Drs. Justin Kane and W. Hodges Davis discuss how MIS techniques are revitalizing foot and ankle procedures with new technology designed to achieve higher patient satisfaction.
1. Lam, P., Et Al, Foot Ankle Clin N Am 2016 SKU: AP-014250A
What I'll do is I'll go through my experience. I'll go through very briefly the 30,000 ft view of the M. I s system. I'll go through a few of my cases. I'll put up a video just to kind of show how I do it. And what kind of go from there? Here we go. So my experience, it's actually 2016. I went to the fast meeting to present some data and right medical had a, um, lab that they were doing for a minimally invasive Bunyan and friend of you that know Dr Joe over in Wa um, pretty charismatic, definitely better head of hair than I have. And I really was enamored with the technology and just how convicted he was that I'm convinced that he was that that it really, um, improved this practice improved his patients outcomes. And even though I had learned it two years prior, it took me a little bit of time, and I was a little reticent, uh, to go ahead and do the first one. Um, but in 2018, I had a nice young lady who came in she had into four of the surgeons looking for somebody to do a minimally invasive Bunyan. And she came to me and she was like, Look, I've been to four other people. Everybody says they do minimally invasive, but nobody will actually do it for me. So I said, Well, you know, why not? I know how to do it. Uh, the guys over in Europe are getting good results. Um, let me call in a favor and see if I could get the RV into town. And thankfully, the RV was there. Um, funny story about the RV is I wanted to do a left and a right. So they thought to different specimens. Me, they actually the same patient. And it was actually in a contra plastic dorf. So the feet were too small for me to actually, um, practice on. So, um, we had some choice words. And then the next day they brought it back, and I actually had a real foot, and we were ableto practice a little bit before I did the first case. So that first case was really very eye opening to me. And, you know, before that I've done Lapidus scarf was my real workhorse, But I did Chevron's I did Love loss. I did a lot of different osteo autumn ease, and I was really, really kind of by the book. You know, I looked at the inter metatarsal angle, the hell it's about this angle, the sesamoid station. If there was any rotation and I followed the algorithm and this first case that the young lady came back to me a two weeks and she had taken a dressings off herself, had put herself back into her Tory Burch sandals and was walking in like nothing happened and I couldn't believe it. I really I was like that. This is it. This is what I have to do. So currently. Now this is my workhorse procedure. I always help my residents and fellows that you need to find a procedure that works in your hands, and that should be your go to, unless there's an indication that you need to do something else. And right now I'm correcting about 90% of how it's analogous through minimally invasive technique. If you include bilaterals, I've done 172 of these. So far, I've only had seven complications for them or hardware removals. One was actually a chemical burn from the skin prep. It wasn't even at the bunion site. But if you're being a purist about looking at your data, this is a complication. One person had a delayed wound. Complication. I put my patients back in tissues in two weeks, and I think the young lady just kind of got after she was on her treadmill on on her on her stand. Nestor and she came in and she had irritated the where the ost iata me is done. And I wound up having a put her on oral antibiotics but didn't need to take her back. And then I had one patient who had I extended shortening with guitar. Sal Gia, Um, my personal opinion. You should adopt this. This This is a procedure that is highly reliable. Once you get the hang of it, it's reproducible and, you know, for lack of sounding like an extremist, I don't I don't really think there are many bunions that you can't correct there a minimally invasive procedure and my practice has had a real paradigm shift. I did my fair share of 4 ft, but I would tell you on any given week I see about 15 to 20 people who we sign up for bunions, and there's a good share of people who are flying from out of state who come in. I do their Bunyan. They fly home two days later and resume at two weeks and resume at six weeks. And if there's no issues and knock on wood, there hasn't been any issues. Um, I don't hear from them again unless they text me or email me on. And we've done people. Last week we did a young lady from Minnesota. We've had people from New York from the Northeast, from the Pacific Northwest from South Carolina. You name it that they're coming in and we have extreme line now. They come in on a Wednesday, we do the surgery on a Friday and on Sunday they're flying back. So this is something that if you adopt it and you're comfortable doing it, um, I think you'll find that this becomes one of those procedures one of those techniques and one of those technologies that is practice changing. And there's a few of those that have come up through, you know, my career. What is the the total ankle prophecy and this is the next one. And I'm sure for some of the other surgeons out there they have ones in their mind. But this has changed my practice, and it's really easy to talk about something that you thoroughly believe in. So I'm always open. You all can always reach out to me. Talk to me. I'll send you videos. I'll tell you what I what I know and what I can help you with. Because experience really is the best teacher. Um, so the ideal feature for your metatarsal last iata me. You got to get adequate displacement. It's gotta be reproducible. You gotta have stable fixation. It needs to be anatomically biologically safe. So you don't wanna damage the blood supply. You don't wanna have necrosis the bone leading to non union. And you don't want to injure the surrounding thio structures like the soft tissue. You also don't wanna disrupt the capsule if it all possible because it's avoid stiffness. I think that this for me really hits all of those. It's a high torque, low rpm birth. So you're not getting thermal necrosis. It also has a little irrigator on it. So you're not getting soft tissue necrosis. You're staying out of the joint capsule so you don't see the stiffness that you get when you do your video capsule repair implication. Um, and you're not injuring the surrounding structures. And one of the ways that I avoid that is on my incision that I'm doing the ost iata me through. I always think of Freer and to free up the the Perry Osti, Um, just to avoid dinging that dorsal media cutaneous nerve. Um, I really have had good results with the patients not having hypertrophic scars. They don't get the swelling that you see with open bunions. I remember my scarfs. You know what, three months they'd be coming back in and really complaining about getting back into shoe where comfortably, they have to wear a size bigger just because they still have soft tissue swelling. And that is not the case. I really have to slow my patients down because you know that the patients come back and they're they're six weeks and they're saying, you know, I'm running two or three miles and I'm like, Oh, my goodness, you you shouldn't be doing that, But they dio um So the evolution of the techniques will really briefly talk about this just and, you know, simple terms. The early results were really crummy. I think it's our resurgence in Europe with the minimally invasive group out there, and they refined some of the techniques techniques. They will find some of the instrumentation, and they will find some of the hardware. And those results are sort of where we've sort of piggybacked on toe bringing and introducing here in the United States. And my results of sort of echoed that that they saw in Europe and again, anything I could do to help you all sort of figure this out and get comfortable because this is not, you know, your mentors ao technique. You know, you look at an X ray and it's it's not gonna be a pretty Azaz, you know, a scarf or love law for a lapidus or approximately percent IQ. But it works, so we know the literature, the literature. There's less pain. Most of my patients come back and they tell me they didn't take any pain medicine or they took pain medicine for the first two days. Um, my patients in shoes by 3 to 4 weeks. Six weeks is probably the far end of when my patients get back into shoes, and what I tell all my patients is the benefit of doing. This is not a year down. The road is not two years down the road. It's the immediate benefit that you get. You don't have the discomfort, you don't have the swelling and you really are able to get up and take care of yourself. The scarring is minimal there, there are patients. And we just hired an M A from one of the surrounding areas who worked for a foot and ankle surgeon. And I brought her in tow, one of my one year bunions, and I said where the scars and she's like You did a bunion on that and I said Absolutely, and she couldn't believe it, and I showed her the X rays, and she's like, Holy cow, that's that's incredible. Um, and the patients are happy. The patients are probably my primary source of referral. I mean, I'm doing like families of bunions. I you know, last week I did the last member of the family. I did all six of the women in the family's bunions, and you know it's it's kind of cool to see that the patients are sending other people that your way because they're so happy and they all hear the horror stories. And we've all talked and counsel the patients that it's not as bad as all the horror stories that you hear out there. And this is just something that if if you do it, the word of mouth is going toe really take off and you're going to see a tremendous uptick in the amount of bunions that you're doing in your practice. Eso with the pro step you're doing obtuse angle Chevron. I think it's important. Just to mention here, you've got to trust your anatomy. Um, we've all done open Chevron's. You should do it the same way minimally invasive, and it's all about the motion in your wrist. Your you're not pushing the birth, you're actually permitting super dating your risk to get it across. What I would tell you here be really, really, really liberal your use of Floro initially until you get comfortable and once you're good, I take two or three shots and and I'm done. Um, you do it right in the metadata Seal junction. So when I'm looking, I mark all my spots on floor. Oh, I marked right at that spot. And I know that's where I'm gonna make my osteo. To me it's extra capsule, er so again, you're not doing any capsule work. So theoretically. And in my practice, you're not getting that stiffness from that medial application. The only real soft tissue dissection I do again is off of that ost iata me incision to make sure that I don't wrap up the dorsal media cutaneous nerve. It gives you really, really rigid internal fixation. And I challenge any of you do the procedure and then go live on Flora and crank the tow back and forth and you will see how stable this thing is. And I usually combine it with a soft tissue release. And I would say about 50% of my patients are getting an ache in, um, they're walking the day off and on a rigid postoperative shoe, they come back in two weeks, and I tell them sometime in the next two weeks, you can start weaning into a regular shoe as you're comfortable, allow pain to be your guide and then the birds that come with that you have your array of different birds. Um so my indications, just about an I know what the technique says. But I would tell you that just about any Bunyan that I see as long as it's not hardware or arthritis I could do because I'm I'm comfortable displacing the ost iata me greater than 100%. And I'll show you a picture to prove that it heals. And I don't have an explanation for it other than to say, because you're not disrupting all of the Perry Osti, Um, you have that Perry Osti a sleeve. And just like with mescal A the bone forms through the Perry Osti. Um, the bone does The bone grows across your ost iata me and you see it and it's really kind of cool. Eso obviously infection. You're not putting hardware in, um, inadequate patients. I mean, it is what it is. Any irreparable tendon Sophia of cock up deformities or any type of sesamoid metatarsal complex issues clear that it's not an indication, um, you know, bunions or not elective procedures or in the sense that they're not cosmetic. So patients who come in with no pain. I shake their hand and I say, When you have pain, come on back Eso Those are the ones that get conservative treatment in my in my practice open Phi Psi's You're not gonna put hardware across the Fyssas on board? I haven't seen this, but patients with high level of activity I think you just need to caution them that they can't get into that level of activity for a little time and even if their pain is not there, you know biology is biology. Biology doesn't change. Um, osteo Penick bone. I will avoid bilateral surgery and some of those patients on those cases I'm doing 100%. I'm doing two screws. Some of the patients I'm getting away with. One screw arthritis. The first mtp. Those were getting a fusion still in my hands first TMT arthritis with instability. I'm still doing the lapidus uncontrolled diabetes with sensory loss. Those they're not getting this procedure Inflammatory arthritis. If they have cystic changes in the bone where you're not gonna have good purchase those people who I'm avoiding this in And then again, sesamoid pathology anybody to do if somebody has wicked metatarsal sesamoid arthritis. They're still gonna have pain through plate reflection doors reflection because they're getting paid in the planter aspect of the first MTP joint. So for this, the feet hang over the end of the table. If you're doing bilateral in my in my hands, um, if you're doing a unilateral, I think the best way to do this is to use a piece of bone foam or elevate the foot above the other foot. And the reason is you can quickly switch from AP lateral without having the other foot get in your way without hitting the other foot with your cam of your mini C arm on. Then I have the mini crm come from the foot of the bed and the mini CRM that we use cams forward so you can actually get a really nice AP and swing it to a lateral very easily. I put the borough on the contra lateral side. The scrub nurse is on the lateral side. On. You have the sailing cooling irrigation system, which I think is helpful. So this is the set of that they have, and you could see the flora is actually from the side of the patient. I don't think that that's necessary. And I like to work from the foot of the bed. And the reason is that you could work from either side of the floral. If you have it on one side, it's hard to get your hands in between. So I like to be free on both sides so I can come in with one hand to hold and the other hand to do all of the Osti autumn ease and the and the instrumentation. So, yeah, Adam Nation here kind of. What is if it works, which it doesn't appear to be worked up. There we go. So there's your nick incision. You're freeing up everything around their tow. Avoid the door from media Cutaneous nerve. You introduce your birth. I introduced the burr under Fluoroscope E and I make my cut. I actually make the plant or limb first, and I do that because I think it's easier because if you do the plantar limb second, you destabilize it. And I think that this is really important what they showed here. I'm gonna pause it for a second. I believe in TMT instability, and I think that this is classic for some of my patients. And I think this is one of the pitfalls that you could have If you're not paying attention, your TMT joint actually gaps open if you do an aggressive translation. And we know from the literature from Roger, Man and Coughlin that with their approximate lost economies, they more they swung over there ost iata me the more they tightened up that TMT joint. So even in tm tm stability, I think that if you're careful, you can get away with doing a minimally invasive bunions and you drill through you make sure you get to courtesies on the proximal metatarsal. Then you put the screw across. Um, here they show you, putting the second square across, it's gonna be a little bit smaller of the screw. What? I would caution you. Um, it's again. It's not like what we used to dio. I don't vary the screws all the way to the metatarsal head, crossing it and getting about a centimeter past the ost iata me is more than enough. The thing that I worry about is, God forbid there's some shortening I don't want to screw to breach and here you go you're doing, You're taken Taken is sort of a green stick Cost iata me if you leave the far cortex with one side and then you have ah, closing media. Wejust iata me really, really easy and reproducible. Um, one of the tricks I learned with this you put the screw in or the wire and you measure it. And then what I like to do is I actually drill the wire through the other end of the foot so you don't pull the wire back out when you're done drilling, and it's pretty easy books. So for me, cut measure twice. Cut once. Make sure that you are making the incision in the place that you're trying to do it. One of the goals here is you're making smaller incisions to make a whole bunch of incisions and Swiss cheese. The skin is not ideal. Make sure that you're gonna make the plane of your chevron perfect. You could lengthen the bone if you need to. If it's a little bit short, you could endorse reflex. You can plant or flex. If there is a little bit of elevators there, Um, make sure that your guide wire for your proximal screw fixation is good Before this displacement of the ost IATA me, um displace your ost iata me, fix it your ost iata me and then follow it. I would tell you once you get comfortable for me, I actually do the distal soft tissue release first. And I find that when I do that I take the toe and I pulled into various to make sure I can, uh, relocate the metatarsal sesamoid complex. And that really helps me understand some of the deformity. So again, this this this talks about some of the different ways that you can either lengthen or shorten the bone and you're not making a nasty autumn e in line with the foot. You're making it parallel to the bone to the bones. Gonna have some degree of inter metatarsal angle. And if you can match that inter metatarsal angle, you're not going to shorten it. But you can shorten it if you want to, and you can make it more oblique if you want to lengthen it. And you can also either plantar flexor Dorsey flex, depending on the angle that you hold your so here you go. Very, very easy. Make sure you're getting two points of cortical fixation in that proximal fragment and you see that the bone sort of grows right. Intuit's not a pretty X ray, but, you know, honestly, it looks good. Clinically, the patients have no pain, and it's good rigid fixation. So here you go again. The the stepwise fashion. They actually make a little church key that goes in there. I find that easier to use. And what I do is I palmed the church key, hold the metatarsal head, the metatarsals, someone complex between my index finger and my thumb, and I'm able to translate and control rotation and control planter, flexion, endorse, reflection. And that makes it really easy for me to get where I want to make sure the k y is going where I wanted to go. And then I take orthogonal imaging to make sure that it's perfect. So I don't know what that excess versus Uh yeah, I'm not really sure what they're trying toe to show here. Um, but when when you do your medial evidence shaving, this is actually the wrong bird. The bird right is gonna be the better bird that we call it The big nasty. It's the Blackbird. The other two are silver. One is one hash mark on that one has to hash marks on it. Um, again for screw insertion. Make sure you're putting that 1st 40 Sanford, Screw by cortical e and kind of see it getting that cortex. You need to get that cortex to get 12 corpses of fixation to prevent that screw sort of floating around distantly. And that second screw goes right over and you could drive it in a little bit more. So again, you know, there are X rays out there with people putting the screws more distantly. And what I would tell you is, with the amount of translation you're getting, you need to start more proximal. That way you could do inappropriate shaving. So again, this is your metatarsal, sesamoid. Release your modified McBride. And again I do it all the time. But you don't have Thio. I've talked to people in other parts of the country and they're not doing it. And then, for your sake, in your 12 millimeter cut bird is gonna be the one with the two hash marks on it. You go right through you come up, You leave the meat, the lateral cortex, and then you do your closing wedge and you can actually see here. The K wire is actually through the lateral skin. And that's exactly how I do it, because I wanna make sure I don't call that k wire out the minimally invasive. It does make it a little more challenging if you pull a screw out to get right back into the hole because you can't see the whole from my post operative management. I do. Ah, Bunyan dressing. I let him walk right away. I tell them the elevate when they're not walking for as long as they contol aerated on bacon, start bending the first MTP joint starting two or three days out. Um, I'm a little more aggressive than saying sedentary and a stiff soled shoe for six weeks. I let him get back into the sneaker Any time after two weeks, I tell them that if they're going to do something, they have to do the elliptical or stationary bike. But I let him start running at six weeks, and this is again. You know, you got great mobility of two weeks because you're not disrupting the soft tissue envelope. It's really no it z phenomenal. Um so the pitfalls. This is hard When you first start out, it's hard and it's not the IATA me, my experience We're talking to people. They're scared of the ost IATA me. Don't be scared of the IATA me. It's gonna be putting that K wire and is going to be the most challenging part because you've got to get your version right Trust your anatomy. You know anatomy is king. It's what I always teach. So know where your anatomy is. Note that getting the K wire is the most important part of the case. It's not the s Diatta me because you can dio a direct transfers cut and it'll still grow in Um, check the plane of your ost iata me is put the proximal screw guide wire in before displacing it. When you get more comfortable, you don't have to do that. I don't do that anymore. I actually take the foot and rotate it and rotate it laterally. I hold the church key in my two fingers on either side of the metatarsal sesamoid complex toe Hold the toe where I want it And then I drive my K wire and and then you put two screws a fixation for your for your Chevron. Do yourself tissue release. Do your Achon. So this is just a quick video showing how I do it Just so you can kind of see my set up. It's a little bit different. Hopefully it loads up here. Here we go. I'm on the hospital network, so it's a little slow. Sorry about the delay. All If it doesn't start, we'll just, uh there you go. So again, you can see I'm coming from the foot of the bed rather than the side of the bed. You could see I pull it right and pull it right out doing the ost iata me there. And I see I'm palm ing the church key and I'm holding the metatarsal sesamoid complex with my fingers and I'm putting the key wire. And where it needs to go is he already did her other sides of both The feet are hanging off the bed and you could see how I could flip easily from ap lateral without it getting in the way. And you could see I could work on both sides of the feet with the X ray being out of my way and that that's my concern with coming from the side and you could see what I'm doing. I'm externally rotating and putting all the hardware and doing all the work that way. There's a quick shot of the extra you can kind of see that comes up here once I do the free. But, um, after this, you'll see the clinical at six weeks and it's Ah, it's really unbelievable putting a little local in, uh, no suitors just steri strips and glue 11 quick monocle underneath the skin and knows who just removed. And they look great AP s laterals just to make sure you're there and then I do my bunion dressing. There you go. That's six weeks. No, no scars whatsoever. No Bunyan, no crossover. Super happy. So for me, in my experience again, first TMT instability Israel, you're going to translate that metatarsal head and you're going to see at the base that inter metatarsal angle grows. And I think the more it grows, the more you tighten it up. So the less likely you are to have recurrence and knock on wood. I have not had recurrent yet. The planter loom of your Chevron Trust the anatomy. You know that the first metatarsal is gonna player flex about 10 degrees or so. So it's really gonna be almost parallel to the bottom of the foot rather than downward. So you know, you could do that cut. But for me, I like making that plant a little a little bit longer again. I palmed the metatarsal head with the church key when I'm positioning the wire in this crew and then I judge if they need a naked after I do all of that work, use Flora. Flora is gonna be a friend when you first start. It's scary enough to use the new technology, especially one that involves you trusting. Um, you know, the way that the foot looks rather than looking at the bones and position your patient to your comfort because if the patient is not in the right position, it's gonna give you hell and you're gonna hate the procedure. So these are some of my case examples you can kind of see here. So this is at two weeks, so there's still a little bit of soft tissue swelling, but again, pretty darn big big deformity here, lateral ization of the sesamoid complex. A little bit of a spur right there that I was able to take out with the with the aggressive birth and you can kind of see here, that's that's the long limb that I made right there, and you could see the I am angles almost negative. But the Halik Validus angles normal and, you know, at two weeks he's back and shoes. He's a cardiologists out in East Texas again. This is another one that this is a year out. You can kind of see that the bone does grow around it, so it makes it a little bit thicker. And did some 23 hammer toes there as well, another one that again. Similarly, this is probably a mild to moderate Bunyan, but you could really see the difference in the shape of the metatarsal head. We know that there is a rotational deformity and guys down in Chile, like Pablo Wagner, talked about that light bulb appearance of that metatarsal head, and you're you're changing that morphology as you correct the the rotational deformity in the metatarsal. And then I think this is This is the one that I want to show everybody because this is, uh this is the one where it's like here, hold my beer. I promise you, it works. So that would big deformity. But sesamoid have shifted. Its got that light bulb appearance. But look at the inter metatarsal angle there. I mean, that's clear TMT instability. I don't know what happened to my screen. Hold on. Let me go back down to it. So that's clear TMT instability. But here she is in a year. She loves it. She's running six miles a day. She's a P T out in West Texas. Andi, I've gotten a whole bunch of people from her. They can't believe that she's so good. But look at that bone growth. You know, I remember showing one of my buddies from residency who's a foot and ankle surgeon up in Pennsylvania, and he was like BS. There's no way that's going to hell there. There's just no way can't. And I showed him the one year X ray, and he's like, I can't believe it, that I just I can't believe that that's riel. Um, so it works. This is what? One screw. There was no rotational instability there 120% displacement, and you wind up really getting a nice result. The patients are very happy. And if you look at the skin shadow here, you see how big her Bunyan is. And you kind of see it here in a year, and she's just really don't happy. So I'm gonna hand it back off to you, Dr Davis, and we can go through everything. And if you all have any questions, I'm happy to answer. Just have a couple of questions. You said you do a distal soft tissue after Davis on now. Um, yeah. Can you hear me? Now? Can you hear me now? I can hear you, Dr Davis. Okay. Yeah. Justin, can you hear me? Yeah. Um, yeah. Shannon, you can hear me. Yes, sir. Yeah. Justin, can you hear me? No. Okay. It's gonna be be a tough one. Um, yeah, way. Might wanna text Dr King that he may have muted the screen. He did something when he when he on. Yeah, um, he's on mute now, but we'll get a hold of Dr Kean. Take care of it. Okay. Um, it's hard for me to do cases when, uh, yeah, when I don't have anybody to doing west. Um, so a couple of things that that Justin has evolved to that we can talk to specifically first is he does the distal soft tissue release in most of hiss. I've gotten to the point where I only do it. Um um Well, I only do it When? When I can't reduce him to neutral or past neutral. At least until a little bit of eras. I still can't hear you. I'm sorry. Yeah, Just in some some things up with you. You might have to sign out and then signed back in. Yeah, I don't know why. Um, Okay, you got it. Any better can hear me. You got it. Um, and, uh, and typically that that releases just done with a beaver blade. And and it's pretty simple to do, but But it is something, um, something that that you dio So a couple of questions first is Have you encountered any stress fractures after placing two screws? How aggressive do you get with burning the distal media Met shaft or the med head? Eminence? So, um, I have not seen any stress fractures I have had the one complication I've seen in my patients. Were Cem settling? And the patient was 80. And so So in theory, I think that that that probably is something that you can see because we all know that the fixation and those folks are always a little iffy. Um, but I have not seen any fractures through the hardware. And now if you look at the literature that that is something that has been reported, but I haven't seen it. I decide whether to burrow the distal medial met shaft or the Met head by feeling the foot once I'm I've done with the procedure. So I've done my I've done my shift. I put the screws in, I've done my achin, and if there's a prominence at that met at that, it's usually the medial Met shaft. Then I will. I will slide a borough, Um, and I'll use it. One of the wedge birds, the 3.1 wedge Berg and I will slide it up from the bottom from one of the holes that you, uh, that we used, um, for for the screw. And it's fairly easy just toe just to burr that off. Um, I have one time felt that the Met head was still prominent. And in that in that patient, I used the same incision that I used for my osteo tomy. And put that up up over that. What I have not done yet is a Chi elect me in a in A and the bunion activate together. My feeling is that on those patients, you really have to decide where the pain is coming from. Because I do Do em. I asked collect Amis. I did that today. Actually, I, uh I slid over. Felt a pretty prominent dorsal, uh, osteo fight on the metatarsal head. And what I did was from my, uh, lateral, the distal soft tissue release. I slid one of the one of the aggressive birds underneath there after dissecting it out and just did it collecting me right through that incision. Yeah. I mean, you certainly can move them, but I always hate toe. Feel like you're fighting it. Um, So one of the questions was How aggressive are you burning that distal medial met shaft I saw on the one that you shifted 100%. You? You certainly did that, but was telling that what I do is I feel, and if there's a prominence, then I'll then I'll respect it. Um And that happens, you know, maybe 25% of the time. What's your experience, Justin? I think the more you translate, the more likely it is that you're gonna feel that medial edge. And I don't use the X ray as my litmus as to what I'm going to dio I burn until Aiken make sure that I don't feel any bony prominence over that medial metatarsal. And the way that I approach it is because I have done that parry hostile elevation where I do that, uh, my chevron. I come through that incision and I come under the Perry Osti in, and I go ahead and I shave it down until I can't feel it. And then I take it out and I use magic. Kath and I just irrigated with normal saving. And till all that junk comes out all right, the next is, uh is there an advantage of leaving the planner shelf as opposed to the trans verse cut to a trans verse cut? I mean, I don't think the literature supports that. But I would tell you, just from my comfort level, I wanna have as much phony opposition is possible because even though I showed that X ray with 100 plus percent displacement, you know, again, it goes back toe are classic teaching that we know that we need bony opposition to get healing. So if I can leave that planner shelf there, I know that there's at least a little bit of bone hanging on where they're in communication. And maybe some of those, uh, you know, osteoblasts get across there, and that's where you get that healing. But that's just my personal preference. I have found that the reason I do it is because when I'm holding the head and this shift, I can push up on it and the shelf catches if you it catches and holds it there. So So that's part of my maneuver. As I shifted over and then I hold it and I push up on it and it keeps it from, uh, it keeps it from Dorsa flexing, but it also allows me to prevent it from planter flexion, which is really what it wants to do. And so if I could put my finger on that as I'm making my shift, I think it it makes it just reduces that and that. Doors reflection, planter, flexion. It gives me something to push against. Yeah, I think that certainly helps. You know that that you know that transfers cut. I just worry that you're gonna have a hard time controlling plant reflection, Doris Reflection, rotation and where it's gonna be if if you have some plant, are shelf of bone, you really have a lot more to work with, and you really have a lot more to hold on to. All right. Another question is, when do you decide to use two screws versus one? And how do you feel about surgeons? Onley using Steinman ends well for me. I make that decision based off of intra operative live flora. I'll put my one screw in and I'll take the toe and I will crank it into his much various is possible. And if there's any toggle whatsoever on my floor, uh, I put a second screw. It's maybe about 10% of the time. I really haven't seen a lot of people who needed a second screw when you get that by cortical fixation with screw? Um, you can use Diamond Pin. I don't I don't think there's a reason. Um, not too. I think probably My biggest concern with using a Steinman pin is the fact that it's a fully threaded screw you're gonna control um, where you put it out the length. If you use a smooth pin, you know, that thing can toggle that they could get longer shorter. Plus, how are you cutting the pin down, or are you taking the pin out? And I think that defeats the purpose for me. At least in my practice of getting these guys up, moving super quick and and really having, ah, much quicker recovery you'd have to use the threat had been for sure. Okay, uh, this is from Dr Alan Weiss, who is ah said Dr Kean, Point of information regarding timeline for mental and surgeon in the early seventies, several productions for doing this for bunnies, etcetera and got totally shamed and ridiculed into stopping this technique as not util utilizing reasonable surgical techniques and principles. Just a point of information. Dr. Weiss says My bell bottoms are again back in fashion. Eso Alan, you're absolutely right. That that that happened. It was not. I mean, it went all the way into the eighties. Um, there are Cem, Cem significant differences in what Justin just described to you and what was happening in the in the eighties and early nineties. The birds are different. The fixation is dramatically improved. Onda whole concept of of, um, fixation with early motion has changed. And, uh and so So I do think that the seeds were planted back in the seventies and early eighties and there was a textbook on mental incision surgery and all that, Um, but But I do think that the technology has caught up with the idea. Um, and yeah, comments on that. Just No, I agree. Justice too young to really remember that time. But But I wasn't born in the seventies, thank you very much. And you could quit talking about that right now. That's all right. All right, so we're gonna do some cases. Um, and, uh, and so the first is a 55 year old, super active female longstanding Bunyan and has an unstable second MP joint. She would tell me that she loves to speed snow ski and and the second toe came out. Um, while she was snow skin and she fell and she didn't like it. So eso she's complaining of both Both the second toe and the Bunyan. Um, here and here. Um, where? How do you approach this? Right. So this is a common problem is the Bunyan, which hurts her. Her is causing her toe. Have second MP instability. Also, um, how do you address this and what you're approached in today's time? Yeah. So I tell all my patients that if you're just putting it into laypersons terms, I call the big toe the bully of the foot. I mean, the big toe is gonna be your driving force for deformity of your lesser toes often and without correcting the underlying pathology at the Alex, you're not gonna be ableto keep your correction. You're gonna have to do. Ah, Planner plate repair here. I mean, it's clear the Tosa blocks aided and the plantar plate is insufficient. So I think my my concern here, we're looking at this. If you look at the plantar aspect of metatarsal head is, it does look like that. Maybe there's some metatarsal sesamoid, arthritis but again, For me, it's a lot more clinical than it is radiographic to see if there if they hurt their Ah, lot of the times at least in my experience, once you get those sesamoid re reduced into the crystals so they're not pushing on that bump of bone in between, they become a lot more quiescent. They don't cause much pain. So she has No, no says more pain now, are you? If you're going to do something to the planter played are you doing? I think the guys in Europe would say, Do the distal metatarsal last iata me with a little soft tissue release on the medial side of the second on. But you got it. If you're gonna do to, you gotta do 34 also, have you Have you done that? I did not see any pictures of the d m m O. I don't do three and four. I do what hurts. So for this I would probably dio a really, really, really minimal while oft iata me push it out of the way. Find the plant er plate re implicate the planner plate in tow, the latter on the medial collaterals to get it to sit where I want to sit. And as I approached the bunion rather than doing a dorsal minimally invasive because you're gonna be there anyway, at the second, what I'll do is I'll do some blood dissection down to the lateral aspect of the metatarsal sesamoid complex and do a formal modified McBride through the incision that I make where I'm going to approach the second. So I would do this as long as there was no set someone a I would feel comfortable doing this with they with a minimally invasive and then treating the second. Um, I would probably put a screw down the second as well, because I worry about the second forming a hammer toe. So this is, um, this is what I did Actually did a pro step onion with an open planner plate repair in a while, and and she was back skiing this season until they closed the mountains. Um, so So it was an interesting because it was the first one that I did that really came in primarily for second toe issues. Alright, 60 year old Alex Valdas bunion pain, and she's got these windswept toes and to me these air some of the harder patients that we treat because it looks like there I am angle is minimal, but the metatarsals deduct This kind of kind of gets that out of the way her says Moritz. She's clearly got a rotational issue both in the same order as well as in the metatarsal. Eso Justin, what do you How do you address this? I mean, this is a little different. Yeah, I'm concerned because the mtp joint, they're actually looks congruent. And if you got it back over, I'm worried that you're gonna have issues with pain, so I would probably more prone toe fusing this on, then addressing the lesser toe deformity after that again, our second looks pretty long here too. So possibly even putting a while in the second just because if you do shortened a little bit with your MTP fusion, I worry about some transfer metatarsal. Geant. Well, Justin, So when you when? When Kobe leaves Texas, I'll come down there and be your partner. So yeah, so I agree. Totally. I think these metatarsal deduct is the fusion's, um, in my hands works so much better. I think in really, really young patients. I'll do a Lapidus with with multiple met Osti autumn ease. But this is one that that in a 60 something I think it was fairly simple to convince them to do a fusion. Alright. Eso four years before, um, she had ah, Lapidus. Um And she also you can see has an artery sis crew, which I did Onda gas rockslide because she really had pain with flat feet, but also this unstable bunions. So I did the Lapidus. So she comes in now with these x rays. She's she's complaining us, um flatfoot, but definitely complaining of of funding with Mao rotation eso How do you How do you handle this? I mean, she's got an unstable media column. Um, how do you handle this with with my s. So I think this is an easy but I wouldn't say easy case. I think this is a good indication. As long as she's not having riel flat foot pain, she doesn't have a lot of uncovering of the tailor Particular joint Simmons ankle isn't all that off memories Ankle isn't all that off. I think this is one where I would pretty much tell a patient hold my beer. Watch how much quicker you recover from an M I s rather than from doing our first TMT arthur basis. Okay, Eso So I thought she had a pro nated Alex, and she and she really did its's. And I tried toe together for Anorthosis insurance. Wouldn't pay for it. So So I did an M s m d c o with a with a lap of fuse, and you could see how I got our rotated back. And so, um, I I think I still would would have done this. And you could see how Mary's angle got fixed with these two procedures. Um, so, yeah, this is why I think that I think the lapidus really works. Um, works good. Um, another question is on our Q and A. Is do you approach? Um, how do you approach Alex Valdas with First Ray Levada's? Do you change your direction of your ber? Anything. Any tricks to that? So there's there's two ways to go about it. Um, you can change the direction of your bird to bring it planter flex as you slide down so your Chevron could start mawr dorsal, medial and come or plantar lateral. So as you're sliding, you're sliding down the other way. If you're not happy completely, you could finish dialing it in juice by player, flexing it a little bit. Okay, I have seen that for sure. And I usually will handle it by just I just raising my hand a little bit when I make the initial insert. Painful, Alex Analogous. Kind of got that rounded head that we see a lot. Do you? This is a This is a slam dunk for, um, I s I would definitely do this, M i s I think what you'll see is, as you correct this that that I am. Angle's gonna open up, and it will surprise you how much it opens up. And it's gonna allow you to get a lot more translation that you than you think you're gonna get. And you're gonna get rid of that light bulb appearing metatarsal head, and you're gonna have to do Ah, soft tissue release on this and probably a naked as well. Um Alright, Louis. Uh, sorry. I have my Q and A open. Um, so So I did a big shift, chef. Oh, actually, I didn't do this when someone else did it. But a big shift. Chevron Achin and I ended up getting the X rays. And uh, she looked at this at first post op, visited six weeks. She's Rickard with this distal and it looks like there's a rotational something going on here because this says mods now look worse after eight weeks and she's not happy you could imagine. So how do you How do you come back from this? Would you now doing M I s and someone that's already had an open procedure. So I worry about the amount of medial reception there that if you try to get a big correction distantly, you're gonna wind up having Hal. It's various as your next complication. This is one that I would probably do a TMT Arthur Jesus, and then assess if we need to revise the achin and I would I would go from there. Um so this is one that I did the Lapidus procedure and agree with you? I was ableto you see, I get this as more drive by bye bye d rotating it and got her down and and she she did gangbusters. But but to operations um He was a 55 year old with a failed Lapidus. Now you've got you've got a fixed. I am I am angle because the TMT joint fused, um, and has had a bunion ectomy. Can you do this, mes? I think you can. One thing that you have to look at is that the toe is definitely in elevators. The metatarsal. So it's Doris reflects through the lapidus. Uh, but I think if you take that one cross grew out, you can get screws through that. And this is one that if you're comfortable and you've done a lot of these this is one where you can get that metatarsal Head planner flex. And you could really, really get it over nicely. And you don't have to worry about the I am angle shifting anymore. You probably get This is one where you get over 100% displacement. Okay, so this is one that I really felt I had a positive grind. And so I went ahead and did a did a revision Lapidus and cut through it and then came into the fusion and and I do my fusions open. I don't do those m I ask have you done some mes fusion's? I haven't. One of the things I worry about is just the geometry of the metatarsal head in the base of the proximal phalanx. I want to make sure that I get that good cup and cone shape, so I can really make sure I suck it down. And again, I like putting a plate on it because I wait bear them from day zero. Yeah, and I don't love doing this operation where I fused both of those joints. I mean their stuff, and they really are limited on shoe wear. Eso 53 year old lifetime of bunions with increased bunion pain. And she's also got second Met pain again straightforward for you. I worry about the second that pain I think you have toe haven't least in the back of your head that maybe there's some planter played insufficiency. I probably go in there and dual Ackman's test in the in the exam room. Make sure that there isn't any planter played insufficiency. It looks nice and dead on there. Um, but this is one where you could get a little bit of length if you wanted to. With an M I s approach Thio toe Offload that second If there isn't some planter played insufficiency, but I would have a low threshold toe Go do something to the second If if I was concerned from clinical exam so and this one I did a did a big shift Chevron in a while because of the second Um, I now in my practice, I'm tending on the ones that have significant what I would call you medial column and stability. I've tended to go toe Lapidus is for these. Andi, this is really just a scarf E chevron. So it's similar to what? You what you described. And you showed that picture of the scarf on dure able to shift it. I mean, you can't really shifted distal, so you're gonna have to do something to the second, Which is what I did here. Um, all right. 41 year old, this is This is you have to keep up with this one. Severe diabetes. Neuropathy had a TVO Cal Caneel fusion four years before, and she's complaining of her bunions. Right. So she's neuropathic. She's got very every complication that a 40 year old could ever have with with diabetes. except she still has both of her feet. I've operated on both sides for shark. Oh, um, you you mentioned that diabetes was a contra indication for my s. Um and I was trying. I talked her out of this for years. Two years, and it's not like she wears special shoes, you know, because I would have thought a fusion would be reasonable, but she didn't want to hear anything of it. Um, am I s on these. Is she having pain at the interface Langil joint or the MTP joint? Because she's got that really classic diabetic, 4 ft. So I'm gonna have to do something to that also. Yeah. No, I still like Clayton Hoffman for these. I worry about alteration. It looks like she bridged from that flipper foot across the CC joints. So I'm worried about how rigid they are again. You know, we see so much diabetes here, and I see so much foot ulcers. Here I am. I have a really low threshold toe to take out points of pressure and dew met head receptions not for the first, but for the lessors. And then maybe do an I P fusion. Well, I didn't want to put much of a scar on her. So, honestly, this was my patient, Alfa, my first patient, And I was able to fix the hell X i p by doing a little Moe Berg, you could see I Dorsa flex it, and she loves it and wants me to do her other side, which she's not. She got beams and bolts on the other side. I go. No, I don't think I could do that. But anyway, um, there's one other that I'd like to show. Um, yeah. So this is this is a lady, um, that I did a lap in a song and 10 months post op. She comes in complaining over recurrence, and and we've talked about it a little bit, but I really think, you know, normally I would do an open, distal chevron for this recurrence, and and this one I was I did em. I asked with a single screw and, uh, bacon, and she's done great. So I do think you can use it for four revisions, which is which is really nice to know. Um, and I didn't get a huge shift, but I got enough where she I think I almost just kind of rotated as I shifted her. And so that's where we are. All right, so I think we are. We're over our time allotment. Um, Shannon, do you wanna come back on Justin? Always fun doing these things with you. And, uh, I can tell you I appreciate I know you had a busy day and always appreciate working with you and hearing your views on things.