are usually attributable non-modifiable patient factors such as infection osteonecrosis stem non-unions some malunions and obviously dbts and thromboembolic events or sometimes you just can't avoid them unavoidable infections the risk is very small when i'm on a surgery these are small incisions um so there's not much uh exposure to infections i think if you avoid the skin burns and you're fast and you avoid bone burns you're going to avoid infections i have not seen very many infections with my m.i.s cases um how do you manage infections really like anything else unfortunately you don't usually need uh surgery for them they're usually cellulitis or topical i would excise any skin burns at the end of the operation uh that's a night is for an infection i spend a lot of time washing on any debris in the wound um or antibiotics are usually effective and if it's severe then you treat it just like any other open surgeries unfortunately um open uh big complications are very rare with m.i.s surgery how about non-unions um it is a rare complication m.i.s surgery again we're the whole the beauty of the of these procedures you're avoiding stripping the soft tissues and you're really maintaining the periosteum the blood flow so less than one percent of the time do we get a complication and of a non-union and i would say if you see a non-union just wait these can take longer to heal than open surgeries i wait a year or more and eventually they usually heal sometimes when they're non-union they're actually asymptomatic so i don't necessarily jump in and fix them right away anyway the malunions are unavoidable so here's an example of the case a fairly straightforward bunion deformity uh postoperatively at two weeks um it was looking fine as you can see they're walking on two weeks i would maybe argue my first metatarsus had slightly plantar flex but really at this point there's not really a complication but when i see her back at six weeks notice that my proximal phalanx has dorsiflexed so this would be a dorsiflexion non-union i could not have predicted that i thought i had good fixation i think she walked on it too soon probably put too much weight and lost correction unfortunately she was doing fine and no pain um but you know it's a malunion that happened well how do we manage these malunions uh first of all um we try to avoid getting them obviously um and we try non-operative treatment so offloading um and and just waiting and waiting and waiting waiting and if they become a non-union that's symptomatic then you revise the operation with internal fixation uh and we add biologics again always work with high torque low speed burrs that avoids many of these problems and always always cool that burr with either blood or saline here's an example of a mal a non-union that ended up needing open fixation with biologics now less the last category are the non-unions i'm sorry the complications that i wouldn't consider complications so hematomas edema dysthesias delayed bone healing these are things that we see all the time in m.i.s surgery and i would just really educate your patients and tell them it's not really a problem so um many of these osteotomy especially well some of the osteosomies are unfixed so you're getting secondary bone healing which does take longer to heal and you're going to get a hematoma you're going to get swollen you're going to get some bleeding um and it may take longer to resolve than expected. So you just need to tell your patients, hey, this is fine, we'll just watch it. Compression, we'll usually resolve these and they do just fine. So rest, ice, compression, elevation, compression wraps. We have them come in pretty routinely for co-band wraps and just change the dressings and these almost always resolve on their own. Distance seizures are really, again, not a true complication. Really, it's very common, but they mostly always go away. It's mostly caused by swelling or bruising. And like we talked about earlier, if you know your anatomy, if you enter your skin with your beaver blade at a parallel position to the nerves and the tendons, it would be very rare and very uncommon to damage a nerve permanently. So usually they go away by themselves. Here's an example of a delayed healing that is not a complication. So preoperative standard bunion procedure, by six months, this bone is still not healed, by you're finally healed. So the lesson is just wait and reassure the patients. As long as they're asymptomatic, they usually get better and they do fine by themselves. Stiffness is usually not a complication. It's rare in MIS bunion surgery, but I would say that if you meticulously remove all the bone debris and we start early motion, then you'll get much better outcomes. So again, finally, preventable complications is all about training, practice, practice, and practice. Don't be cavalier on patients. Really use proper tools, use irrigation, change your burrs, cool your burrs, and you're gonna do fine and you'll have very little complications compared to open surgery. So good luck on your MIS journey. Thank you very much, Steve. I think for time's sake, we're gonna hold off on any of the questions. And I'd like to introduce our final speaker, Dr. Elizabeth Cody. Practicing at Hospital for Special Surgery. And she's gonna finish tonight's topics, managing hallux valgus in the setting of other deformities. So Liz, I'm gonna pass the baton to you and have you finish this up for us. Hopefully we can tackle a couple of quick questions at the end. Thank you. All right, so let me share my screen. All right, so like Becky said, I'll be talking about managing hallux valgus in the setting of associated deformities. So those really difficult bunions that have lots of things going on. These are my disclosures. So the things that I'll be focusing on, we'll kind of touch on lesser toe deformities. I know there was recently a webinar on this, so I'll glide over that part. And then pes planus with associated hallux valgus. And finally, the one I dread the most, metatarsus adductus. So when thinking about these cases that have a lot going on, I think it's important to acknowledge that there's no one size fits all approach. You really have to tailor the procedures you're doing to the deformity, to all aspects of the deformity and to the patient themselves. Patient goals and expectations are extremely important. So you really wanna talk to the patient and get an idea for what exactly is bothering them. What are the roles? What do they expect out of the surgery? And often those things alone can affect what procedures you're going to do. And these are complex deformities with lots to think about. So you want to make sure that you take the time to really consider everything that's going on. So with hallux valgus and lesser toe deformities, there's obviously a wide spectrum of deformities. The toes can be going all different kinds of ways. So I think everyone knows that you have to correct hallux valgus if you're addressing the lesser toes, even if the patient is really only complaining of the lesser toes. I feel like it's a pretty common thing that patients come in and ask, well, why can't I just take care of lesser toes? But you really do have to address the hallux valgus, which is often a contributing factor. You do not necessarily have to correct the lesser toes if they're asymptomatic, but if there is significant lateral deviation of the lesser toes, I do like minimally invasive osteotomies to reduce that gap that you get between the first and second toes. And I think maybe that helps prevent recurrence of the deformity. Minimally invasive osteotomies are also especially useful when you have deformities of multiple toes, like all the toes drift in one direction. They can be a pretty quick, easy way to address that and improve the overall outcome. So my kind of general approach to hallux valgus with lesser toe deformities or flexible deformities, I will typically do a percutaneous flexor tenotomy with or without a flexor tube sensor tendon transfer. So that tendon transfer is really useful to address elevation of the toe. For rigid flexion deformity, I'll do a PIP fusion, again, with or without that flexor tube sensor tendon transfer. And for angular deformities where you have the toes drifting medially or laterally, that minimally invasive proximal phalanx osteotomy can be very useful. And then metatarsal osteotomies as needed, depending on how tight the joint is and other factors. So touching on the minimally invasive osteotomies, I'll do a medial or lateral closing wedge at the base of the proximal phalanx. And usually I'll end up completing that osteotomy. So you can see here in this patient, the toes were deviating laterally. So I did small medial incisions and did like an oblique medial wedge resection osteotomy, and then completed it by bringing the toe into varus. You can also cheat the osteotomy plantarly to address toe elevation. Although I've found the tendon transfer to be more effective to address that toe elevation. And you'll use the two by eight Shannon burr. Since there's no hardware, the dressings are critical. This just shows the dressing that I use. I'll change it every two weeks for the first six weeks after surgery. This is an example of a patient. She's an 84 year old female with a longstanding bunion. And she's complaining about her lesser toes being very crowded and painful. So with this elderly lady who really just wants to get back to walking as soon as possible, you see that significant incongruity at the first MTP joint. This is a perfect candidate for a first MTP fusion. So you can see the nice correction we got here with the first MTP fusion. And then I did a second metatarsal shortening and a PIP fusion of the second toe and percutaneous flexor tenotomies of the other lesser toes which were flexible. And those had pins in for two weeks. And this is her final outcome six months after surgery. This was really nice for this elderly patient. She could walk on it right away. I do heel weight bearing for eight weeks after, sorry, six weeks after surgery. So it's immediate weight bearing. And she was overall very happy with her functional outcome. This is a 66 year old nurse. Again, pretty severe deformity, but really her main complaint was her fourth and fifth toes rubbing in shoes. So you can see that the big hallux valgus deformity that kind of windswept deformity of the lesser toes which makes this really difficult to treat together with some metatarsus adductus. So here I did a lapidus procedure and I did minimally invasive second and third proximal phalanx osteotomies to address those toes that were drifting over thinking that would kind of take the pressure off of the fourth and fifth toes. These were her first postoperative x-rays. You can see I got a pretty good correction. But then of course, by eight months post-op she's lost some of that correction. She got some recurrent deformity. And of course she's still having pain in the fourth and fifth toes. So I took her back. We did a minimally invasive Aitken osteotomy. We did metatarsal shortening osteotomies of the second and third metatarsals. And I did minimally invasive osteotomies of the second through fourth toes. Again, repeating it for the toes I'd cut before. And percutaneous flexor tenotomies of the fourth and fifth toes. And ultimately six months after this she's finally feeling better. She still has some recurrent hallux valgus. I'm not thrilled with how the x-rays look, but she was happy. So I guess we're happy with how this case turns out. But it just illustrates how difficult these cases can be. And these can be a real challenge. This is a 76 year old woman with metatarsalgia and painful rubbing of the second toe and shoes. I think a lot of people would just amputate this which would be my instinct as well. You just amputate the second toe, nice easy recovery. However, the patient did not want that. So we did a minimally invasive Aitken osteotomy. I did a second toe flexor to extensor transfer to address that crossover toe. And then minimally invasive osteotomies for the lesser toes. And we got quite a nice clinical outcome here. She has no pain. She's very happy. And interestingly, she had pretty severe arthritis at the first MTP joint before surgery but this was not hurting her. And she actually had great motion at the joint. So we chose to just do the Aitken osteotomy. That worked out very well for her. And you can actually see improved congruity at that joint which was a bit of a surprise to me. Moving on to hallux valgus and pes planus. What do we know? So multiple studies have shown that patients with pes planus have worse bunions when compared to patients without pes planus. However, most studies have found no difference in how patients do after hallux valgus correction whether or not they have a flat foot. However, there is a wide spectrum of deformity and there's really not much in the literature on this topic. The question is, do you have to address pes planus or valgus hindfoot in somebody with a bunion if you're treating the bunion? The answer I think is really no unless the patient also has symptoms related to the pes planus. Since whatever procedure you do can have complications you really don't want to go messing around in something that's not symptomatic. Although some authors have found higher hallux valgus recurrence rates in patients with pes planus more studies show equivalent outcomes and recurrence rates between patients with and without pes planus. So then which hallux valgus procedure is best for patients with pes planus? So in my opinion, first TMT fusion or lapidus is most reliable for severe deformities. It's nice in the setting of a flat foot because it will improve your medial column stability and I think possibly lower the risk of recurrence. And there is some literature showing higher recurrence rates in patients with hallux valgus and pes planus treated with a first metatarsal osteotomy relative to patients without pes planus. The minimally invasive bunionectomy has been shown to have equivalent outcomes in patients with and without pes planus. However, in my practice I still reserve minimally invasive bunionectomy for patients with mild hallux valgus and pes planus. If they have a more severe deformity or evidence of first TMT instability then they're definitely getting a first TMT fusion. So if first TMT fusion is best in the setting of first TMT instability some of the other speakers have already talked about this. How do you determine that first TMT instability? So the clinical exam is a little bit subjective but in the really obvious cases I think that it is quite obvious clinically. Often the patient will even see, you can see the base of the first metatarsal kind of shifting dorsally. And on these x-rays here, so on this AP view you can see the slight incongruity at the first TMT joint. And on the lateral view what's telling is the plantar gapping that you see here. So in these cases, these would definitely be cases where I would do a first TMT fusion. This is an example of a patient, 18 year old with symptomatic bunion and metatarsalgia. She also had more general foot pain and knee pain and difficulty being on her feet for a long time which I attributed to her flat foot. So for her, we did a laparoscopic bunionectomy and I did also do a heel slide to address her hind foot valgus. And you can see she had some Fribergs of that second metatarsal. So I did a shortening there and overall she ended up doing really well, much more comfortable spending time on her feet, much less pain. Although you can see that radiographically and also clinically she was still flat. Moving on to metatarsus adductus, which is the worst. So why is it so tough? Well, there's greater than a two times increased risk of recurrence after surgery compared to a run-of-the-mill bunion. There is a 53% prevalence of lesser toe deformities in patients with metatarsus adductus and they're much more likely to have midfoot arthritis than other bunions. So these are all things that can make treatment more difficult. This is a study of patients with metatarsus adductus who were treated with a lapidus procedure compared to patients without metatarsus adductus. They found that patients with metatarsus adductus had greater residual hallux valgus postoperatively. They had a trend towards a higher recurrence rate, so 17% versus 7%, a trend towards higher promise pain scores at one year and a greater risk of needing revision surgery. So overall did not do as well as patients without metatarsus adductus. However, this was better than previous literature on patients treated with metatarsal osteotomy. So you might conclude that for patients with metatarsus adductus, a lapidus procedure could be more reliable than a metatarsal osteotomy. This is an example of a 69 year old female with a painful bunion, also having painful rubbing of her lesser toes. You can see she has a pretty severe metatarsus adductus. So this is a case where I think in order to adequately correct the metatarsus adductus, you have to fuse at least the second TMT joint. So that's what I did here. So you can see the pretty nice correction I got of the metatarsus adductus as well as the bunion. And she did also have that lateral drift of those lesser toes. So this was a perfect case for those MIS osteotomies of the lesser toes. You can see I broke the second and third toes right at the base. We had the fusion of both joints and the osteotomies and here's pre-op to post-op doing really well so far, happy with her outcome. This is a 68 year old male with bilateral painful bunions, obviously pretty severe deformities, lots of metatarsalgia and pain in his lesser toes, asymptomatic pes planus, pretty severe midfoot arthritis, but no pain from it. So there are all kinds of major reconstructive procedures you can think about for this patient. But again, getting back to what's bothering him the most, it's really his bunion, inability to wear shoes and the lesser toes. So I chose to do first MTP fusion for him, gives a nice reliable correction. If you really take care to position that joint in just the right spot, people will generally be extremely happy with this procedure like Pat was also talking about. So we did that first MTP fusion, we shortened the second and third metatarsals. Again, the minimally invasive osteotomies of the lesser toes worked really nicely here. And you can actually see that it looks like the adductors angle is a little bit better from pre-op to post-op. This is the left side, which we did a few months later, very similar procedure. And then ultimately here, the pre-op to post-op x-rays, we really accomplished the patient's goal is getting him to fit comfortably in shoes, less pain with walking. So this was overall a win. So new directions, are we heading towards addressing metatarsus adductors with MIS procedures? So these are some cases courtesy of Holly Johnson. So this is a patient with really severe metatarsus adductus, where she did a minimally invasive lapidus together with distal metatarsal osteotomies. And you can see the radiographic progression from the initial post-op x-rays to six months post-op when they're fully healed. And overall, it is a very nice radiographic correction, a little bit of recurrence by the end, but pretty impressive results. And despite some recurrent deformity at the most recent follow-up, the patient's happy with the outcome, and you can see definitely improved appearance of the foot. Are we moving towards maybe more proximal osteotomies? This is the osteotomies at the base of the metatarsal. Again, like I think it was Pat or Steve who talked about this, but these are really challenging osteotomies to do, I think, and we really don't have data on how these do. So this is an area where I'm very curious to see what the data shows in the future as far as healing rates and complication rates. But just like everything else is headed towards MIS, I feel like this is where we're headed in the future. So my approach for helix-thalagus and associated deformities, just to summarize, lesser toes get addressed if they hurt or if needed to help prevent recurrence. You always want to go MIS if possible. Asymptomatic flat feet get a first TMT fusion unless the deformity is mild with no instability at the first TMT joint. Then I'll do a minimally invasive Chevron and Aiken. If there's significant metatarsus adductus with lesser toe deformities, I fuse at least the first and second TMT joints. I think that's really the best way to get an adequate correction. And if there's limited motion at the first MTP joint, I'll always do a first MTP fusion, especially for patients with more severe deformities and for older age. There's lots of nuance, of course, in all these cases. You really have to consider all aspects of a deformity as well as other patient factors like activity level, age, BMI when decision-making. And of course, it's good to include the patient in that decision-making. Thank you. Thank you, Elizabeth. And thank you again for all my faculty for tonight's excellent presentations. This has been a pretty robust conversation about hallux valgus correction, MIS, and some of the nuances and stuff like that. We are over time by about 10 minutes. I don't see any other questions from the panelists. Again, I wanna thank the faculty. I think we'll leave that open. I invite any of you guys to reach out to any of us. All of us are happy to assist any of you guys, particularly those of you kind of early in your journey when it comes to incorporating MIS techniques in your practice. And again, thank you all for participating tonight.

Hallux Valgus

Open surgery

Minimally invasive surgery

Symptoms

Joint incongruity

Arthritis

TMT instability

Revisions

Complications

Deformities

Patient-specific assessments