I'd like to welcome everybody to our webinar. This series of putting it into practice webinars focuses on the basics of foot and ankle care. And tonight we have a webinar on the forefoot. The topics are very pertinent to in-office care as we have talks on lesser toe deformities, nail issues, and writing orthotic prescriptions. I'm delighted to introduce our first speaker, Dr. Paul Toulousan. Dr. Toulousan is an associate professor of orthopedic surgery at the University of Michigan. He grew up in the Boston area and did his undergrad at Boston College and medical school at Boston University. He was a resident at Yale and New Haven in Connecticut and did a foot and ankle fellowship at Union Memorial in Baltimore. When we asked him to give us a little background, he said, when he's not working, he's either driving his kids somewhere, playing hockey or mowing his lawn. So I'm delighted to have Dr. Toulousan here to speak about lesser toe issues. All right, well, thanks for the introduction and thanks for having me. It's great to be here. So, well, I guess we'll just kind of jump right into it. So I'm gonna be talking about some of the lesser toe deformities and yeah, here we go. So these are my disclosures, nothing really relevant to this talk. So we're gonna start with bunionettes, which I love treating bunionettes to be honest with you. And when you hear bunionette, you think little bunion and it's not little bunion necessarily. It's more like bunion on the smallest toe. So that's what your bunionette is. And typically it's kind of a bump on either the lateral or plantar side of the fifth metatarsal. And usually worse with shoe wear and things like that. X-rays can sometimes be impressive and sometimes they're not that impressive. And a lot of times you'll feel a patient's bunionette and you can even see the bunionette and then you get an X-ray and you're like, there's not much there, but you can really feel like a hard bump or something there. And that's oftentimes because the lateral eminence or the bump is actually, it contains a lot of cartilage and not a lot of calcium. So you can't necessarily just go by the X-rays. However, our classification system is based on X-ray made by Michael Coughlin. And we don't really, I don't know, I don't necessarily use this classification system sort of day to day, but it's more like if I'm treating a bunionette, I kind of, is it a big bump or is it something else? So these type ones are basically, it's a normal looking X-ray and then they just have a bump on the side of the foot. Type two, I would argue is probably a little more common and that's where it's actually bony deformity that someone's born with. And if you look at the fifth metatarsal here, it's kind of bowed. And so it's bowing out laterally, which is causing the metatarsal head to be pretty prominent. And then the type three is, it's not so much a bowed metatarsal as it is that the metatarsal is forming an abnormal angle against the fourth metatarsal. So it's actually a wide intermetatarsal angle and the bone is essentially just in the wrong place. And so, we always try to treat these non-operatively, essentially like you gotta figure out what the problem is. And so if it's really just the bump and it's hurting in shoes, we might try these pads. It's kind of a ring around the pinky toe and then it's just a pad covering the bump. In patients who have like, if the fourth toe and the fifth toe are kind of rubbing against each other and you wanna try to separate those toes, plus cover the bump, then there's sort of this style and really all these inserts and things are like on Amazon essentially. And then there's other things out there, this type of thing. I actually recommend this one a lot just because it's sort of a sock with a silicone pad over the lateral eminence and it does tend to like stay. One of the problems with those other inserts is that they sort of can flop around and stuff. But if we try non-operative treatment and it's still really bugging somebody, then I'm happy to offer surgical treatment. So with these type ones where it's just kind of a big bump but everything else is fairly normal, those are cases where we'll actually just, I say just, but we'll make an incision and shave down the bump. And so if you look at this patient, this is on the left side, this is a before picture and it's really just kind of like this little peak, almost a little point on the bone, but there is like a fairly big cartilage cap on there. And then you look at the x-ray and you wonder if I really even did anything. But like I said, I mean, a lot of the bump you can't actually see. So we cut that bump out and those do pretty well. More common though is like the type two or the type three bunionette deformities where we actually have to do a little bit of bony work and it's very similar to what we do for like bunions actually. So more recently, this is a type of surgery that a lot of us are doing in a minimally invasive way. Using just a little incision and then we basically use like this little burr that will cut the bone. But even if you do this like maximally invasive, I mean, your incision, the minimally invasive incisions probably like a centimeter and the like bigger incisions, maybe seven centimeters. So it's not, even the maximally invasive surgeries, not all that big of an incision. But what we do is, what we're trying to do is we're trying to shift the metatarsal head more medially, sort of like narrowing the foot. And the way we do that is we'll make a little incision right by the eminence there. We cut across the bone and then this picture on the right, it's a little weird, but we'll take this K wire and put it through this incision and we'll stick it out the tip of the toe and run it along the side of the phalanges. And then we'll shift the metatarsal head over and then we'll take this big wire and kind of just shove it down into the shaft of the metatarsal. It's pretty barbaric and it's very, it's not sophisticated, but it works very well. And this is kind of like, I mean, I think there's a fair amount of people who do it this way. There's other ways to do it and that's totally fine. But really the principle of the surgery or treating this is to, you're trying to shift the metatarsal head more immediately. Here's another way we did it. So, or not really another way, this is a different patient and this is a type three. So they actually had traumatic injuries. Like this was a motorcycle crash and this is about the best we could do for him. But if you look down at his tarsal metatarsal joint, there's a bunch of arthritis and he actually has a lot of erosion there. And I think that's what caused his fifth metatarsal to sort of deviate, causing him to have a painful bunionette. So we took him to surgery. As you can see, I got rid of the plates on these other metatarsals. But what we did here is we cut across the bone, shift the metatarsal head over, run the wire out, like along the side of the toe, out the skin, and then take that wire after we shift the metatarsal head and stick it into the shaft of the metatarsal. We'll leave it there for about four-ish, four to six weeks. I let him walk on it. So I let him, like waper is tolerated in a post-op shoe. The pin comes out in the office, usually about four to six weeks later. Sometimes you'll get a phone call from a patient that says like, I took off a sock or someone pulled off my bedsheets and now the pin is missing. And it is what it is. It's usually okay. We have ways to salvage it without sticking a pin back in there. Now it's a pretty, as far as like, compared to the surgeries that I do and the amount of pain I inflict on people and things, like a bunionette surgery is definitely on the more mild end, but we never take any surgery like mildly. So this is a patient I did bilateral bunionette surgeries and his left foot over here healed up great, but the one on the right got a non-union and I actually took him back and sort of redid it. And then he was still a non-union. And then I said, all right, well, now it's getting interesting and we're gonna get in there and do some bone grafting and whatnot. And he said, you know what? Just cut it off. And which I did. And a quick recovery from that, but he was just in so much pain that he was like, you know, just take the toe off. So, you know, non-unions and infections, they're rare, but you know, you can end up losing a part of your body over these things. Now we're kind of getting into the, you know, sort of classic lesser toe deformity. So there's even like orthopedic surgeons don't fully grasp or, you know, have like a great sort of command of what is the difference between a mallet toe, a hammer toe and a claw toe. So if I can do anything for you all today, it's like, tell them that you can differentiate between a mallet toe, a claw toe and a hammer toe. So a mallet toe, I think of a mallet as sort of a simple hammer, I guess. And so this is sort of the simplest of the deformities because you just really need to remember that the DIP joint is flexed. The rest of the toe is basically normal, but it's sort of forming, you know, a mallet, I guess. And so the DIP is flexed and you'll tend to get like calluses and things on the tip of your toe. And you know, how does this deformity happen? And so usually this is like your traumatic deformity where like, well, essentially there's an imbalance, right? So there's an imbalance between the flexors of the toes trying to flex or curl the toes. And then there's the extensors which are trying to straighten the toe. So I'm always telling patients, you know, a straight toe isn't just sitting there. A straight toe is really just, you're seeing like a neutral game of tug of war between your flexors and extensors. And so say you drop a can of soup or a knife or something on the top of your foot or stub your toe really well, you could get an extensor laceration, which now you're unbalanced. If your extensor is not working and then you get a mallet toe, sometimes it's a flexion contractor, but oftentimes it's actually both where it starts off as either an extensor laceration or an avulsion of the extensor tendon off the bone, you know, and then the tip of your toe is in flexion for a while and then it kind of just gets stuck there. So, so yeah, I mean, we'll see these in trauma usually, and sometimes folks with diabetes and neuropathy, you'll get this deformity too, you know, treating it without surgery, you know, so we sort of use these brass knuckles. The principle is basically try to get the tip of the toe off the ground. So these toe spacers, or I always just call them brass knuckles. Sometimes it works, sometimes it doesn't. And then there's also putting on these toe caps, which, you know, sometimes it works and sometimes it doesn't. And really you're just trying to prevent the tip of the toe from rubbing too much. You know, I'm a surgeon, so I love doing surgery. So, you know, this is kind of an example of what we would do if somebody has a flexible mallet toe and, you know, they have an extensor tendon, either laceration or it's a bony avulsion. Usually we'll, you know, put the toe straight and hold it with a pin. And then we'll also sew the tendon, or, you know, sometimes we, you can get more creative than that, but essentially we're repairing the extensor tendon. And then you let the extensor tendon heal, and then you pull the pin. And usually they'll need a bit of therapy and stuff afterwards. But another way to do it is with flexor tenotomies. This is, these pictures are, they're not necessarily doing a mallet toe, but it's just an example of doing like a percutaneous flexor tenotomy. On the picture on the right, on the bottom is actually, they have transfected the flexor tendons, like right at the DIP joint, and so oftentimes we're either using like a needle or just a very small scalpel, and we can do these in the office. And it's pretty immediate gratification when you do it that way. Now, sometimes these things aren't flexible. So we have, if they're a rigid toe, then we have to do something like more aggressive. And that's where doing fusions comes into play. So, so this person has a rigid mallet toe of their fourth toe. And so we took him to surgery and get the toe straight. And then in this case, I use the screw. Sometimes we'll use a pin or depends on the surgeon and all that stuff, but it's a piece of metal holding the toe straight to fuse that. So claw toes, claw toes is different than mallet toe, and they're not interchangeable. They're different things. So a claw toe is actually when everything is flexed. So the DIP joint, the PIP joint, those things are flexed. And then you look at this picture and say, well, isn't the MTP joint dorsiflexed here? And it is, but that's not really like an active thing. It's just when the toe is curled up and you try to stand on it, it's going to dorsiflex at the MTP joint. But this is really a problem of PIP joint flexion and DIP joint flexion. So how do we get this? So this is more of like a tendon contracture type of situation. So we'll see it in neurogenic issues, strokes, neuropathy, Charcot-Marie-Tooth disease, old compartment syndrome. Those are usually what I think of when I see claw toe. And so this is a patient with some claw toes and we take them to surgery. The non-op stuff, kind of the same as what we would do for mallet toes. And the claw toe surgery is we basically fuse all three joints, or sorry, both joints in the phalange. So the DIP joint and the PIP joint. And you can use pins, you can use screws, but oftentimes we don't have to do anything with the MTP joint because everything there is fine. It's just that all the flexor tendons were flexing the toes. And so we get them straight. Sometimes we use screws. This is a person with Charcot-Marie-Tooth disease. And we did a big reconstruction. And then for the toes, in this case, I use pins. To be honest with you, it just kind of depends on, sometimes it depends on my mood or what implants are available to me. I'm not really married to using screws versus pins. Pins are cheaper, screws are expensive, but anyway, it's a little beyond what, it's beyond the meat of this talk. And so this is that same person, probably like six months later. And so, all their osteotomies are healed. And if you look at the toes, it's all just, each toe is just one long bone from doing all those fusions. Okay, so splay toe is a little bit different. So splay toe is when the collateral ligaments are not working so well. And those are the collateral ligaments that are basically on the medial lateral side of the NTP joints. And so if one of the collateral ligaments isn't working, then the toes are gonna deviate sort of side to side. And so this is a picture of a patient where it's really just isolated, like collateral ligament issue. You can body tape them. That's kind of the only thing I can really think of. And then sometimes we'll go in and we'll do a ligament repair. And this is that same person, like six weeks later, toe straight. And I wish they all looked like that, to be honest with you. And I'm sure, you all have probably seen this. Nothing ruins this surgery like follow-up. That's for sure. Here's a cool surgery that I've never done, but I'd love for a patient to ask me to do for splaying toes. And that would be to do a syndactylization where we'll take two normal-ish looking toes and then we'll sew them together. And yeah, no one's really asking for that one. Now, hammer toes. Hammer toes are way more complicated than mallet toes and claw toes, at least in my opinion. And here's why. So a mallet toe, the deformity we're gonna see is dorsiflexion of the MTP joint. And that's kind of where the root of all evil starts with this deformity. So the MTP joint's dorsiflexed, which then leads to passive flexion of the PIP joint. And then sometimes you get extension of the DIP joint. Here's what your typical hammer toe will look like. Now, the hammer toe is probably way more common than a mallet toe or claw toe or splay toes. So hammer toes are the more common thing, but it is definitely, the mechanics of it are more complicated than I ever could have imagined. So in a hammer toe, you kind of get this classic callus on the top of the PIP joints, because it's rubbing in shoes. And then the other thing people will complain about is metatarsalgia. So when the toe is dorsiflexed at the MTP joint, it actually pulls the fat pad that's covering the balls of your feet, it pulls that fat pad forward. So then now you're essentially just weight bearing on the metatarsal heads, on the balls of your feet. And so that's something that's pretty painful too. So how does the hammer toe happen? So this is kind of the thing that really, it's weird, but it gets me going. So what happens is the plantar plate ligament, either tears or stretches, which then leads the toe to basically dorsiflex, passively just pop up and dorsiflex. And when it does that, the intrinsic muscles, which is like the lumbar poles and things. So that tendon, which usually is supposed to flex the MTP joint, once those tendons get displaced with chronic dorsiflexion, they will sort of pass the center of rotation and they are no longer able to flex the MTP joint. And they will extend the MTP joint, basically giving you a persistent, like popping up of the toe. And when the toe pops up, the flexor, the flex, like the tension in the flexor tendons becomes altered. And that's what causes the toes to flex. And so, and then, you know, at first it's usually a pretty like flexible deformity, and then eventually it will become a fixed and rigid deformity. So for these, or just, so here's the plantar plate, just so you can see it a little bit better, but it's like, it's fiber cartilage on the bottom of the MTP joint. And it's the thing that resists hyper extension. And then we saw the collaterals already. So if the plantar plate is not working, if you look at this person's left second toe, if the plantar plate's not working, it's gonna start cocking up and floating. If the collateral ligament only is not working, then you're gonna get some splaying of the toes. But if it's a plantar plate and the collateral ligament's not working, that's when your toe starts popping up and crossing over to the side. And the reason these happen, so there's a lot of different reasons. There's inflammation, there's long second metatarsal, bunions, trauma, steroid injections. And then oftentimes, yeah, so when there is something else there, a lot of times you have to get rid of the root cause. And so in this case, treat the bunion, get it out of the way, and then you can address the plantar plate and the hammer toe. If you have a long second metatarsal, we can shorten that metatarsal. And then a lot of times people will have sort of tight calf muscles. And so one of the treatments we'll do is actually aggressively stretch the calf so that people aren't bearing as much weight on the balls of their feet. And so, yeah, when people show up, they got the crossover toe or a pop-up toe, something called the drawer test is what we use. So this is a stable, good, normal toe. This one is an abnormal, unstable toe. And so that's kind of the test we'll use to determine whether someone's got a plantar plate tear. Yeah, x-rays pretty, we usually were looking for other things, but you'll see that sometimes the second toe is kind of popping up a little bit. I don't get MRIs that often but if you do like we'll see that the plate like this this black stripe on the bottom of the joint is the plantar plate in this case it's torn and this person also has some like synovitis in their MTP joint. So treating these non-operatively I mean basically you try to find shoes that fit the foot so something with a big toe box sometimes we'll do toe strapping like the principle is reduce and just put the empty reduce and stabilize the MTP joint tape works well but it's not very flexible and it leaves behind a sticky residue so like it works in some people it doesn't in others boot and splint is nice because it's kind of flexible but sometimes it's too flexible you know and then with surgery so you'll see this it's also it's all over the place as far as the way we treat these but some people will pin the joint which is fine it sort of works but like would you pin an unstable shoulder no you know you'd usually fix the ligament in the shoulder so that's kind of where I've gotten into plantar plate repairs like you know fix the fix the lesion there's a bunch of different ways to do it there's planter approaches which not a lot of us do so we don't like making incisions on the bottom of the foot and then there's dorsal approaches which is kind of the more traditional way to do it make an incision on the top of the toe it's it's a real tight space to get down into the plantar plate but we'll get down in there Pat like that's the plantar plate there throw a couple stitches in it with you know there's different devices out there that allow us to work in these tight holes and then essentially reattach the plantar plate to the bone and then the toe is much more stable it's not perfect this is one of mine you can see the toes kind of popping up a little bit and so you know we don't totally have this figured out it's probably a bit of like extensor tendon scarring and a little extensor tendon contracture probably has something to do with it but we're still working it out but traditional plantar plate tears like yeah there's it's not perfect but it's pretty good you can sort of skip through this video based on time but it's really just like the technique that I use but anyway with the it's kind of a newer technique the way and what we found is that like we've been pretty good at getting people's back to getting there you know doing their ADLs plus plus exercise and things something that's more new is minimally invasive surgeries and I think that you know I definitely dabble in minimally invasive surgery I don't I think it's got it's there's good and bad stuff about it but essentially what the people that do minimally invasive surgery do is you know like if you look over here they've cut the metatarsal bones using like this little burr and so it keeps our incisions really small and the surgeries go really fast but sort of the dirty secret is we're sort of like cutting these bones so you have a curved toe we'll cut the bones to give them a straight toe but if you look at their x-rays their bones get all curvy because we've sort of like it's sort of a workaround but it does work pretty well and so you'll probably see more minimally invasive like you know patients in the future and the incisions are really really nice so it is hard to it's hard to hate minimally minimally invasive surgery but anyway so just to you know conclude here so you know non-operative treatments usually I mean it's always what we start with usually pretty effective but you know there will be people that sneak through that non-op stuff doesn't work and then we're doing surgery you know my general principle and this is very general but we're trying to offload things that rub and then you know stabilize things that are unstable you know with taping toes and things like that you know with surgical intervention we're always we're always trying to you know obey the principles of how the foot works and we're definitely not certain perfected this this is still definitely a huge work in progress you know we've essentially perfected like you know knee replacements and hip replacements but lesser toes is just a complete like black box and a mystery still maybe minimally invasive surgery in the future shows some promise but with that here's just some fun reading you could do and these are my two boys that I just drive them around all the time so thanks for your attention and and happy to answer questions during question time thanks dr. twos and that was that was a great talk I like all of the devices you showed for taking care of the patients in in the office and all the great clinical cases and thank you well I'm sure we'll have some some questions at the end our next speaker today is Tracy Herrig she is a family nurse practitioner in a foot and ankle orthopedic practice in Reno Nevada she teaches at the University of Nevada Reno and the School of Nursing she is my co chair for the allied health part of the Education Committee and she's very passionate about allied health care and getting more people involved and whenever I speak to her she's always at work but but she does tell me that she really would rather be backcountry skiing so anyway I'm very I'm very much looking forward to this talk on nail nail deformities so buckle your seatbelts all right let me share this and give me just a sec and play from start perfect can you see that okay yeah all right my name is Tracy I'm a nurse practitioner I live and work in Reno Nevada and and I volunteered myself to do this nail care talk and my disclosures are none although I should probably be apparent that I don't love nail care I don't I try to get out of it any chance I get and so this was probably really good medicine for me to get back to the literature and see what we should what we should be doing in our clinical setting and a lot of primary care folks find this in front of them and a lot of us nurse practitioners and PAs are put in front of this task but I don't think we get a lot of this in school so my hope for this talk was to be a little bit more practical hands-on so I hope that you learned some of that from this okay so objectives I will talk about ingrown nails I had I could I was getting into this and I thought oh I could do an entire thing on just onchocomycosis so I trimmed it back a little bit but just nail trauma infected nails and then some billing considerations and then when to refer so ingrown nail this is a gosh this was like my bread and butter when I was in primary care I did tons of these and we still get a lot of referrals to our foot and ankle clinic and so there's essentially three stages and they come in in all three stages is my experience so a stage one is where it's just you know you first start noticing something is amiss it's red a little bit pain with pressure but nothing is draining and for these guys we try to do some real conservative therapy with them we have them do Epsom salt salts soaks if you have it in you know like up to four times a day for some warm foot soaks and also a poultice will work really well so this is like the witchy years but if you soak a washcloth in some warm water with Epsom salt you can put that over and that sort of helps to kind of to drive out like an Epsom salt soak would so it's a little bit easier not quite as messy and nail trimming so a lot of this has to do with just like poor nail management for people do you remember you know you cut across and not the circle kind of thing and shoe or modifications is I would say in my life I have a lot of sports kids and they give themselves this with their cleats so talking to mom and dad about cleats and in changing that up a bit is usually enough to get them gone and stage two is when they look yucky so they are starting to drain and now there's a clear little infection happening and I've seen people turn around these with some soaks and some time I think that's probably because I do anything possible to get out of an avulsion in clinic so I'm like oh I think you could just soak that for a little bit longer and it'll be okay so I've seen I've managed these conservatively longer and these you know most of them seem to come okay but if not they pop back and and now you have to do something about it so if it becomes chronic and sometimes you'll see people come in and they're like I've had this since you know I don't know the Reagan administration and it's like you've got that granulation tissue on the side and it's just the hypertrophy of that lateral skin is out of hand so those are kind of a bear to do in clinic but that's when we're doing definitely the avulsions with the wedge excisions and and possibly talking about a matrix act to me at that point so this is when they get infected and both acute and chronic reasons for infection and I think we all see this all of them although hopefully not nail-biting but anyways I'm not here to judge so picking hangnails I'm getting manicures boy we see a lot of this dirty dirty manicures and then we where I live we have a lot of athletes and they do a lot of running and skiing and we get a lot of these from just chronic trauma or the trauma from the running shoes or the ski boots and the under the chronic stage you know I think something I don't think about as much is the immunosuppression so folks that are on some of these immunosuppressive drugs tend to get these chronic infected toenails again they're the conservative treatment of soaking warm water sometimes you can get away with just some antibiotics and not having to do anything surgical or invasive this Swiss roll technique I tried finding you guys a video of it I don't do it I can't speak to that it was on this slide and I thought oh I don't anyways I'm gonna move on from that and then systemic anti or topical antifungal medication we'll talk about that with the onchocoma closes matrix act to me so oh you know what I have this I'm going to go back this little five-minute site was excellent for videos on how to do avulsions so I didn't spend a ton of time in showing technique but because I just didn't have enough time but there were some great videos on how to do a nice avulsion with like a wedge excision and I think I think videos are better than me talking anyways but I can't recommend that enough I went down a rabbit hole last night for a long time and I'm watching those videos so a matrix act to me there's essentially three different types what I would call a surgical matrix act to me which is the excision of the germinal matrix okay oh there we go are you still hearing me okay or I did away with zoom we can hear you okay good okay I just can't see you okay that's fine I don't need to see my face okay so surgical matrix act to me and so this is where we actually make an incision into the germinal matrix there's this Winograd procedure again great videos on this online you do that partial nail avulsion and then you are sharply excising that matrix you're suturing closure and clinic these do really well although I I caution patients that it it's a I don't know in my world it seems about 75 80% effective like those nails just sometimes have a mind of their own with these matrix activities like you think it should be gone and it just magically grows back I've seen this more so with kids like so I've had I've seen a couple of surgical matrix activities with kids that they just come back I think that just has to do with not getting all of that germinal matrix you got to really get in there and clean it out some of the some of the folks do it in clinic and some of the folks do it in the OR I would love to see a comparison if maybe you're you're doing a more complete job in the OR but I've also seen those grow back as well so I will say as a warning for people who are starting out and doing matrix ectomies that they can surprise you and come back which is such a major bummer so chemical is another way of doing a matrix ectomy this is the matrix ectomy that I do the surgeon that I work for tried for very many years to convince me to do a surgical matrix ectomy in clinic it felt very gruesome and I just never wanted to do it and so I got into doing these chemical matrix ectomies when I first looked at the literature I remember there being like a you know 20 to 25 percent recurrence rate the I was trying to find that original literature last night when I was doing this and I could the literature that I was pulling up had this like miracle recurrence rate of like you know 4% I don't know I caution patients that again to me it's about you know 25% of these will recur again that probably has a lot to do with just how much of that phenol you are applying and how good of a job you're doing at cleaning that out I use phenol that's the most widely commercially available product in the United States there's a little bit of question as to how long you apply that for when I was setting up my protocols it seemed to be the literature was around 30 seconds and then up to three times so like taking three of those swab sticks and then doing 30 seconds a piece I went back and did a literature review last night and it's still kind of all over the place there was a very recent study that recommended the 45 second application the trick here is that that phenol is tough on the skin I mean as you can imagine it's it's burning away the germinal matrix and so you can get chemical burns you can get a local irritation I definitely see more untoward side effects with this type of matrix ectomy compared to the surgical with drainage infection and so I will put these on a couple of days of Keflex plus I'm doing it in the office which feels you know dirtier but definitely more drainage I definitely spend a longer time with wound care you know making sure that they're gonna keep it clean and and then there's this electro carterie and this seems easiest in the OR I've never done this and no one in my practice does this but there's some great evidence right now and you're essentially doing it along with a surgical matrix ectomy so you make an incision and you open it up and then use the electro carterie to get down into that and then sort of like zap away the germinal matrix obviously there's a risk of thermal injury and then more specifically thermal injury over that bone so that would be the risk that that would carry that a surgical wouldn't so I'm not I'm not sure it didn't seem it didn't seem that was worth it to me but anyways it looks like a lot of folks are doing that this is my favorite thing in the world to do is a subungual hematoma trepanation I know so this is where you've had a injury to the nail bed and it bleeds right so you create a little hematoma right under that nail and this can be with or without a an associated fracture the trepanation works best if you do it really early on so if you wait a day or two in my experience the juice just isn't worth the squeeze and if you have a very small mild hematoma that's not painful there's no reason to do anything about it I've I get these all the time with my ski boots and they just you know they look silly and then they get better but if you get pain with them and there's you know about half of the nail is covered in that hematoma you will feel so much better if you just drill a little hole into that into that nail so just like this guy's doing here you just go straight down I also use an 18 gauge and I keep these in my in my backpacks and it is just a very quick release of that pressure it's super satisfying it's like the pain goes away if you have a big bloody traumatic crush injury you know you're asking a lot of that 18 gauge and that's when if you've got lifting off of that nail that's really when it's best to go ahead and pull that whole nail off I probably showing my age but I've been around enough to where I've just seen a lot of different kind of crazy things come in from the ERs in our area from nail trauma so like they'll sew the nail back on always with nylon so I get to take that out in clinic or they will have this I had someone come in with this piece of foil kind of sewn on there's great research that says none of that is needed you either leave the nail or you take it off if it's lifting and it's a situation you likely have a nail bed injury and then it's best just to take that off and repair that right then in there those do the best rather than waiting for it to work itself out did I get that yep okay so this was such a fun rabbit hole to go down I'm so grateful to AOPS for letting me do this so onchocomichosis risk factors it feels like everyone that we see has this I am now super paranoid that I'm just gonna get it by virtue of being around everyone but being older having diabetes immunocompromised athletes family members comorbidities you know if you have a fungal infection elsewhere likely you've got one there too psoriasis is a huge comorbidity very very common vascular disease hallux valgus smoking and this asymmetric gait toenail unit syndrome never heard of that but it's essentially the flat-footed folks who have that sort of that mal alignment of their toes just a little bit that forefoot and then they wear tight shoes and so they get this sort of chronic trauma onto that nail and then they get this secondary infection fungus cultures I've never in my life sent out a fungus culture for a toenail but it turns out that that is best practice especially when you are planning on treating with one of the expensive topicals and I talked to a dermatology friend of mine and she said you can't even get that stuff approved without a positive fungus culture so it's tricky because Medicare won't pay for those fungus cultures unless you demonstrate that you're going to be treating them medically for a long time and then you can't get the medication medically if you don't send out the fungus cultures so that feels that feels American barriers to treatment toenails grow very very slow and when and they have a lot of layers of keratin and when you get that thickness of the toenail the medications just can't penetrate so and all of the literature on the medications which we'll look at added just a second once you get past 50% of that nail involvement which gosh it feels like almost all of my patients um the medication is not gonna work like it's not shown to be effective which you know is a bummer so again the patients who are immunocompromised, if they have the permanent matrix nail bed damage, they also do not do well. Also, a lot of these older folks have concurrent mold in their nails. I couldn't spend that much time on looking at those pictures. It's not something I wanna think about. Here is the treatment, systemic. I have done this about three times in the last 14 years, because it just seems like a lot of risk, but I do have patients ask for systemic treatment, and I probably should get over myself, because it looks like for moderate disease, it can be fairly helpful. Tobitophene is the one that's most recommended. It has a slightly higher cure rate. The dose is 250 milligrams daily. 12 weeks for toenails. It's, I think, six weeks for fingernails. The complete cure rate is 38%, which doesn't sound high until you start looking at the topicals. It can absolutely be hepatotoxic, so it definitely needs hepatic and renal adjustment dosing, but you also should be checking your liver enzymes. So my protocol, when I was doing it way back in primary care, was I would do baseline liver enzymes, and then I would do monthly on treatment. I wouldn't give them the three months at a time. I would make them do the labs before I released the refill, just so that I wasn't killing anyone's liver off. And then there's another off-label use of fluconazole, which is very well tolerated. That's the stuff we give for lots of different infections, including vaginal yeast infections, and so they're very well tolerated. It looks, I was kind of surprised about this complete cure rate. Unfortunately, you do have to take it weekly for 12 to 18 months, which seems like a commitment for your toenail. These are the topical considerations. So the problem is penetration. We just cannot get that medicine into the nail. There's like, I don't know, 80 layers of keratin that you have to get through. The infection causes that change, that torturous change in the nail itself, and so there has to be very specific medication on a molecular level to really even penetrate that. And so most of the medications that you'll see on Amazon just don't have those properties. So what we, we have a couple of nail nurses in our clinic, and they are very adamant on, they do grinding every six weeks. My very sweet nail nurse said that it's essentially like a hair follicle, like it sort of, it grows, it sort of seals itself over, and so you have to grind down that layer to allow the medication to penetrate. And she'll be happy to know that I found a couple of studies that actually supported that at a sort of chemical, like what we're doing physically grinding down that layer absolutely helps to get that medication down into the lower levels where it can be helpful. There's all sorts of adjunct therapies that can help get the medication in as well. So lasers, I would love to have a laser, my office likely won't pay for it. Ionophoresis, microneedling, acid etching, I don't know what that is, and low frequency ultrasound has been explored in literature to add penetration through the nail. I see a lot of dermatology clinics offering modalities like this. So what I, what's happening is that they're using some sort of physical breakdown and then they're adding the medication and that seems to be helpful. These chemicals, that hydrogen peroxide, it's just things that is usually added to the medications that allow an increased penetration. And then know your limitations. If you've got this super thick nail that's completely deformed and covered in this fungal infection, it doesn't matter really what you do. The studies are pretty clear that the medications are not going to help. And so the recommendation really is just to remove that nail. And if you want to try again, that's fine, but you do still have to treat the new nail coming in for the same amount of time, right? So, and we'll get to that right now. So this Keratin and Jublia, these are the brand medications. They are super expensive. So Keratin retail is 1800, Jublia is $900. You have to do it daily for basically a year. Check out these cure rates. So Jublia, complete cure is 17%. And Keratin is complete cure 7% and partial 24%. It does work better than the old Cyclopyrox nail liquor, which although, I mean their standard total cure rate is 7%, but this Keratin says that they've got this greater penetration. So anyways, it seems very expensive to me. In our clinic, we use this good old tea tree oil. So the nurses that we work with have been doing it for very long time. And they all swear by tea tree oil. There's some pretty fun studies. There's some in vitro studies that show eradication of the fungus on these little human nails, but I couldn't find a head to head. So I'll keep looking, but this is what we use in our practice. It is very cheap. There's no insurance. I'm not sending off fungal cultures. We still do the same protocol as you would with the prescription stuff, meaning you grind the toenails down every six weeks or so, and patients can do this at home with their own nail file. And then you add this on a daily basis. So you just have to really get in the habit of using this. And in my experience, this works great for those sort of mild to moderate. Urea is something that we use to soften calluses. I think it's an awesome workhorse to soften up calluses and like those cracked heels. But I read a couple of articles of people using urea over their nails at night to help soften up that keratin and then put that tea tree oil or whatever topical medication on over. So I thought that was a pretty cool idea. And I think I'll add that to my little regimen. Pencil nail deformity. I had no idea that there were these surgical treatments for this because we don't do this in my practice. This is when those nails just sort of have that very curved appearance and they're super duper painful. In our world, we usually just do a matrixectomy with them. Like we take them off and then we do a permanent matrixectomy that seems to solve the problem. But this is the sort of salvage procedure that I saw described that I thought was kind of fun. But it comes from most commonly ill-fitting shoes, onchocomycosis, but also the use of beta blockers which I thought was kind of interesting. So nail grinding brace, urea paste, all the same thing. So not super different from the onchocomycosis but a different surgical technique. So I thought that was kind of fun. This is my little spiel on billing. I am not a billing expert by any stretch of the imagination, but I reached out to my billing person at my office and she sent me a bunch of links and I compiled these all here for you. So we don't bill Medicare for foot care for the most part in our clinic. We do it on a cash pay basis and then refer out for a lot of our foot care. But I do know a lot of people who do foot care and it's definitely billable but you have to do a good job of documenting. So here are the conditions that justify and then some of the verbiage that Medicare likes. These are the links if you want to jot them down. And surprisingly this site was very easy to navigate. When I was doing this, I updated my Epic Smart Phrases to make sure that I was adding that verbiage in when I do the occasional nail care that sneaks by. These are the CPT codes for debridement and avulsion and wedge excisions and callus pairing. Turns out I was doing this wrong. Apparently you can bundle the wedge excision with the avulsion. So I was not doing that. Avulsion is where you actually take the nail off, right? So you take the nail off and then the wedge excision is when you're actually cutting into that granulation tissue on the lateral fold. And you do that either with a 15 blade or sometimes just some super sharp, tiny little scissors will do the trick. And then there's your nail debridement or your cleaning of the nails, if you will. Here's my take home message on this slide is that there's a whole lot to toenails and it's really out of our wheelhouse. I've seen melanoma a handful of times in toenails and dermatologists are really just doing the Lord's work out there with figuring out what's going on with the nails. But there's a lot of underlying health conditions that I'm probably missing when I'm looking at these nails. And so if you sort of see these and you can kind of recognize them, I think it's up to us to refer and make sure these patients are getting the proper care because it's definitely outside of our scope in foot and ankle practice. So anyways, I did send a little thank you to my local dermatologist for taking all of my nail referrals and she's very gracious with it, even when I'm wildly wrong. So I think that is all I have. Thank you so much for listening to my nail talk. Tracy, that was really a great talk. I learned a whole bunch about nails and it's something that our patients are always asking us about and that was a really great, great overview. So we have one more speaker this evening and we'll have more time for nail questions later on. But our next speaker is Teresa Albert and she is a member of the Allied Health Education Committee and it's been great having her on our committee. She's a pedorthist, she's faculty at the University of Colorado and she works with Dr. Ken Hunt and some of the other foot and ankle surgeons at University of Colorado. She's the president and education liaison for the Pedorthic Foot Care Association and I'm looking forward to her talk tonight on tricks for writing orthotics and orthotic overviews. So thank you, Teresa. For your patience, everyone. So we're gonna go through this fairly quickly. First of all, we're gonna start with the basics. What's the anatomy of a foot orthotic? So there's a lot that goes into designing your orthotics and you have to keep the end in mind before you even start thinking what you want to accomplish with your orthotic. Do you want to provide control and function and change the biomechanics of the foot or are you trying to just accommodate your patient's foot? So the anatomy of the foot orthotic starts always with the shell and then we add the top covers. We also can incorporate accommodations like metatarsal pads, dancer pads, wedges, heel posting to accommodate the functionality of the foot. There are rigid orthotics. They're made out of stronger materials like carbon fiber or graphites or your plastics. They're often heat moldable and adjustable. We have semi-rigid. Again, they're heat moldable. They're made out of plastics. They also can be adjusted with a heat gun, often with a hot water bath and you can add additional modifications to these as well. They're also easier to grind if you need to make any modifications in the office as well. Then you have accommodative orthotics which are your softer materials. They have minimal structure. They're really there to accommodate and to offload and they're usually a total contact type of orthotic. So they mold and they're very accommodative to the foot. So let's talk about these forefoot conditions. Dr. Tolson did a fabulous presentation and covered some of the nitty gritty for toe deformities, bunions, hammer toes, mallet toes, claw toes and all of these can be accommodated with orthotics including sesamoiditis, neuromas, hallux limitus, corns and calluses. And what we're looking for in an orthotic is the whole picture for the patient because it's not just the orthotic. We now also have to put that in footwear for the patient as well. So with these conditions and all of you mentioned it, Tracy mentioned it, Dr. Tolson's mentioned it, we need to start with the footwear. That's the foundation for the patient. We need a wider shoe for that patient to accommodate these foot deformities. We need a deeper shoe for that patient to accommodate the hammer toes. We need softer upper materials so that it's not damaging or creating sheer friction for those calluses that you saw on the pictures that Dr. Tolson showed on the claw toes. And you need a stiffer sole so that there's not so much flexion with every step of push off or a rocker sole to make it easier on those metatarsal heads to take off the pressures. So the footwear is critical to the prescription and you have to look at the person's shoe and see where the wear patterns are. That'll give you the whole picture. We call it footwear forensics and pedorthics. You'll see where they're wearing out the sole of the shoe. You can take out the inlay of their shoe and see exactly where the pressure areas are. So that will already tell us as a pedorthist, as an orthotist, what we need to accomplish in our orthotic design. So for the orthotics for these patients, we wanna have full length because we're dealing with the forefoot. So we wanna accommodate it by having a full length orthotic. We wanna have accommodations like metatarsal pads or a bar if necessary to accommodate the entire parabola. Maybe a dancer pad if we wanna offload sesamoids or we need a first rate cutout to drop the first metatarsal head. Maybe we need a turf toe extension for hallux limitus or rigidus to provide more of a splinting agent and propulsive control for the first ray in the medial column or any other type of offloading cutouts that we may want for calluses or offloading of the metatarsal heads. These orthotics are often a combination of materials, dual laminates or tri-laminates of materials. They're often made with a softer cushioning material for offloading on top of a semi-rigid and or accommodative cork or semi-rigid as I said, type of orthotic material. Also socks, the seams of the socks are very important especially if you're dealing with an insensate foot or a diabetic foot, you don't want those seams to rub or cause any abrasions to the skin. Two-ply socks, there's lots of studies done that two-plies reduce shear and friction against the skin. So a lot of runners will double up with their socks. If you're hiking, there are many socks on the market that are actually two-ply that the sock interfaces with the other material so that it absorbs more pressure. So there are a myriad of ways to treat the forefoot conditions using orthotics, using footwear, as Dr. Tolson suggested, using toe sleeves, silipose toe sleeves and so forth. And we'll show some examples of those in our pedorthic toolbox. Here is a first rate cutout on an orthotic on a copolymer more rigid shell. The blue material is the poron cushion. The second picture demonstrates a dancer pad with an offload made out of felt. And then you can see on the last one is a turf toe extension in a custom orthotic. And don't forget carbon fiber shanks are very, very useful in shoes to be a splinting or to limit motion in the foot. And now footwear like many of the brands are coming out with carbon fiber shanks incorporated in their soles to provide this type of control in their footwear. OTC medical grade orthotics are available to relieve these bunions, hallux rigidus, turf toes. They're targeted to take and support under these joints and to relieve the pain by using Morton's extensions. They're heat moldable. There's many of them on the market. So you can talk to me or call in local reps. They're happy to give you in services on all of these products. Again, here's another one that's a very low profile one. You can see here, I demonstrated this because it's so low profile. I use it in cleats. I use it in ice skates. It has a metatarsal pad incorporated in it. Great for metatarsalgia, neuromas and hammer toes. So plantar fasciitis, everybody has plantar fasciitis. So we literally throw buckets of cold water on plantar fasciitis. You have to try everything. But again, starting with the footwear. And sometimes it's the footwear that causes the plantar fasciitis, right? They haven't changed their shoes often enough and they're worn down. So you want supportive footwear. Birkenstock sandals are the original orthotic with a top cover. It's a deep heel cup with an arch support and a toe crest. So every time you take a step, you're using your extrinsics. You're exercising your arch. You're innovating the gastroc with each step because you have that toe crest in that particular sandal. Raise the heel height in a cowboy boot. Take off the plantar plate stretch by raising the heel or using a wedge shoe. Use a rocker sole. Make it easier in the glide from heel to toe progression. Use a high top. If you disperse the weight from the plantar aspect of the foot up to the ankle, it will take the weight off of the plantar fascial band. Orthotics, we like to use semi-rigid or functional orthotics, often with a medial post for these patients. Using a deep heel cup to contain their own fat pad under them to absorb the pressure at the heel. Accommodations using arch feel, using a soft heel plug or using a horseshoe cutout. In the office, you can even make a horseshoe cutout using felt. You could use a felt heel lift in the office to get immediate results to trial a patient to see if an orthotic is gonna work. Compression socks can be helpful. Padded heel socks can be helpful. Telling your patients not to walk around in their house barefoot. Using night splints and don't forget the calf stretching and physical therapy. Very critical to do the calf stretching. In the pedorthic toolbox again, as I mentioned, the Birkenstock, cellopost heel cups, making sure the arch support is aligned with the arch using a medial heel post there. Again, we wanna put out the fire. We're putting buckets of water on this. You have to incorporate everything in this. Research says that most plantar fasciitis will resolve if you give it enough time. Two years or more, but no one wants to wait that long. So the first thing people stop doing is their physical therapy calf stretching. So you have to remind them to do their toe curls, their lunges, their calf stretches, using ice, dry needling, wearing their shoes, and their orthotics. Over-the-counter medical grade orthotics, so we usually use a dual laminate with an EVA top cover so they get some cushion, rebound there. You know, hard on hard never feels good. This is a particular orthotic that we use in clinic. It has a medial post, it's subtalar neutral, it controls the pronation, and it adds that arch support. So for a pronated pes planus foot, the flat foot is certainly easier to manage than the pes cavus foot. Again, Athletic Footwear is the new orthopedic footwear. It offers all the bells and whistles if your clients are fit in the appropriate footwear for their foot condition. You want a shoe that has medial counters to support the medial counter of the shoe needs to hold up the posted tendon, the medial arch. High tops will give you more support, boots even more, and a stiffer sole shoe. We want a semi-rigid orthotic, or even something more rigid like graphite, depending on the weight of the patient. If it is a fixed flat foot, you can't take a fixed flat foot and give it an arch. That is not gonna feel very comfortable on that patient. You may have to have a surgical consult with that particular patient and talk about something more complicated, like a calcaneal slide and transfer the tendons. But if they're presenting with knee pain and other anomalies because of their flat foot, their pes planus foot, footwear can help them by raising the heel height or putting a heel lift under there. If you control them in a UCBL, a deep heel cup orthotic, if they can tolerate that in a flexible flat foot, you will get tremendous control. They need something more than that. You can use a SML, a submyeloid orthotic, sorry about that, or even come up higher to an AFL. So again, it's all about medial forefoot posting using a soft top cover for them and socks should be form fitting. So in our pedorthic toolbox again, here are some examples of orthotics. You can control the hind foot with a medial post, but don't forget the forefoot. The foot is like a washcloth. If you control the back of the foot, the hind foot, you must control the front of the foot. Otherwise that patient's just gonna over run the orthotic and run right over it. And they're not gonna get that medial column control. You can do medial wedges on a shoe as a modification for more stability. You can use posting wedges and control this type of hind foot alignment. Supination, as I said, pescavus, it's a little bit more difficult to manage these patients, but again, you need shoes that will provide them with a deeper seated heel, something that has an adjustable upper because their foot is more rigid. So it's more difficult to don inside the shoe. So a boot with a side zipper or boot with laces that open up or Velcro closure or something with a stretchier top that allows the foot to go into the shoe is gonna be more helpful. The orthotic, you want to have a full length orthotic because these patients often have a more of a tripod foot. So there's more pressure at the heel and at the ball of the foot, these patients present with calluses under the metatarsals. So you wanna have a softer material at the front of the orthotic or offloads for those calluses, those dropped metatarsals. And a semi-rigid orthotic is more appropriate for them. You wanna arch fill and a lateral post as a kickstand to kind of help to control that supination as they strike on the lateral side to encourage them to now move through the stance cycle and then to push off in a pronatory motion. Metatarsal bars are very helpful and toe crest as well. Socks, there are many that give additional arch support and you may wanna bubble toe sock because they often present with these hammer toes or claw toes and socks can be very irritating for them. So again, here are some examples of a lateral buttress on a pair of athletic shoes to control that supination, a higher arched orthotic. Remember, if you're gonna build up the medial column, you have to consider the lateral. You don't wanna build it up so high on the medial side because you're building a high arch. They have a pescavous arch, but you don't want them to roll off to the lateral side. You can use felt pads, scaffolding pads, metatarsal pads. Do you want to align this foot on the orthotic device? Here's an example of a foot where I put a wedge underneath it and controlled the supination. You wanna distribute that pressure over a greater area. There are over the counter medical grade orthotics that are intended to provide a deeper heel cup. They're also heat moldable. They have medial and lateral flanges to support these patients and they're cost-effective. You can dispense them in the office as well. Functional orthotics are your more semi and rigid foot orthotics like the UCBL, the University of California, Berkeley labs. Those are made out of polypropylene, sorbethylenes. They're plastic, they're hard, they're deep heel cups The SMOs are super malleolar orthotics. They come up higher on the heel, containing above the malleoli to give you more medial lateral support. And then you have SCFO, subtalar control foot orthotics that come up even higher. So they're more like a little inner boot. I circled this picture because it doesn't really matter how high up I go on the patient. If it be a foot orthotic, if it be an AFO, if it be the hinged part of a knee brace or KFO, it all has to incorporate with the footwear. So again, we always have to start with the shoes in mind. Combinations of UCBLs and SMOs are a great option for post-tendon dysfunctions. I use this a lot in clinic. Patients like this a lot because it fits in their shoes, it's great for osteoarthritis or any mid-tarsal joint collapse. It's more than an orthotic and it's less than an AFO brace. I have soccer players using this. So this is a nice little in-between. It's more than the orthotic and less than the AFO. If you can't manage it in those types of braces, then you need to come above the ankle. It's like if you have a tree that has a knob on it and you wanna train that tree to grow in a certain direction, you have to put a brace below it and you have to put a brace above it. And it's the same with the foot and ankle. So if you have severe post-tendon dysfunction or you have a diabetic patient with a Charcot foot, we need to treat these patients with total offloading by using something like a crow walker or if you have a drop foot patient, we need to use something more like a dynamic action AFO to help with that dorsiflexion assist. And again, all of these need to be incorporated in the footwear. And don't forget your rocker soles, the stiff soles of the shoes, the alignment of the rocker soles, where they're placed, offloads, the fulcrum points at push off and that heel strike. And it's important for your shoe fitters, your pedorthist, your orthotist, and for you to get to know your shoe stores, your fit and sit stores, so that they can fit your patients appropriately in the right footwear. So with that, know where you're sending your patients, know what your outcomes that you want to achieve. You may not know the tools that we have in our toolbox. We certainly don't know your surgical techniques. We're not surgeons. I'm privileged to work with a fabulous team at university and I'm grateful for all the knowledge that they share with me and we collaborate together. So I know what they want to achieve and they give me the leeway to use what's in my armatarium to achieve their goals for their patients. And with that, I have to know what my lab can do for me. So it's important for all of us to get on the same page, know how to write our prescriptions and to communicate with each other so that our patients can have the best outcomes. So with that, I thank you all for your time and your patience. And I think at this point, I'll turn it back over to Dr. Zell and thank you again. Thank you, Teresa. That was a great talk and really a whole bunch of great, great information. We have about 10 minutes to go through some questions and there are some on the Q&A board here. So I'll start at the top here. Some patients with the bunionetic pain at the plantar lateral aspect of the fifth metatarsal head area rather than the lateral aspect of the fifth metatarsal head. Do you think surgery or MIS-osteotomy can work for this case? And I guess a follow-up question, are there any good non-operative things we can do in the office for this condition? Dr. Toulousan. Yeah, I mean, I definitely would start with non-operative things, as we always do. And I think, well, you can yell at me if I'm wrong, but I think this is a good case for something accommodative where you got, or really the principle is you can offload the plantar aspect of the fifth metatarsal head. And I think that's a good case for a non-operative thing. Of the fifth metatarsal head. And I think we just learned about various ways that one can do that. And every patient's different with what's comfortable for them. But well, from the surgical area, I really shouldn't even answer that part, but the surgical part of it, yes. If it comes down to doing surgery for it, I think this is a place where you can do a transverse osteotomy of the metatarsal neck. And a lot of people who do MIS will pretty much say, like you cut it and then you let them walk on it and it'll find its happy place. And I think that this is kind of where that could apply. And I mean, you could go all day about, well, if it moves around, you could get a non-union and all that. And that's all true. But I think that in general, I think this is a great, that would be a great reason to do some sort of an osteotomy. And it should help to offload the plantar part of the metatarsal. So one other technical question on that surgery, one of the attendees wanted to know what size of wire you would use for that. Yeah, so you'll see in those two pictures I showed, one of them was probably a 2.0 millimeter and one of them was probably like a 1.2 or a 1.6. It really comes down to like, to be honest, if I'm doing other things in that case and there's other K wires that are just up, I mean, I'll usually just ask for what's open, and if there's something nearby, I try to not spend too much money. So, if there's a K wire that's in pretty good shape, then it's a 2.0 or a 1.6, something around there is what I'll use, but it's generally one of those two sizes. I'm sure your OR director is very thankful for being so accommodative. Well, I do end up spending a lot of money in a lot of other places. Eric, the other speakers can jump in here with questions, but I have a question for Teresa. You showed that short Arizona or short gauntlet type brace. What patients should we consider for that brace? So, midfoot arthritis, fabulous. Post-op, I would say, fabulous. Post-tendonitis, tendinopathy, it's great. If you have someone recovering from like a cuboid fracture, it would be great. Navicular fractures, great. You know, they're healed and they wanna get back in the game. It's just a really nice little stable brace. Thank you. Another question for Dr. Toulousan. Sometimes we see inflammation of the second MTP joint, and you did go through some of the causes of that. Is it a problem to inject those joints with steroid? And that's not done in the past, but after thinking about this, maybe that's not the greatest idea. Yeah, there's actually been a couple of case reports, and they're only case reports, but case reports of steroid injections into a metatarsal or into an MTP joint for MTP synovitis. And then, the patient shortly after developed like a cock-up toe, indicating plantar plate repair or plantar plate tear or other toe deformity. So, collateral ligaments or something. With the thought being that the steroid like attenuated those structures. You know, I think it's, I don't inject them like frequently. I don't inject them like I would inject knees or ankles or, you know, big toe. But I'll do them occasionally, really case by case. You know, patients about to go on vacation or they're just a really bad surgical candidate or they're in a ton of pain and they need something like right now. But I do warn them that, you know, they could end up with a deformity at the MTP joint. And so, it's more of a, you know, you gotta think about it. I don't just inject them routinely, but yeah, I mean, if you're gonna inject one, as I do, you know, have a good reason, basically. Thank you. I have a comment, if I may. Tracy, in our clinic, when I'm dealing with the nail patients, one of the things I do for our protocol is I tell them to get an Emory board and break it up into five pieces. And I tell them to just rough up a nail and throw that piece away and take the next nail piece and rough up the next nail. Never use the same nail file to each nail. And then they take the Penelac and then they polish the nail. And then they take it off at the end of the week. And then they take a new nail file and they rough up the nail, a new nail file on each nail for the next week paint and then take off again. But that's what we find is that people don't fall down, like you were saying, to get it in. And then they're using the same nail files to transfer from one nail to the next nail, you know? So I think it's really important for the patients to understand, go to the dollar store, get a box, you know, and just cut them in little pieces. You only need a little piece, and rough up each nail individually. That's a great suggestion. And then someone suggested in the comments that, I think it was the Keratin maybe was sold at, oh, I answered it. Yeah, it was available at Mark Cuban's Cost Plus Drugs for about $35 a month without insurance, which I thought was incredible. I've never, I don't have any experience with that. So I added that to my phone. So thank you to Sterling Campbell that said that. Because I think we're still doing prior auths in our area, which seems a little silly for that. So, yeah. Oh, someone's asking about PRP for plantar plate. I mean, in general, I'm just not a real PRP person. So can't really comment on it. Although based on what I limited stuff that I know about PRP, like, I'm not against it. So, you know, like if someone, you know, if someone has a plantar plate, so, you know, like if someone can afford it and knows someone who's willing to inject it, I wouldn't stop them. I had a local plastics who was injecting fillers into the plantar plate area for, I'm assuming fat pad atrophy and metatarsalgia. And it seemed like it worked for a little bit and then it ruptured the plantar plate and give this lady a deformity. So we had to straighten that toe back out, but I thought it was a nice try. And I thought maybe we could use inner to do that, but alas, it didn't turn out well. Yeah, I mean, we still don't have great answers. I mean, I think we're always getting better at how we treat them and understanding, you know, plantar plates and lesser toe deformities. But honestly, like, I think it's just never been an area that got a lot of research energy. You know, I mean, we're still at a point where we're just kind of holding them straight and sticking a pin in them, you know, and it's like a very accepted treatment. And it kind of works, but it kind of doesn't. And that's how they all, everything we do, like kind of works, but kind of doesn't, to be honest. This might have to be our last one, Dr. Zell, but someone mentioned a patient that had uncontrolled diabetes with a history of ulcers. Would you be more or less likely to surgically intervene with a hammer toe? And I feel like he touched upon sort of the next level indication for surgically managing those toe deformities. Oh yeah, I think, yeah. So I know that question I think is, if you don't do anything, it's going to become an amputation, you know? And so, you know, I think that if you're going to try to save a toe, it's not whether you do something necessarily, it's more of like, how do you do it with the least amount of risk? And I think that's where minimally invasive surgery definitely plays a great role in just like tiny incision, cut the bone, you know, sort of pin it straight, I guess, or do something. And yeah, I mean, because otherwise it'll probably turn into an amputation. I think that's all of our time for tonight. I'd like to thank all of the three speakers. They were great talks and well, we'll look forward to our next put into practice webinar. Thank you. Thank you. Sounds good. Thank you. Good night.

foot and ankle care

bunionettes

non-operative treatments

surgical interventions

nail deformities

matrixectomy

onychomycosis

orthotic prescriptions

plantar fasciitis

multi-disciplinary approach

footwear

patient outcomes