Hello everyone. Nice to virtually see you. My name is Jonathan Kaplan. I'm here to talk on minimally invasive surgery of the lesser toes. I'd like to thank the AOFAS for having me and particularly thank all of you for listening. I hope you find this exceptionally helpful and please don't hesitate to reach out if you have any questions at the end of this. These are my disclosures. I do teach on these topics. So to be honest, I don't think that the lesser toes are probably the most exciting topic, but the truth is I'm particularly excited about this because there's a lot of things that we can do and I think that it's just growing and I'm going to kind of go over a bunch of things that I hope will really help change your practice. I'm going to talk about the distal metatarsal metaphyseal osteotomy or what we call the DMMO. Different techniques you can do for hammer toes or claw toes including periarticular osteotomies, PIP arthrodesis and expanding that into the DIP with claw and mallet toes, soft tissue releases, autocorrect varus and valgus deformities with aconects, bunionette deformity correction, and metatarsus seductus, which some of you may be thinking, well, the metatarsus seductus is the midfoot, but the truth is it has a huge play as how we approach forefoot issues, not only including how it's valgus deformity, but lesser toes commonly with those windswept deformities. So why MIS? Well, it's same outcomes, faster recovery. A lot of this comes from our bunion data, but I really think it's safe to extrapolate this to the lesser toes. Patients have less pain, they have less stiffness, lower wound complication rate, better cosmesis, and a quicker return to work. And again, that's for bunions, but I think it holds true with lesser toe deformities as well. I mean, you can see here, I'll try to see if you guys can see the laser pointer, but it's a patient that did a bunion deformity, small incision for the MTP release, small incision for the hammer toe, you can't see one on the bottom, I'll show you that later. And then for the bunionette as well, you can kind of see here and moving over, you can see two small incisions for the bunionette. And this is because they need to screw, which you don't always have to, most of the time you can even get away with one. So first we'll talk about the distal metatarsal metaphyseal osteotomy or the DMMO. And the indications for this, you can do them in isolated metatarsalgia. I think they're especially great when you're doing it with a gastrocnemius recession and metatarsal osteotomies. You can do it for a bunionette deformity, that'll be a separate section in this talk. You can add it to your lesser toe deformity algorithm when you're also kind of addressing claw toes and hammer toes as seen in this patient. For example, this patient came to me, they had a hallux valgus deformity that was asymptomatic. They had a bad experience with the bunion on the other side, so they did not want me to correct their hallux valgus deformity, but they had metatarsalgia pain and had claw toes and hammer toes that they wanted corrected. So the technique is you're going to kind of come in dorsal medial or dorsal lateral to each metatarsal. It really depends on your hand dominance. So I'm right hand dominant. I stand at the foot of the bed. So if I'm doing a left footed patient, I will come from dorsal lateral because my right hand is sweeping. You're doing a supination motion. If I'm working on the right foot and standing at the foot of the bed, I'm coming from dorsal medial for that same reason because of my hand dominance. I'll show you an example, but you want to be at an angle of 45 degrees to the metatarsal in the sagittal plane. And you're kind of doing a supination motion where you're finishing perpendicular to the long axis of the metatarsal. You use a two by 12 millimeter shanaber. Now I was always taught that you must do the second, third, and fourth metatarsal because of the inner metatarsal ligament that would prevent enough shortening. But in truth, I think you can do an isolated metatarsal or you can even do two metatarsals, but I think you just need to expect a little bit less shortening. And truthfully, when I consent the patient, for example, if I have a patient who's coming in with just pain under the second metatarsal, maybe the second and third, I'll consent them for a second and third metatarsal osteotomy with possible fourth. And I'll gauge that intraoperatively based on how everything's lining up. You also want to look at the cascade. No fixation is needed. You can add cannulated screws if desired, but I think this is actually harder than it needs to be. They heal well without any fixation. So in general, I do not use fixation. So I picked this case to show you a few things. Number one, you can kind of see where those metatarsal osteotomies here in the second, here in the third, and here in the fourth. But I also picked this to show you how I can do the plateau corrections where I work through the interphalangeal joints. I'll show you that technique later. I also picked this because in retrospect, I probably should have consented this patient for a possible fifth metatarsal osteotomy. Looking at the cascade, you might wonder, oh, are they going to get transfer metatarsalgia? This is what it looked like when she was healed. This was her standing. So it's a little bit better alignment to the cascade where the second metatarsal is a little longer than the third and the third is a little longer than the fourth and the fourth is a little longer than the fifth. But in general, I think it's never harmful to add things to the consent and you can see really good healing. It almost heals like a fracture, to be honest, where you get abundant callus formation. So this technique with the DMMOs has been around for a good amount of time, and there's been a handful of papers that have come out looking at MIS procedures. I picked this one particularly because I wanted to show a few things. This was by Dr. Kren and also Hans Trinken and colleagues, and they were looking at their first 27 patients in the learning curve. And what they showed was that there were improvements in the PROs, including the SF-12, FFI, FAAM, and the AOFAS. They also looked at pedobarographs, and they showed a significant difference and improvement in the pedobarographs of where they were loading their feet. I picked this picture to show you that 45 degree angle. Basically, you're coming in at that metadiaphyseal junction at the metatarsal neck, and you really want to start with your hand at a 45 degree angle. And then again, do a supinating maneuver where you're ending 90 degrees perpendicular to the axis of the metatarsal to make it a nice oblique osteotomy. This paper I thought was important because they showed, though, that there was a notable learning curve. I think sometimes we wrongly assume that this is probably just a straightforward, easy procedure that has no complications, but that's not true. If you're not coming in at a good 45 degree angle, you can have some very real complications. You may not get good shortening. You can have persistent pain. They showed patients had a malunion deformity. Some had a cock-up deformity, and they even had risk of nonunion. And this may be due to heat necrosis of the burr. If you're not in the bone using the cutting parts of the cutting flutes of the burr, you build up some heat there. My good friend, Oliver Shipper, constantly talks about and has published a paper on the importance of chilled saline as well. I just think it's really important that you be cognizant of the risk of heat necrosis that can lead to some nonunion as well. And I think this is one that's also important to understand that you don't want to make a vertical osteotomy. You need it to be an oblique osteotomy so that it compresses when they're weight-bearing to stimulate healing, and also so that it doesn't get a malunion in the sagittal plane. If you make a vertical osteotomy, you run the risk of them getting a dorsal malunion or even a plantar malunion if they're not walking on it and it heals down. So those are all things that you really want to be cognizant of and aware of. These are a few more papers that I think are really well done. I didn't want to belabor the point for the sake of time, but I included them here for your reference as well. Moving on to the bunion, I mean, this is essentially a DMMO, the fifth metatarsal, so it's a very similar technique to what I just talked about. For indications, if someone has a type 1, you could, in theory, get away with an isolated MIS lateral condylectomy, which, again, you can do minimally invasive, but this is rare in my hands. Most of the time, they're getting a DMMO, and you can do these for type 2 or type 3. The technique is very similar where you're, again, coming from dorsal medial or dorsal lateral to the metatarsal. Depending on your hand dominance, you're using a 2x12 millimeter Shannon Burr. You, again, want to use that angle at 45 degrees and come and finish 90 degrees perpendicular to the long axis of the metatarsal. I think the really nice thing about this is no fixation is needed. You can do a cannulated screw if you want, but the vast majority of these will heal without any fixation needed. I will show you an example of how you can do a cannulated screw and some tips and tricks for that, and I'll also talk about the situations where I will do this. So this is a patient who has a haloxvagus deformity and a bunionette. Both are mild, but their symptoms were limiting them. They failed non-operative measures. I'm going to show you what it looks like. I do want to point out that the fifth metatarsal is already notably shorter than the fourth metatarsal, but you don't really have to worry about excessive shortening. If you're just doing this in isolation, you're using a 2 millimeter Shannon Burr, so you're going to shorten by 2 millimeters, and it usually does not cause issues. And this is what it looks like afterwards, and I really like to always show this image because you can really see all of that very good callus formation. The head literally translates laterally. It's nice and straight and stable, and the patient's doing much better. Here's a good example. There's multiple studies on this, but this is a good example from one of my good friends, actually, and colleagues, Jorge Javier Del Vecchio and his peers. Looking at 74 patients with a minimally invasive bunionette deformity correction, they showed significant improvement in all radiographic and clinical outcome parameters. They had high patient satisfaction, which essentially 99% of the patients said they were excellent, very good, or good. They had a very low complication rate. Two cases of delayed wound healing. They healed on their own. It just took a little longer. Two delayed union, both of which did heal by six months, and one case of heterotopic ossification that required surgery. And I thought this was interesting, but they can form a little bit of bone. Because they form all that callus, they can form a little bone dorsally, and sometimes you have to go in and do a little chiolectomy there. One thing I have not shown you yet, but I want you to note where they're making their incision. So you're making your incision distal to where your actual osteotomy is. Most of the time, what I'll do is I'll actually put my finger over the MTP joint, and then I'll place my beaver blade just proximal to that. That's where my incision is. And then use a spreader to spread down bluntly, and then use the burr. Very good paper. Moving on to fixation. Again, the vast majority of the time, I am not fixing my bunionettes. However, if you felt like you needed to, you can. In my hands, there's a few situations where I will. It's on the bottom of this slide. So number one, if I inadvertently make the osteotomy more vertical. And I think this happens a little bit early on in your training, in your practice. But if your osteotomy is a little bit more vertical, and you're worried about it being unstable, you can put a screw in. Or if you have a patient who has osteoporosis, or vitamin D deficiency, or some form of bone healing issue, and you just want more rigid fixation, a screw can be placed. But you want to be cautious when you're shaving down that lateral cortex, or that lateral edge. Because you can splinter where the screw is, and you can lose your fixation. I'll show you an example of that as well. This is an example of a patient who had a bunionette deformity. Went in, did the osteotomy. I believe they had osteoporosis, which is why I was using a screw. But I like this, because I can show you what I'm doing. So here's where the osteotomy is. You can see that osteotomy right here. Automatically, you can already see that the head is translating. By the way, to get it to translate more, there's two things you can do. Number one, you can simulate weight-bearing, and that head will translate more. Or number two, you can actually put your finger on the lateral edge of the fifth menotarsal and push it over a little bit. But you just want to be cautious in this lateral plane. Make sure you're not dorsiflexing or plantar flexing it. So here's the osteotomy. I will get my starting wire in, where I'm going to place my screw. You want to be more proximal than you think, because you really want to give yourself as much bone in that lateral cortex to avoid screw failure. And then what I like to do is percutaneously put a small K-wire down the medullary canal, and you can see that that really shifts the head over more. You can see it really brings it in a little bit more, and also holds it in place, so you don't have to hold it while you're advancing the K-wire for the screw. Then I'll advance that K-wire across. What you can't see here is oftentimes I'll place my thumb in either my index or my middle finger on the metatarsal head dorsally and plantarly, so as to avoid a dorsal or plantar malunion when I'm placing this pin, because sometimes it wants to push it. Sometimes you'll even see it wants to tilt it medially or laterally, so I think this helps control it. Once I've done that, I'll place my screw. Again, being cautious not to be too distal. Usually you want to take a few millimeters off your measurement, and then I'll shave that lateral cortex to avoid any bone prominence. But again, you want to be very cautious with this, especially in those osteoporotic or vitamin D deficient patients. Don't get overzealous on this. This is what it looks like, where you can see a good shift, good screw fixation, and a nice smooth contour, that lateral aspect of the metatarsal. And this is the lateral view here. And this is our post-operative radiograph showing that this patient has good bony healing, and on the side you can receive really good oblique osteotomy, good bony approximation, and good screw fixation. So this is a case of screw failure. I wanted to show you this just so that you're really cautious of this patient who had a bunion deformity. I went in and did an osteotomy. On the AP view, it looks good. Looks like there's good shift. But then on the lateral view, you can see that that screw basically splintered, and it happened post-operatively. Intraoperatively, there was good alignment. It was right in the middle. But post-operatively, when they're walking, which I let all my patients walk, but it's probably because of being a little overzealous, and that resulted in not having a good bony bridge there for the screw, and it probably splintered out. If this happens, don't panic. I still let them weight bear. It still heals. It heals like a fracture. So you wait it out. Let the bone heal. And then at a minimum, you go in and do a hardware removal. Sometimes they'll have that heterotopic ossification. You can shave that down and do a chylectomy. On rare occasion, if they get a malunion, you can revise it. But most of the time, you don't need to do that. So moving on to hammer toes, this is a procedure I particularly like, periarticular osteotomies. And I'll do these for semi-rigid or even a rigid deformity. And what you're essentially doing is you're doing a plantar closing wedge of the first proximal phalanx, as seen here. And you're doing a dorsal closing wedge osteotomy of the second or the middle phalanx. And you're basically doing these periarticular osteotomies. And I'll talk about the soft tissues as well. In general, when I'm doing the first proximal phalanx osteotomy, as you can see I'm describing here, I'll make my incision plantar to the P1 at the metadietasial junction. I use a snap to spread down to bone, really moving the toe flexors out of the way to protect them from the burr. And then I'll do my plantar closing wedge osteotomy. The middle phalanx is easier to do. You just make a small incision with the dorsal aspect in the middle phalanx, and then you use the burr as well. You can add a biplanar wedge if you need to correct varicevagus deformity. In general, the teaching is that you don't need to fixate these, that you can do toe strapping. Although I tend to lean more towards a K-wire, because otherwise you have to toe strap the patient. Sometimes you have to see them weekly for four or six weeks. And I like a K-wire because it just avoids me having to strap them over and over again and inundating my clinic with these dressing changes. Don't forget the soft tissues. I'll use a beaver blade. You can do almost all of this, if not all of it, MIS. So you want to do an MTP release dorsally, as you can see here. You do a PIP release plantarly, as you can see here. And I'll use the beaver blade to also release the FDB as well. If needed, you can release the EDB above the MTP joint. I will oftentimes do that. And then you can do an EDL lengthening. I like to do these mini open because I like to do a Z lengthening. I just feel like you get less comments from patients about their toe being floppy. If you do a percutaneous release, technically it doesn't go full floppy because it scars down the holes. You haven't disrupted the adjacent soft tissues, but I just feel like it's a little bit better control and I can dial it in. This picture, by the way, is from a phenomenal article from David Redfern and Joel Vernois, people who I owe a lot of my MIS experience to, talking about percutaneous surgery for metatarsalgia in the lesser toes and foot and ankle clinics. So I highly recommend it. So this is the technique. I'll mark out where my incision is going to be radiographically because you want to make sure you're in the right spots. And then I'll make my incision. I spread down the bone and I place the burr in, check and make sure I'm at that metadiaphyseal junction. It's hard to see. So I marked it out with the red line here. I'll do the same thing over the middle phalanx, do my osteotomy again, check it before I complete my osteotomy. And then I like to advance the KOR down the medullary canal and tuck it. Then you can see preoperatively versus postoperatively the correction of the hammer toe deformity that you get with this. Moving on, you can also do interphalangeal joint arthrodesis with this, the PIP arthrodesis. This one's pretty straightforward. You can come in from dorsal, you can come in from medial or lateral with the burr using a two by eight millimeter Shannonburg. This is important because the working part of the flutes are inside the bone. So you protect the adjacent neurovascular bundle. And then you resect the joint surface. You irrigate with irrigated debris. Again, you do your soft tissue releases. A lot of times I'm doing my soft tissue release before I'm doing the bony work. And then I'll fixate it with a KOR as well. Some people will place a screw. If I'm just doing a PIP arthrodesis, I tend to stay away from the screw just because if they get an adjacent mallet deformity down the road, then I'm not having to work around a screw. But I don't necessarily think there's anything wrong with that. I think this works great for claw toes and mallet toes. You can do PIP and DIP arthrodesis. This is an example of a patient who I did their second through fifth toes. They had claw toes after a calcaneal fracture, whether related to from scarring or the flexors from the injury or from the surgery, or even possibly a compartment syndrome. But they had these toe flexors. Assuming they had these toe flexion deformities, pretty significant severe claw toes. Went in, did it all at my ass, and did it with screws. And the patient's recovered very well with this. So another cool trick for lesser toes or varicose and valvular deformity corrections are what we call akinet corrections. I like these for mild and moderate deformities. You can do them on a severe one, although you're not going to get as much of a correction. You use a two by eight millimeter Shannon burr, and you come in from dorsal medial or dorsal lateral to the P1 metadiafasal base. And you really just preserve the far cortex and then lever the toe closed. Similarly, you can do toe strapping or K wires. They tend to heal very, very well. This is an example of what it looks like a patient had a hallux valgus deformity and windswept second and third toes. Correct the hallux valgus deformity through MIS PICA technique and then second and third akinets. And you can see that it's just much better improved. Are the toes perfect? No. And I also tell patients it looks goofy on radiographs, but their toes are nice and straight and they fit well in shoes. And that's all they really care about. And they're very happy with this. This is a good paper coming out of Dr. Ray and colleagues. And they looked at 40 patients in which they corrected a valgus second toe deformity. They showed a significant improvement in the second toe valgus angle. They also showed 91% of patients were extremely satisfied or satisfied. 100% union rate, no wound issues and two radiographic recurrences. And in my hands, even when they do recur, patients tend to still be very happy and do well. Another technique you can do is a long oblique proximal phalanx osteotomy. I think this is technically more challenging because you're trying to come long obliques through that proximal phalanx, which is this very small bone. But you can do this in a mild, moderate or severe deformity. You can get shortening if you want to as well. So sometimes patients have those long second toes. They want you to shorten them as well. And this allows you to shorten a little bit more. You're similarly using the two by eight millimeter shanaber similar approach. And then again, you can strap it or K-wire. This is what it looks like a patient who had an open hallux mtpr throdesis, but I did second, third and fourth DMMOs. I did a second and third P1 oblique osteotomy and I corrected the fourth and fifth toes to the interphalangeal joints. This is what it looks like when they're healed. Abundant callus formation on the metatarsals, good formation, good bony formation on the proximal phalanx. A little recurrence in the fourth toe, but overall she was very happy. And then last but not least talking on MIS metatarsus seductus. And there's a few things you can do for this. I'm particularly really interested in this technique because I think it will evolve and how we approach a lot of forefoot issues. You can do lateral closing wedge osteotomies in a mild deformity. If it's moderate or severe, you can even add a bit of a translation with the closing wedge to really dial that in. And the technique is you come in dorsal lateral to each metatarsal base and really just work your way from the second to the third to the fourth. And you really do this before you actually correct your hallux valgus deformity if you're doing a PICA technique or a lapidates because it gives you more room for the bunion correction. This is a patient who had a hallux valgus deformity as well as these windswept toes and they're setting a metatarsus seductus. They had previously had their other MTP joint fused. So they wanted me to fuse it, which works really well. Truthfully, I had no problem doing that. But then I did the second, third and fourth metatarsal basilar osteotomies. And you can see here, so here's the second, here's the third, and here's the fourth below this. I picked this because I also want to show you, you want to spot check on radiographs and have caution because sometimes you can get into the adjacent metatarsal as you're sweeping across, but they tend to heal very well. And I also did second, third and fourth DMMOs and lesser toe hammer toe corrections as well. This is the oblique showing where the actual fourth metatarsal osteotomy is as opposed to where I kind of violated that butyl cortex in the fourth metatarsal. And I picked this image, this is the pre-op and post-op where you can just see the drastic difference where you really get a good metatarsus seductus correction. You get the DMMOs that line up a little bit better and then the lesser toes that are lined up really well. And this patient was really happy, did it all through small incisions. For those of you who say that the deformity is in the TMT, or maybe the patient has arthritis of the TMT joints, well, you can do this through the metatarsal, through the tarsal metatarsal joints as well. This is a patient who had very mild metatarsal seductus, but they had, they had tarsal metatarsal arthritis as well as the bunion. And so I went in and did a hallux vagus deformity, but I did a percutaneous second and third TMT fusion and a fourth metatarsal base osteotomy. Very similar technique with a two by 12 millimeter Shannon burr. And then I'll fixate the fusion with screws percutaneously. And this is what it looks like. These are her clinical photos where you can see the biggest incision is actually the small incision we use for the lapidus nail, whereas everything else has been very small and nice and straight. This is an example of what it looks like if you want to just use screws as well. Again, very small incisions, whereas these used to be very, very large incisions. You'd have to make, if you wanted to do a first TMT and second and third and fourth work, you may be making a large medial incision, a large dorsal midfoot incisions, and it's just way less soft tissue disruption. This is an example from Chris Miller because he's so much better at taking clinical photos and I don't always remember to take them. So thank you, Chris, for this. A 68 year old female who had pain over the hallux vagus deformity, lesser toes is kind of classic metatarsal seductus, bunion, wouldn't stop toe deformity. And this is what he did. And it looks good. And you can see clinically, you can see very nice alignment to the toes. Did a PICA or first metatarsal and first proximal pharynx osteotomy technique. And then metatarsal seductus, metatarsal osteotomies, and these aching and deformities and everything looks good. To be hypercritical, you usually want the second metatarsal osteotomy. You probably want to be just a touch more proximal, but overall, good example of how it heals very well. These are my references. I'm happy to send you guys any of these if you want them. I also have a lot of clinical and intraoperative images and photos, but for the sake of time, I did not include them. Thank you all for listening. I hope this was tremendously helpful for you. I want to say that these minimally invasive techniques have not only changed my practice thus far, but I really feel like they're going to continue to do that and just help us improve our outcomes for our patients and minimize complications. So thank you very much. And this is my family here, my wife and my son, and we have another one on the way. So thank you very much.

minimally invasive surgery

lesser toes

distal metatarsal metaphyseal osteotomy

periarticular osteotomies

soft tissue releases

bunionette deformity correction