CME OnDemand: Surgical Correction of Lesser Toe Deformity-Surgical Correction of Lesser Toe Deformity

Surgical Correction of Lesser Toe Deformity

Video Transcription

All right, thanks to the AOFAS for letting us do this webinar and thanks for everyone for signing up and being here.  We got some really great speakers today and we're going to talk about a really complex issue being the lesser toe deformities.  We're going to listen to some talks and then hopefully we should have plenty of time for questions and discussion at the end. So please put those questions in the chat.  The first speaker is Dr. Christopher Miller. He's at Beth Israel in Boston. He did his residency at Yale when I was a resident there.  So I have a lot of stories about him that I can't share here, but maybe some other time. And he did his fellowship at Brigham and Women's.  So let's just get right into it and take it away, Chris. Thanks Paul. I'm always nervous when you're introducing me.  So I was tasked with talking about minimally invasive lesser toe correction. So we'll get right into this. Okay.  So I know Jim's going to talk a little bit more about some of the anatomy, but clearly whenever you're talking about and thinking about minimally invasive procedures, understanding  kind of how these tendons work and function is even more important than when we're doing an open. And that's as always critical and without belaboring too much, but we have to worry  about what's holding the toes in proper alignment at each of the different segments. And then what's happening statically and dynamically.  And we know that the anatomy is complicated. And I will be the first to admit that in my residency and fellowship, my eyes were sort  of glazed over when I looked at some of this stuff. And as I've gotten more into the MIS world, I think having an understanding of what's  happening with these different muscle groups becomes more and more critical. And hopefully you'll get a sense of that.  And it's not just how it's supposed to work, but how are these structures then functioning as we start developing deformities and malalignments of the joints.  And so as an example, and I'll be talking mostly about hammer toe corrections here, because we only have about 10 or 15 minutes, but as we think about it, a hammer toe is  often sort of where you have overdrive of the extrinsics muscles. And if in a hand comparison, it'd be more of a intrinsic minus type problem.  And you have, as the toes start deforming, your interossei will sublux dorsally become more of a dorsiflexors. The long extensors will become plantar flexors at the PIP joints.  And then the lumbricals, which are trying to hold everything straight, become much less efficient because they're being forced around the transverse ligament plantarly.  So if you've listened to any MIS talks, I'm sure you've seen some of these pictures here. And what I like about this one on the left is that it tries to explain in a diagrammatic  form, what's happening to the muscle forces as you develop more of a hammer toe deformity.  So as the MTP dorsiflexors, your long extensors become primarily extensors at the MTP joint, and they lose their function more distally.  And at the same time, as you get that contracture coming up, your long flexors will start holding and clawing down to strongly flex distally.  And this is going to help give that some of that deformity we see on the right there. And we know, and I'm sure we'll talk about hammer toes and open surgeries here, but this  is what most of us are familiar with. And this is what I learned in residency and fellowship. And it works reliably, and it works in a lot of different ways.  And what I would point out is, before we get into sort of the weeds of the MIS world, you can do this with a minimally invasive approach.  And so this is just a quick case I like to show. But this is a patient of mine who had CRPS and then developed, had a spinal cord stimulator placed.  And afterwards started getting these contractures in the foot and ended up with a hammer toe deformity, which you can see here.  And so from a MIS perspective, I started with an Aiken, I moved it over to make a little bit of room. And then I came in and I just resected the joint with the burr.  And so for the two, second and third toe, I resected the joint, small incision for that. And then I pinned it percutaneously, drilled over the top.  You can't measure directly, so I just hold it up next to it. And it's usually in the mid-20s range. And then place it right across and hold it.  And so you can get your MIS fusions for both the second and third quite reliably. And you end up with incisions that look something like this.  So you don't have to change some of what you're used to doing, but you can start doing it with a more of an MIS perspective if you want to. So you can do the same surgery.  You can just do it with this approach. And so I like to throw this out there to say, you don't have to get into the weeds with this if you don't want to.  This can work very nicely, as it did with this person who already had CRPS and I wanted to avoid any incisions on her.  But as I like to say, you know, this is the part that for me was very complicated to understand.  And probably the last step of the journey for me to get to the MIS surgeries that I like to do now. And I encourage everybody watching, take a screenshot of this one.  This is a great paper. I think I read it four or five times before it started to make sense to me. But a lot of what we're going to talk about next is written in here.  So I'll just leave that up for a second and then move on. So this is where this came from.  This, again, shows the deformities that we experience and what happens with our muscle balances as we start developing a hammer toe.  And then this one starts showing what we can do to try to correct the hammer toe deformity with an MIS perspective.  And this was, I have to applaud the international MIS group, MIFAS, and particularly Miki Palmo at Barcelona for his anatomy on this and research on the anatomy of the toes,  because it really shows what you can do in terms of percutaneous releases of tendons and ligaments, as well as bony osteotomies. And I'm going to go through some of these now.  So the other thing that you'll see as we're going through here is that there are certain themes when it comes to looking at MIS approaches to hammer toes.  And what I would say is that we start with a sort of rigid or flexible component. You're going to talk about either soft tissue releases or osteotomies.  And I would say in general, as you can see with this flowchart here on the on the right from the same paper, if you have a flexible deformity,  they're going to argue that you should start with a bony correction, a bony osteotomy.  Whereas if you have a rigid, you're going to start by releasing and trying to create a flexible deformity and then proceeding with your bony corrections.  And if we run down this quickly, if we start with the hammer toe up at the top, if you have a flexible, mild, moderate deformity,  they would argue for a osteotomy at the base of the proximal phalanx.  If you have a more rigid deformity, the first goal is to start with a release of the PIP joint and then convert to flexible.  And you move down as you move down as in terms of how much deformity and what you have to do.  And I would point out that they still argue that if you have a dislocated MTP joint in an active person for them, that's going to be an open procedure.  So despite loving minimally invasive surgery, you can't forget your open procedures. I'm always excited to hear Caitlin and Paul talk about open repairs for the plantar plates.  So if we start talking about the soft tissue releases and this was quite a tricky one for me to learn, but the idea for this is if you have a rigid contracture at the PIP joint,  you can selective release both the plantar plate at the PIP as well as the short flexor. And you can see in the bottom right picture here,  there's a space underneath the proximal phalanx where you can pop underneath that bone and release the plantar plate and the tendons to allow the toe to become more flexible.  And you have to get both slips of the FHB tendon there. Sorry, FDB tendon. So in my experience, if it's sort of mild, moderate, rigid, there's a little bit of flexibility.  I'll go with this. If it's very severely rigid, I'll go straight to a fusion, as I showed you before.  So what does this look like? So this is trying to convert a semi-rigid hammer toe. And so here you can see I'm unable to fully, even by reducing the proximal phalanx,  I still have that rigidity at the proximal, at the PIP joint.  And then here I've done my release, I've done the small incision here, swept my beaver blade underneath the proximal phalanx to the middle phalanx,  releasing the plantar plate, and now the toe will sit straight. What that looks like when I put it down, as I bring it down here, I can have that toe sit much straighter.  And as I look at this now, I think I could have even done more release.  I try to actually get a little hyperextension at the PIP joint. And that's where I know I've done a sufficient release there.  So that's your PIP release. You can do a MTP release as well. Again, I'll use a beaver blade for this.  And you can either selective release just the dorsal capsule by taking the beaver blade underneath the tendons.  Or if I think I need to release those, I can go straight through those, cutting both either the EDL and EDB,  or selectively, as long as you know that the EDB is going to be more laterally.  And unlike with the open, and I remember doing many open hammer toes, you come in, you find your EDL tendon,  you put the snap underneath, you strip all the soft tissue attachments to it, and that's the extensor hood.  Then you do your Z lengthening, and the proximal thing always will zip up into the middle of the foot.  If you don't take the extensor hood off, it'll lengthen, but it'll stay relatively close proximity. And therefore, you can regain some of that motion back.  And so this is what it looked like in a recent case of mine. And there was sort of this gossamer hood holding that in place.  And so if we cut that, it only separates, you know, five millimeters or so before stopping.  Then we start talking about the lesser toe osteotomies, and this is where it starts getting a little more interesting,  because it lets you customize what you want to do to try to correct each deformity at each level of the toe itself.  So unlike with a more traditional open, where you're going to do a resection arthroplasty or effusion,  and you're sort of looking at the toe as a whole, and you're just going to make it straight with the screw or the K-wire,  this lets you look at each different segment, whether there's rotation or, you know, medial lateral deviation. And you can correct each portion of it with the different osteotomies.  And so at the P1 osteotomies, you can create a planar flexion, as you can see in A. You can do a medial lateral deviation. You can do shortening if needed.  And if you need to derotate or get more short, you can do a bicortical osteotomy so that you actually have a complete fracture there.  And then more distally, if you still have some residual planar flexion that you haven't been able to correct with your PIP release,  you can go ahead and do a dorsiflexion osteotomy as well. And I'll show you some examples of this. So how do you do it? First, I feel for the metatarsal head.  I come about a centimeter distal, and then I'll pop in through the skin. You can see it still looks like you're kind of in the foot here,  but the proximal phalanx on the plantar side comes quite a bit into the foot itself. And then I'll create that planar flexion osteotomy that you see in the top right.  I'll do that after I release my PIP if needed, and then I can do a dorsiflexion of the P2.  And the goal here is that once I've restored this, as long as I haven't cut my EDL, I can hold that in line.  And now, instead of just pulling up at the MTP joint, it's going to help extend through all of those joints and osteotomies, help hold the toe straight as it heals.  So what can we tell you from the literature here? There's not a lot, as many of you no doubt know, but this was from Barbara P. Clay in 2015.  57 feet, 98% happy with cosmetics, 80% in terms of pain. And interestingly, most of them were able to retain some active planar flexion through the toe.  They were able to grip the ground. And even though 74% had some rigidity pre-op, only 12% had it post-op, and only a quarter of those went on to a revision fusion.  This was a study looking at open versus MIS techniques. And you can see similar rates, a little bit lower for toe infections of percutaneous group,  but no pin issues, no deep wound dehistances, and less scarring. Interestingly, this did report a higher rate of impaired wound healing.  When you look into this, this was really a reflection of the fact that with unfixed osteotomies, you have more swelling of the foot and more hematoma,  and they were counting that against the percutaneous group. But that is something that you do have to counsel your patients on,  that their foot's going to be swollen for several months after this type of procedure. And then in terms of trying to demonstrate the customizability of this,  so here's a case where a patient had more of a curly toe, clonodactyly-type position. You can see that trapezoidal P2 of the fourth,  and they were able to correct this with a simple osteotomy coming in from the lateral side  and just closing it down, making the toe straight without any K-wire fixation or big open incisions. And so for me, things like this is what makes it interesting,  trying to figure out what can I do at each level of the toe to make it straight, whether it's bony correction or soft tissues. Dressings, critical, and if you go to a course,  they should spend a good amount of time trying to show you how to do this because this is what's taking the place of the K-wires. You have to find a way to strap it intraoperatively  and then routinely post-op every one to two weeks for the first four to six weeks. So you may save some time intraoperatively, but you do take more time in the post-op care,  bringing them back to change these dressings. And one of the things I will often use is a sort of toe putty splinting  once they've gotten out of the acute phase to help hold it for a little bit longer. And this tends to work nice. They can take it on and off themselves and clean their foot.  So a couple of cases I wanted to show you. So this was a second and third toe. The second was rigid. So we started, and this is where we got it to,  but we started with the FDB release at the PIP joint. I did a bicorvical osteotomy of this proximal phalanx and the dorsiflexion of the second with an MTP release,  but I left the tendons intact. And then for the third, because it was flexible, I only did the P1 osteotomy to have that sit down straight. And this is where she healed.  I did do some DMMOs as well, which I won't talk about here so much, but it shortens the metatarsals. It's the MIS version of a while procedure.  And so she healed like this and ended up quite happy.  This was a little bit more complicated. So a bunion with a ductus and some windswept toes.  And so we corrected the bunion with a MIS procedure. I did proximal metatarsal osteotomies to correct the metatarsal ductus,  release the collaterals, and then what I call these aconets to make the toes straight, even though the bones themselves are a little bit wonky looking there.  And this was her other side, which she has since signed up to get fixed. I think in the new year.  So arthritic bunion here, we have some crossover toes and struggling with both pain and the toe deformity.  So I fused her first MTP with the MIS. We did DMMOs to shorten. And then you can see these sort of aconets go in the opposite direction to make the toes straight.  And then I'll show right here, I put a little retention stitch in the lateral aspect of three just to help hold that correction as we were going.  So why do this? For me, I like it because my patients have less pain, they have less wounds, they do have more swelling.  And I have a lot of different options in terms of trying to correct the deformity. It's not a simple, you know, hammer toe or claw toe. I can deal with rotation.  I can deal with the windswept toes and the varus and valgus deformities if needed. I don't use pins very often, although there are some people who may be here who do.  And many of my patients are still able to sort of grip the ground, which I think for my older patients is helpful for balance.  And I often found that they were unable to do that when I did the fusions, particularly if I did it open. So sort of in summary, I would encourage you guys to look at this.  This has a nice flowchart to understand the thought process on how to go about correcting these hammer toes, depending on how deformed it is and where the deformity is.  Barbara Preclay has another article here where she has a similar flowchart and tries to explain her rationale for correcting the toe and looking at the deformity of each segment.  So I thank you and I appreciate the opportunity to talk. And I hope you guys all join the MIS train as well, because there's a lot out there and it makes your patients happy.  Thanks, Chris. That was great. And while Dr. Neri is getting her slides set up, there's a question that was put out there. Do you ever get vascular insults with MIS surgeries?  I haven't yet. So I haven't had any white toes. I think if you're not putting fixation in there and you're doing the osteotomies,  there's going to be enough sort of wiggle in the system that you're not going to kink off the artery, as I saw sometimes with more open procedures. But I haven't had it yet.  I do know some friends who've had some temporary vasospasm and that's gone away with a little bit of time and some nitro paste.  Time and nitro paste. All right. Sounds good. Well, so the next speaker is Dr. Kaitlyn Lukes in Boise, Idaho. She did a residency at the University of Nebraska  and her fellowship at UC Davis. And she's going to talk to us about plantar plate surgery.  All right. Thanks, everybody. So thank you for that introduction. I'm Kaitlyn Neri, like you said.  I practice in Boise, Idaho. And I've been granted the opportunity to discuss open plantar plate surgery, which, Chris, that was an incredible MIS talk.  And I agree with you for the right patient. It's pretty amazing what we can do with minimally invasive approaches to lesser toes.  But there are certain patients that are just going to benefit from a more open approach. And, you know, it's hopefully I can give some tips and tricks  for how to get the toe to stay down and improve MTP stability. But we all know that can be a bit of a challenging thing. Let's see, I'm trying to get my slide. There we go.  So here are my disclosures. So when I think of my personal experience with hammer toes and MTP stability, truthfully, it's been a bit of a process and really a learning experience.  I think that at least for me, sometimes I felt like I did everything right in the operating room. I left the operating room with that toe perfect.  And the patient would come back sometime later with a recurrence of deformity. And it was frustrating. And at some point along the way, I decided to really tackle this head on  and figure out how to be better and really improve the odds of MTP stability. And while doing that and really being introspective about what I was doing,  there was a few lessons I learned that I think are really important. The first of which is the trick to long lasting lesser toe correction  is you really have to address both the coronal and the sagittal instability. They occur hand in hand and you can't address one without addressing the other.  And I think that's really important. The second lesson is you have to have a systematic approach to lesser toe malalignment. So you come up with your system  and you approach the toe the same way every single time. Thirdly, the plantar plate matters and it just can't be trusted. It was bad tissue before. It's still bad tissue.  And so I would strongly consider augmentation and we'll talk about that. And finally, there is a little bit of Jesus take the wheel with lesser toe surgery.  They just have a mind of their own sometimes and you can do everything right. And that's just part of lesser toe surgery is even with the perfect surgery,  sometimes these will recur and that's okay. As long as you have other tools in your tool belt, you can still get the toes straight. So just in terms of general concepts,  thinking about the MTP joint, and this is very general, but this is how I think about it and how my mind works. When you're thinking about satchel stability,  for the most part, this is provided by the plantar plate and with chronostability, this is mostly provided by the collateral ligaments. Now, once again, this is a bit fluid  and I'll show a slide here in a second to prove that, but at least to keep things simple, that's how I think about it. And when these static stabilizers fail,  that's when you get an imbalance of the intrinsics and extrinsics, like Chris just went through, and then you end up with the toe deformity.  So in order to address the plantar plate in an open fashion, you have to understand the static stabilizers of the MTP joint. But fortunately, they're pretty darn simple.  The toes obviously have collateral ligaments medially and laterally. There's a proper and accessory collateral ligament that provides your chronostability.  And then the plantar plate runs along the plantar aspect of the first metatarsal head and inserts onto the base of the proximal phalanx. But if you only take one thing away  from this portion of the webinar, it's this, and that is that both the plantar plate and collateral ligaments are part of the problem. And it took me a while to really realize that.  And a lot of times, I would just try to repair the collateral ligaments, not do anything with the plantar plate and hope the toe would stay down and it wouldn't, and vice versa.  And this is a great webinar by David Macias where he showed a sawbones version of the MTP joint. But you can really see if you've got a floating toe  or a crossover toe, a hammer toe, it's not just a plantar plate problem, it's also a collateral ligament problem. So when we think of the umbrella of MTP stability,  not to belabor the point, but we do have to address both the sagittal and coronal planes. But for the purposes of this talk, I'm going to focus mostly on the plantar plate.  So why are we here? Why are we even talking about this? And it's because in the past, we never really treated the problem.  We did a lot of non-anatomic indirect repairs. I fell into this camp. I was doing the same thing, doing while osteotomies and hoping that that would decompress the joint enough  to let the toe sit down, pinning across the joint when the toe remained unstable, flexor to extensor tendon transfers, all those things. And those can be successful,  but not as successful as we'd like. We've found through study after study that there's a high rate of residual deformity and a high dissatisfaction rate.  And so that's what really progressed us to where we are now, where we've realized we really have to tackle the problem head on. And this is through doing anatomic direct repairs  of the static stabilizers. And with our improved knowledge of the anatomy around the MTP joint, as well as advancements in our techniques and instrumentation,  we can really directly treat the process that's pathologic and as a result, have a higher rate of success with the surgery and really improve the stability of the MTP joint.  So what are the indications for an open plantar plate repair? And I'm glad that Chris alluded to this.  We now have a lot of ways to do this. You can get the toe down through open approaches, you can do MIS, but just because you know how to do one or the other  doesn't mean every patient's gonna fit into that category. And so I try to still be really mindful of who I'm using MIS for and who I'm using open approaches.  So at least my indication for an open plantar plate repair is a clinical exam that's consistent with a painful plantar plate tear and instability of the MTP joint,  some degree of malalignment.  And of course, confirming the tear of the plantar plate intraoperatively, but I think it's really important that I bolded and put painful in red because for me to do this open,  the patient has to prove to me that the plantar plate really is symptomatic. This isn't the elderly patient coming in with a crossover toe that they're just complaining  of rubbing on shoe wear over the PIP joint, but really the toe itself doesn't hurt otherwise. That's gonna be for me a perfect MIS candidate, but I just saw a guy today that came in  and he said, I hurt right here and points to the plantar aspect of his toe. And when I do a drawer exam, it's really painful and he's got a plantar plate tear confirmed on him.  He came with an MRI. So that's somebody who's I think gonna benefit more from an open approach. I do have one major contraindication, which is an arthritic MTP joint.  If you do a plantar plate repair in an arthritic joint, you're just gonna leave the patient with a more stiff and more painful joint. So what is at least my general approach?  And I decided to use this patient as an example for how I approach plantar plate repairs. Obviously, she's got a pretty severe  hallux valgus deformity, rigid second and third hammer toes and dislocated second and third MTP joints, which of course puts the red flag up for plantar plate pathology.  So whenever I'm planning on an open plantar plate repair, I really have two systems available or two different instrumentation sets available.  The first is some type of plantar plate repair system. Whatever you use to repair the plantar plate, of course, make sure you have that equipment there.  But I also bring ligament augmentation to every single case because you never know what you're going to find. And I had to learn that the hard way,  but you never know what the tissue quality is going to be like. There's even gonna be plantar plate tissue remaining to repair those types of situations.  And so you've got to have some suture augmentation available. I do a dorsal approach every time. I know plantar approaches have been described and utilized,  but I think going dorsally makes it very easy. And you can, of course, do all of your other simultaneous procedures. I do a while osteotomy on everybody.  And I know there's a lot of talk about if you shorten the toe too much, what that can also do to the stability of the MTP joint, to the flexion power, et cetera. But what I'll do,  I think this is important to gain access to the plantar plate. I think it's really hard to get to the plantar plate without shifting the metatarsal head.  And even if you can get to it without shifting the metatarsal head, you're only able to access that distal tissue that's really attenuated. And so even if I don't really plan  on shortening the metatarsal, I'll still do a while to get access to the healthier, more proximal tissue. And then at the end, you can always translate the head back distally  and fixate it in a better position. You, of course, want to gain access to the MTP joint. Some type of joint distractor can be really beneficial.  You get a great visualization of the plantar plate, as you can see here in the picture on the right. Now, of course, what we hope is that you get in there  and you see this, where you have really healthy, at least semi-robust tissue to repair. But in the case of the patient that I'm using for an example tonight,  this is what I saw when I got in there. You're looking straight down to the bottom of the joint, no plantar plate tissue remaining, and you're staring straight at FDL.  And in the past, this would have been a toe I would have just bailed, maybe done a non-anatomic indirect repair, or even pinned across the joint.  But as long as you've got your ligament augmentation there and available, there are other options to do more of a direct repair, and I'll show that in a second.  If there is tissue remaining, you then locate the remainder of the plantar plate or release the remainder of the plantar plate off the base of the proximal phalanx.  From there, you're going to pass sutures through the plantar plate. There's various passers available. I really like using this luggage tag type stitch. You can really cinch down  and get good purchase of the ligament  and it's also really important to get as proximal as possible because the more proximal you get, that's usually where the healthier tissue is to grab with the suture.  Now, in a case like this, where the plantar plate is absent, you can still do an augmented direct repair, at least to some extent. And you can do that  if you have ligament suture augmentation available. The way I do it is I actually drill an accessory tunnel more proximal to where I'm holding the myelosteotomy in place.  You can see that with the more proximal wire here.  And I aim it obliquely and you want it to exit just plantar to the articular surface so that it's easy to fish out your suture. And it makes it much easier to do that.  I'll show you in a second. I'll drill over, give myself a nice guide tunnel. And from there, you're going to loop over your suture augmentation and pass it from plantar to dorsal.  And it's important to make sure that through the metatarsal, you're passing the looped end of the suture because you're going to use that towards the end of the procedure.  And so you can see a good picture or a good video of that here. You want to pass the suture augmentation plantar to the plantar plate,  but superficial to FDL so you don't bind up the tendon. And you can see what that looks like once your suture augmentation has been passed. At that point, then you're going to prep  the proximal phalanx in the same fashion. And you just run another oblique wire. You want it to exit out, just plantar to the articular surface. I know there are other techniques  that have been described with two drill tunnels, cross tunnels, there's all sorts of ways to do this.  And really you can do it however you prefer. I prefer one central hole in the proximal phalanx. I think it just makes the procedure so much simpler.  And as long as you keep that hole in the center of the proximal phalanx, you're not going to kick the toe into internal or external rotation. You then drill your guide tunnel.  And from there, you can pass the two free tails of the suture from plantar to dorsal through the proximal phalanx. Also, if you've done a direct ligament repair  and you've got suture through your plantar plate ligament, those also can be passed through the same guide tunnel. It can be tight, but you can get it, I promise.  And at that point, you've got all sutures ready to go through both the metatarsal and the proximal phalanx. Then at that point, if you haven't already fixated your while osteotomy,  do that. And you can really get a good sense of, this is what an augmented plantar plate repair looks like. So you have the ligament augmentation  coming through an accessory guide tunnel in the metatarsal. You can see here, the suture through your plantar plate, as well as the suture augmentation  passing deep to that plantar plate. And then finally you have all sutures through a single drill tunnel in the proximal phalanx. So this is what sold me.  And this is what I think has really made a difference in my practice with open plantar plate repairs is you can actually now set the resting tension of the toe  and the motion limits separately. And what I mean by that is you're going to set the tension of your actual ligament repair separately from the tension of your ligament augmentation  or your suture augmentation. And this really helps because in the past, at least for me, when I was not augmenting the repair,  I always felt like I had to really plantar flex the toe and fixate the toe and plantar flexion just in case the plantar plate repair stretched out.  But if it didn't, then patients ended up with a stiff toe and a stiff MTP joint. And so what I'll do is I'll actually set the resting tension of the anatomic ligament repair,  place a biotinodesis screw in the proximal phalanx as you can see here, and not even worry at that point about the tensioning of the suture augmentation.  And then it's your suture augmentation fixation, which is going to be in the metatarsal where you really set the max limits of motion of the toe.  In other words, how much dorsiflexion do you really want to give the toe long-term? So here you can see, instead of plantar flexing the toe,  I just hold it right at neutral alignment. I pull tension on the suture repair. I don't worry about my ligament augmentation suture.  It's only the anatomic sutures through the plantar plate. And you can really just set it at neutral alignment, which is where we want the toe to sit,  not tensioning and plantar flexion. And at that point, then I'll hold with one hand, I'm going to set the max limits of motion of the toe. So I'll say, all right,  how much dorsiflexion do I want to give this patient? So I'll set the toe at 10 degrees, 20 degrees, whatever I want to give the patient in terms of motion.  And then with the other hand, I'll water ski on that looped end of the suture augmentation, pull it tight, get it set, and then you can place your second biotinadesis screw  in the metatarsal. And that gives you a nice seatbelt to your repair. And it really allows you to have, at least in my opinion, maximize the MTP stability to the greatest extent  that we can. And here you are, you've got, you've completed your sagittal plane stability. But as I alluded to earlier in the talk, you can't forget your collateral ligaments.  Don't forget to evaluate and correct your coronal plane and MTP stability. Even if it's just a quick suture through the collateral ligament, you've got to do it to make sure  that the toe stays in neutral alignment. And just one slide on how I address coronal plane stability with the collateral ligaments. If it's healthy collateral ligament remaining,  or if there's just even enough tissue or periosteum that I can grab on the affected side of the toe, I just do suture repair. And most of the time, I'd say 95% of the time  I'm able to do this. If there's really attenuated tissue, or it's just poor quality, or for whatever reason, I can't bring the toe over, I will consider ligament augmentation.  And that's the nice part about only a single drill tunnel on the proximal phalanx. You still have some room to fit ligament augmentation if needed. And same with EDP transfer.  If there's minimal or no collateral tissue remaining at all, I'll even consider EDP transfer occasionally. So you can see in this patient,  was employed the techniques that I went through here and was able to give her a great radiographic and clinical result. She's done very well. I think this is the game changer for me  in terms of augmenting plantar plate, open plantar plate repairs. I can start moving these patients immediately because I don't worry about the repair stretching out.  I don't have them start passive range of motion. And we all know patients wouldn't be willing to do that the first couple of weeks of surgery anyway,  because they're sore and swollen, but at least I have them start activating their MTP joint. And I think even that little bit of motion, whatever they can tolerate,  helps to keep the joint from getting so darn stiff. And this has made a big difference in terms of having those stiff MTP joints long-term after MTP or plantar plate repairs.  So just in summary, the last few pearls that I'll end with, the first and foremost, or first and foremost, you just have to address all planes of deformity.  You can't address your coronal stability without addressing your sagittal and vice versa. This is really the only way to achieve a predictable long-lasting MTP correction.  Secondly, you have to have a systematic approach, have the same equipment there every time, address the joint the same way every time. It's going to maximize your rates of success.  And finally, don't trust the plantar plate. It was poor tissue before and it's still poor tissue, I promise you. I don't necessarily augment every single one,  but I augment the vast majority of them because the majority of the time, this is tissue that just can't be trusted. Thank you.  Thanks, Caitlin. That was awesome.  And I completely agree that the plantar plate can't be trusted.  And hopefully we can discuss some of that in a little bit. But next up is Dr. Jim Holmes. He's my senior partner and division chief at the University of Michigan.  He did his residency at Michigan and did his fellowship in Seattle. And he's going to,  his title of his talk is a euphemism, I think, because I asked him to basically talk about what we used to do or something like that, or kind of the old school way to do it,  if you want to call it that, or the cheaper way, or really it's Jim's way. So a lot of people do things his way as well, but let's hear what he has to say  about how he addresses lesser toe deformities.  Yeah, thanks, Paul. I'm a sandwich between two plantar plate repairs. So I've got a tall order, but I'll do the best I can to try to show you  that everything that glitters isn't gold necessarily. I'm going to go through this pretty quickly. A lot of the stuff has been covered and I want to be sensitive to that.  We all know what the toes are supposed to do. The original manuscript here from 1990 was on a papyrus written in charcoal, but it's still true today,  which is really the take-home point is that the toes dynamically bear as much weight or unweight the metatarsal heads equally. And so the function of the toes  is really, really important in normal gait. And so all these things are really designed to get rid of that extension deformity, the MP joint inflection deformity, the PIPs,  so that they function normally. And this has been repeated a lots of different ways in terms of gait analysis and pedo-barographic studies.  And you can see in the lower part of this at push-off, not only does the forefoot metatarsal head bear weight, but at terminal push-off, the toes are recruited,  particularly the second and third toes. And it's really critical that we preserve that portion. And that's what all these studies and talks, and I really appreciate it.  I'm learning a lot here tonight myself. This is what we're all trying to do, try to achieve that normal forefoot loading. Chris talked about this as well as Caitlin in great detail.  I would just emphasize and put an exclamation point on it. Intrinsic muscles are really important, and I'm gonna tell you ways that we can help our patients do that.  So I get minimal incision surgery and plantar plates, and it's implied with the other talks, and I'll just reinforce it, that the toe problem is probably the end point  of some other problem, whether it's an intrinsic minus foot or some intrinsic weakness. First-ray insufficiency, either iatrogenic shortening or hypermobility, lots of ways  that the first metatarsal doesn't bear its fair share of the weight. A congenitally long second metatarsal head, atrophic fat pads in elderly folks, a tight Achilles,  a plantar plate tear. I will acknowledge this, Paul, in a traumatic situation, and I will equally acknowledge that the plantar plate's torn in a lot of these.  The question I think really is, is it traumatic or is it attritional? And if it's attritional, fixing it is fine, but you need to figure out why it failed attritionally  in the first place and address that, and I think that was covered as well. And it can be iatrogenic as well, previous surgery and so on. So the solutions really have to address  not just the end deformity, but the origin of the deformities. There's lots of different ways to do it. Historically, Caitlin and Chris talked a great length today  about restoring balance at the MP joint in terms of flexor extensor balance at the MP and PIP joint. I couldn't agree more. I think this is critical.  I think when you do an IP fusion, it converts the FDL to a more or less pure MTP flexor for dynamic stability. I think that's really important.  I think we should keep in mind girdle stone tailor transfers or flexor to extensor transfers work best for flexible neurogenic deformity,  and they're best done with all the lesser toes or none of the lesser toes because of the quadriga effect, and I'll let you think about that a little bit. And then non-operatively,  if you remember nothing else from my talk, remember the name Irene Davis. Irene Davis is a physical therapist, and Chris probably knows her.  She just recently retired, a PT and a PhD at Harvard, recently retired, and she has really popularized that the importance of intrinsic muscle strengthening has several protocols.  So please have your physical therapist, if they're not aware of her work, sort of look that up because it really has made a difference, and I'm drinking the Kool-Aid quite a bit  with regard to that, and I think I would encourage you to try that out. My statically, Caitlin talked a little bit about a while. I'll talk briefly about that.  That can certainly be part of the solution as well as other soft tissue, static balancing, MP capsulotomy, and I'm old school and perhaps much less refined  or arguably almost certainly much less refined in terms of just scarring that plantar plate, much less elegant, but scarring it in and then holding with a pin seems to work  as long as you're addressing the other issues.  To resolve it. So I think K-wire fixation has historically been the standard against which other techniques are compared, and that's not exactly fair to say  because I think it's really an adjunct to other soft tissue and bony techniques. It's actually C-wire, just to be clear, it's sharp on both ends.  I use an 045 wire, seems to work pretty well. Have I had some broken wires over the years? Absolutely, not too many, but you just have to, you can go with a bigger wire  if you want to.  045 wires seem to be better tolerated and less screaming in the office when you pull them out a bit. The advantages of a simple K-wire fixation,  particularly at the MP is it works mostly. You can pull the pin easily if there's infection or vascular compromise, particularly the ladder and recovery room.  It's surprisingly well-tolerated. You have to prepare patients for it, and it does provide solid stabilization wherever you end up putting the MP joint.  You can bend or break it if they're putting weight on it or if they fall, recurrence is possible. And we'll talk about that in a second.  Vascular compromise, almost always due to spasm because of distraction, seldom due to transection. And whether or not patients accept it or not, it's controversial.  I think it's how you frame the discussion, but certainly I'll buy that as a disadvantage. Although I tell patients, if your toe is bothering you enough to have an operation,  then you'll have to tolerate a pin in it.  This is a study that I think Chris talked about earlier,  a small amount of pin migration. Things I worry about most are recurrences, right? Which are probably the most common, almost 6% recurrence.  But the thing we worry about most and we consent folks for is vascular compromise and subsequent amputation, which is pretty rare, but really catastrophic.  And this study showed that really a fairly large series  and combined with other toe procedures  and soft tissue balancing really provided pretty good maintenance correction with a low complication rate and it was pretty cost-effective.  I wanna say just a couple of words about white toe. We haven't talked about that. And I've certainly had some white toes over my career  and wanted to posit one algorithm for you to think about.  After I fixed the toes, I wrapped the toes in warm saline soap laps and I asked the anesthesiologist to let me know when two minutes are up. If we pull the lapse off and it's warm,  we're in good shape. If it's white, wait a little longer, oftentimes pull the pin back to the MP joint. If it pinks up, I reintroduce the wire. If it stays white,  I back it out a little bit more across the PIP joint.  If it stays white, that's a bit of a problem when I put it back in or it turns pink, then it turns white when I put it back in.  It means you have to shorten the PIP joint a little bit and then put the pin back across the MP joint with a little less flexion.  If you pull the pin out entirely and the toe stays white, that's a little different. Then the room gets a little bit warm and dark for a while. And that's when I go to pharma.  I go to nitropase or papaverine injections. I will recognize fully that other people leave the pins in and go right to nitropase in time. There's nothing wrong with that,  but I just wanted to posit this as another approach to troubleshooting the white toe, particularly with pins in it.  I'll just finish up with a few cases. Here's a second MP dislocation. Obviously the plantar plate has to be injured here. We have to fix whatever we need to in the first ray  and with the second MP joint and fix the other hammer toes. So the first was fused and the lesser metatarsals are pinned. And here's six month follow-up,  pretty good preservation of the MP reductions. Again, with IP fusions and coupled with Irene Davis's flexion exercises to try to maintain that,  as well as some physical therapy to maintain MP flexion.  You can do this in conjunction with a while osteotomy if you need to.  Excuse me, dislocation treated similarly with an MP fusion, while osteotomy to IP fusions. And then longer term done pretty well, a little bit of crossover one to two.  This is, speaking of while osteotomy, I credit Charlie Selzman and I'm grateful for his lending me these videos. This is the center of rotation,  the sagittal plane of the MP joint in normal circumstances. And with a while osteotomy, as we see here, this is part of the origin of the floating toe  or the axis of rotation moves proximal inferior, which changes the pull of the intrinsic muscles and is in part responsible for up to 20% incidence  of a floating toe with a while osteotomy. Just a couple other cases, this is axial plane deformity. So not dislocated per se, but a student body left here, so to speak,  a fuse the first MP joint, as Caitlin just said, really release collateral ligament balancing. I don't necessarily imbricate medially, but I certainly release laterally,  couple that with MP pinning.  And here's a two dislocations, two and three, kind of odd anatomy with the second and third being parallel with so problems with both in the axial and sagittal plane.  This was an insufficient first ray treated with an MP fusion and closing with dorsal, excuse me, lateral closing wedge osteotomy. The third, reducing and pinning the MP joints  after we scar the MP joints, no plantar plate repair, but with IP fusions to again, introduce dynamic stability. And at eight months, she's had a good resolution  of that good resolution of her symptoms. Anything can happen in another year or two, but I think I'm pretty confident that this is gonna do a pretty well.  Just a couple of tips with pins, I pin it in slight hyper flexion at the MP joint, slight, maybe 10 degrees, use this pin protector.  I bend pins with a pair of pliers. I know exactly how wide the pliers are. So if the patient comes in, so I pulled out or I push it in, if it's the width of the pliers,  it hasn't moved, I don't need to get an X-ray. These pins fall out or these pin caps fall out everywhere if you use pin caps. So I put adhesive, either tincture of benzoin  or amastazole and make a little stirrup with Steri-Strips that does a pretty good job of keeping them on, just a little tip. So just remember in closing that we have lots of tools.  We use pins with lots of tools in your toolbox and many of them, if not most of these have been mentioned earlier with Caitlin and Chris. So any one or a combination of these things  can be used as well as in conjunction with pins to maintain the reduction MP joint. So I'm old school about this, as Paul alluded to, I'm a PIP fusion guy, resection in the elderly,  extensor tenotomy, not a lengthening, cut it, cut the extensor, cut the dorsal capsule, scarify the plantar plate either directly or with the McGlamory, C-wire,  anterograde through the PIP and then retrograde across the MTP with some exaggerated flexion, white toe algorithm, heel weight bearing a post-op shoe  as long as the wires are in and then pins out at four weeks. K-wire fixation has stood the test of time by and large in conjunction with, I would emphasize  a lots of the other techniques that you've heard of earlier today and I think it needs to be an arrow in your quiver. It can be used for both toe deformity and MTP instability  and it must, I would say, be used in conjunction with other soft tissue procedures and osteotomies and fusions as you've heard from Chris and Caitlin  earlier today and you can maintain correction in multi-planar deformity pretty easily. So thank you very much. Sorry, I wanted to make up a little bit of time  but I appreciate your time and attention. Thank you.  Thanks, Jim. That was great. And even though I do give Dr. Holmes a hard time about his technique being the old school way or something, I mean, I definitely would acknowledge  that that is what most people probably do and it's a skill that is absolutely critical to be able to do, to pin across toes and everything.  So I would never really take away from that. So my talk will be really quick and it's mostly, I don't know, you could probably call it editorial  more than anything, but what I would say is  we need to acknowledge and address the lesion  when it comes to hammer toes and MTP instability. This is my disclosure, but my other disclosure is that the plantar plate is my favorite ligament  and not just repairing them, but the anatomy, the physiology, and I love Star Wars, I love hockey, and I love plantar plates.  So the first thing I'll bring up is this is a recent paper that just came out, David Petowitz and his group,  and they looked at MRIs of patients who were symptomatic with metatarsalgia and patients who were asymptomatic and getting MRIs for other reasons. So people who are asymptomatic,  they found like a very low incidence of incidental plantar plate tears, 2%. And then they looked at their symptomatic patients and they found plantar plate tears  in 28% of symptomatic patients. But what about the other 72%?  Are they symptomatic because they have grade zero tears, meaning that they have attenuated plantar plates that are not functioning, or do they have something else?  Or is MRI just not good enough at diagnosing plantar plate tears? And I mean, I look at a lot of MRIs and I would definitely say that we're not visualizing  plantar plates all that well,  or it's completely something else. Maybe they have tendinitis because they're just like loading the tendons, who knows? I think sometimes it's a mystery.  But when it comes to the deformities,  like we've talked about all day today, if there's a deformity of the lesser toes, like it's ligament insufficiency to start with,  and then the flexors and extensors pulling on the toes will lead to more deformity, and it can be mild. It can be a little bit of a floating toe like this.  It can be a little more severe where you have a floating toe plus some crossover from collateral insufficiency, or you can have a really big deformity. But what I would argue is,  plantar plate, it is robust. I mean, if you look at this ligament down here,  I mean, that is a thick ligament. And when you think about the proximal, like the origin of the plantar plate, it's got two pieces. One is attached to the plantar fascia.  And then the other part is attached to the metatarsal, like head-neck junction.  And I don't think that the origin of it where it attaches to the metatarsal gets enough respect. A lot of the literature says that it's a very loose kind of synovial thing,  but if you ever stuck a monglamory in there, you got to push, you know? So you are like, you got to push through something robust. And then you look at the collateral ligaments,  which are practically see-through,  but as thin as these ligaments are, I mean, they're strong and they play an important role.  So, you know, why am I going to preach about addressing the lesion? And you think about other ligamentous issues in the body.  So if you have an ACL tear, I mean, we do ACL reconstructions. If you have a UCL tear in your elbow, if you need to throw, you're getting a UCL reconstruction.  And then, you know, in the foot and ankle, if you have insufficiency of your lateral ligaments, like you get a brostrom. So I would argue like we should address the lesion,  but one of the questions, and one thing that Dr. Holmes gives me a hard time about is does addressing the lesion work? And so if you look at one of the bigger series  of plantar plate tears by some of the giants in plantar plate literature, you know, in their series, they still have a really high like recurrence rate or at least a floating toe.  So yeah, I would say like current techniques, like, I mean, they work, but we have a ways to go. And so I definitely would say addressing plantar plates  or at least ligament stability, it's something that we shouldn't abandon.  You know, if you think about where we were with total ankles, like the early ones failed and then we didn't do them for a really long time  and now we do them and it's like almost standard of care.  MIS bunions, you know, when this paper came out in 07 and it said, this is like basically a terrible surgery, we didn't do any MIS bunions for like another decade in the US anyways.  So what I would argue is that like, I think we need to evolve our current techniques based on what we've learned about the plantar plate,  one of them being just the blood supply of the plantar plate. The blood supply of the plantar plate, it's coming from two places. It's coming from, well, it's coming from proximal  and it's coming from distal where it attaches to the bone. And then some of it is also coming from the plantar fascia.  And the amount of blood supply that's coming from the plantar fascia or the amount of blood supply that's coming from the metatarsal bone is about 63% of it.  So when you're sticking a McGlamory into the MTP joint  and stripping the proximal origin of it,  we're kind of killing off like 60% of the blood supply. And then the second part of that surgery is kind of when you detach the plantar plate from the phalanx.  So we're eating up the other part of the blood supply. So we're kind of like left with allograft in there, so to speak. And is that one of the reasons why we have  like a decently high floating toe or failure rate with these?  I guess we don't really know, but I would say we still have a ton to learn and there's just not a lot that we know about the plantar plate. But I would argue that,  the principle of restoring ligamentous stability to an unstable joint is something that we should really be doing some research into and then improving on the surgical techniques  that some of the giants have supplied us with. So I'm going to stop there and we can address some questions and have some discussion.  So looking at the,  well, we can start with the Q&A stuff. So somebody's written here that they have a patient with a second floating toe after a while osteotomy  and a PIP, resection arthroplasty fusion. So any thoughts on how to correct? And I think that, well, let's start with Dr. Miller. What do you think?  You're muted.  Thanks.  If it's floating, if there's a floating toe after a while, that's why I've tried to get away from doing a while. So it's one of the most frustrating parts.  But if it's not getting better, that's one of the times where I will definitely go in and do a plantar plate repair to try and tie that back down. And as an aside,  I do like the way you have shown us how to do it, Paul. So that's probably what I would go for.  No, any role for some kind of a MIS thing?  Probably not. If it's a floating toe and they've already shortened it with a while.  Sure. You do wonder though. Yeah, you wonder. That's always the root cause of the floating toe is sometimes a little bit tricky to figure out. I think that not all whiles end up  with loss of flexion power and a floating toe.  And so is it how much you've shifted the head back? Is that, you know, there's things to consider or was there plantar plate insufficiency that wasn't recognized up front  and it's still the plantar plate that's insufficient? For me, it would all come down to the patient. I think that if I thought it was plantar plate insufficiency  and it was bothering them, I would do an open plantar plate repair. Otherwise I probably would consider MIS. I think this would be a great,  I've had good success with P1 plantar closing wedge osteotomies for something like this. And it's a lot easier than going through big incisions again to repair the MTP joint.  And maybe it keeps the MTP joint from getting stiffer after second surgery. So I think it would be a great thing to consider MIS for.  Drill a hole dorsal to plantar and the proximal phalanx and bring the long toe, if the IP fusion is solid and just bring that through that, bring the long toe flexor,  the FDL plantar to dorsal and sew it into the extensor hood a little bit, it'll do a pretty good job of holding it down. You're running into the same quadrigia problem a bit,  but it won't be floppy and you have to kind of be careful tensioning, but it will keep the toe down for sure.  In the same Q&A, Dr. Sanders is asking about using something called the TinoTac,  which is an industry device for plantar plate deficiency. And I think this can tie in with this question. Basically what that device is,  I'm a Paragon consultant, but I don't work with that specific product at all. But essentially what that is, is it's kind of like a screw that you put into the plantar portion  of the proximal phalanx of the toe. And you bring in the flexor digitorum, longest tendon into it. And it's essentially, it's like a tendon transfer to the proximal phalanx.  And sometimes I think that could be, something like that could be useful  in this kind of a situation. If you didn't think you could repair the plantar plate or didn't want to repair the plantar plate, but I think something like that could be an option  where you're sort of using the flexor digitorum and attaching it to the base of the proximal phalanx.  And any other thoughts? Yeah. Oh, sorry. Go ahead. No, go ahead. I was going to be another question about diaphysial shortening. And that's historically been my go-to.  It works pretty well. Fix it with a quarter tubular, a four hole, a quarter tubular plate. It works pretty well. Be careful not to result in, you know, get any angulation.  The knock on that a little bit as you're taking a saw going through the mid-diaphysis and you can kill bone and you can get a non-union if you're not careful, for sure.  But it works very well in terms of shortening the metatarsal and in some ways more exacting than the while. And it's not associated with floating toe per se. So that does work.  It's a little fussier, but you can do that for sure.  Yeah. Anyone else with thoughts of experience with proximal or mid-shaft shortening osteotomies instead of while osteotomies?  You know, I've looked for patients  if they have mid-foot arthritis and I'm doing a fusion and I'll shorten to the fusion as well. That has also worked nicely for many of my patients.  So I don't think you should forget that if they do have second or third TMP arthritis that you can get some shortening through that procedures as well.  Sounds good.  So I have a question for you for the, I know that Caitlin, you do some MIS stuff too, but what are the complications that you see? What are some things like with MIS surgeries?  Like what are some things that you would really warn people about?  I think for me, it's been a learning curve as we all get warned about over and over and they're not, you know, that's not made up.  So it's a little bit, you just have to make sure you don't make the same mistake twice. But the few complications I've had are number one, losing reduction.  I think with a lesser toe, no fixation osteotomies. And I think that I loved Chris's picture of how he does his wrapping. I've, even now I'm still tweaking how I wrap my toes.  And I think that, you know, patients by about the two or three week mark, I have them start taping their own toes, but if they're not compliant,  you can still lose some of your reduction. I've had, I've never had a frank non-union of a DMMO, but I've had delayed unions. And patients that come back even at three months  with still some soreness and swelling through the forefoot. Fortunately, those all still heal pretty reliably. At least they have for me,  but those are the biggest things I worry about. And I've had some patients who have probably my worst complications, although they've all turned out okay,  is a pretty significant reduction loss of the metatarsal heads. For example, someone that has like a windswept deformity of their lesser toes and you do Akinets  and all sorts of osteotomies to bring things back. Well, I think that puts a lot of tension on the metatarsal heads when you do DMMOs.  And I've had the heads basically follow the toes. And then what do you do? And I've left them, they've healed. And unfortunately those patients haven't been too bothered  by their crooked metatarsals, but those have been the biggest things that I've dealt with.  Chris.  Yeah, I agree with Caitlin. I think it's just, it's a lot more follow-up to get the taping right. And you can't pass it off to your, if you have a PA or a nurse practitioner  that you work with.  I see all those patients or try to see all those patients myself. And if it's gonna be complicated, strapping for those reasons. And I'm not sure I would call the delayed union  a complication. I tell patients to expect that. And I also haven't had a non-union, but I tell people it's gonna be a while before their foot's back to, is not swelling.  All right. And then just running through the last couple of questions here, because we're running out of time. With that MRI study,  basically the answer to whether people had symptomatic pain and tenderness locally or positive dorsal, I think it was kind of all of the above. I don't want to like mis-answer this,  but I think it was all the above, but I actually would have to go double-check that paper.  And there's another question. This might have to be the last question. Resources for choosing like MIS systems and taping.  And what are you taping with?  And what are you taping with?  So I strap with a wet spike addressing with gauze. I'll use steri-strips.  There are some good like online things you can look on Umedi that you can see some stuff,  how people are strapping it. I think in terms of choosing the MIS system, I use the arthritic system, but I've used a lot of different practice  with a lot of different systems as well. They all are fairly similar. I think if you have a place that has good support with the reps and you can get good training,  most of the MIS systems in terms of the burr are very similar. So it's what you can get your hands on and get practice with.  Yeah, and where I've gotten a lot of my techniques and information is actually off Dr. David Redfern's website. He does a lot of great, he goes through a whole,  Chris, kind of like your presentation,  he has a lot of similar slides, goes through all the anatomy and then has a great toe taping video as well.  Yeah, and I would say I kind of just started getting into a little bit of the MIS stuff and like the various companies around here in Michigan  have all been very good about, or I mean, even almost overly aggressive about wanting to get me down to a lab or getting my hands on it with cadaver stuff.  And I would definitely say like practice this on some cadavers before you go after a live patient, that's for sure.  But I think if you, there's a lot of different companies that have their MIS stuff. So yeah, I think you should try to get them practice on some cadavers,  but does anybody have any closing remarks, last thoughts or anything?  Well, on that note, I wanna thank all the speakers here, Dr. Holmes, Dr. Miller, Dr. Neary, and this was a really well attended thing. So thanks to all the participants here  and thanks AOFAS for having us.  Good night. Thank you. All right, see you. Merry Christmas.

Video Summary

The video is a webinar where two speakers discuss surgical techniques and considerations for addressing lesser toe deformities. Dr. Christopher Miller focuses on minimally invasive lesser toe correction and presents case examples of MIS surgeries for hammer toe correction. Dr. Kaitlyn Lukes discusses open plantar plate surgery and emphasizes the importance of anatomic direct repairs of static stabilizers. Both speakers highlight the need to address ligament insufficiency and plantar plate tears in achieving optimal outcomes. The video provides insights into the complex nature of lesser toe deformities and surgical approaches used to correct them, including suture repair of the plantar plate and ligament augmentation. The challenges and potential complications of minimally invasive surgeries are also discussed. Overall, the webinar offers a comprehensive overview of the diagnosis and surgical management of lesser toe deformities.

Asset Subtitle

Moderator: Paul G. Talusan, MD
Faculty: Christopher P. Miller, MD; Kaitlin C. Neary, MD; James R. Holmes, MD

Expert faculty will share insight on current trends, clinical outcomes, and techniques in the surgical management of lesser toe deformity and MTP instability. Faculty will discuss minimally invasive surgery, open plantar plate repair, and more traditional open surgery involving metatarsal osteotomy with toe pinning.

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

Describe the outcomes of minimally invasive surgery, plantar plate repair, and open surgery with toe pinning
Understand the indications for minimally invasive surgery, plantar plate repair, and open surgery with toe pinning
Increase your comfort level performing minimally invasive surgery, plantar plate repair, and open surgery with toe pinning

Keywords

surgical techniques

lesser toe deformities

minimally invasive

hammer toe correction

MIS surgeries

open plantar plate surgery

anatomic direct repairs

ligament insufficiency

plantar plate tears

suture repair