Board Review Surgery

Lapidus Bunionectomy: Weight Bearing Status

Lawrence DiDomenico, DPM

Lawrence DiDomenico, DPM discusses the anatomy, mechanism of pathology and biomechanics behind hallux valgus deformity. Dr DiDomenico reviews the indications, goals, complications and surgical technique of the Lapidus procedure and provides multiple case examples.

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Goals and Objectives
  1. Describe the mechanism of pathology leading to hallux valgus
  2. List radiographic findings
  3. Recognize the importance of hardware selection
  4. Relate the surgical technique of the Lapidus Bunionectomy
  5. Identify the benefits of the Lapidus procedure over other surgeries
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  • CPME (Credits: 0.75)

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    Release Date: 03/16/2018 Expiration Date: 12/31/2018

  • Author
  • Lawrence DiDomenico, DPM

    Adjunct Professor
    Kent State University College of Podiatric Medicine
    Chief Section of Podiatric Medicine & Surgery
    St. Elizabeth Health Center
    Youngstown, OH

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    Lawrence DiDomenico has disclosed that he serves as a Consultant to Stryker and EBI/Biomet.

  • Lecture Transcript
  • And so this is on Lapidus and weight-bearing status, so what we have done in our practice now is really we have been doing weight-bearing Lapidus procedures immediately the same day in a walking boot for a couple of years now. And it can be done very safely and I can tell you we are going to come out with a paper that�s going to show a fair amount of patients without a significant risk to you, if you perform the procedure appropriately. And so before doing a Lapidus procedure we all have to understand the mechanisms of pathology and typically these patients of hallux valgus already have some form of instability or hypermobility.

    Frontal plane deformities are a part of hallux valgus deformities, you know Lapidus procedure is the only procedure that you can correct all three planes. You cannot do with any other procedure to the degree that you need to, you can correct the sagittal, frontal and also the transverse plant. So as you can see, here the only procedure that does and we must need to know that. My idea is re-establishing and correcting anatomical alignment in order to obtain a predictable long-term outcome, otherwise you have a chance of re-occurrence with which I have seen over the years with other procedures, not that other procedures do not work.

    But again looking for long-term predictable outcomes, this is going to provide you the best, assuming the surgeon does a good job on the table. And certainly we all have bad days including myself, so it's not always perfect by any means, but if you are on, your patient is going to have much better long-term result. So you have to look at yourself, why are you having these problems, it�s muscular tendon and balancing gain, mechanical advantage over unstable anatomy, it's no different than a hammer toe.

    Nobody is born with a bunion, it's a developmental problem, it's a biomechanical imbalance that occurs. And I always pose a question, it's not the first metatarsal straight in a virgin bunion, so why are we going to take a straight bone, cut it, make it crooked to get rid of the bunion, just think about the logic about that there is really not much logic behind that full-thought process.

    And I'm not you know passionate of the procedures, however though, when you start thinking about, I think this makes much more sense long term. So if you had to look at the mechanical failures, malalignment, it's a valgus rotation and ground reactive forces applied to medial great toe. And it breaks down the soft tissues and it caps those structures. It's an ongoing dynamic process, these are dynamic process and why you don't see newborns with bunions or hammer toe, why you don't see a four-year-old or six-year-old, that's why we see a lot more older people, because the mechanical failure from a biomechanical imbalance is a dynamic process that goes on overtime.

    We have external pressures such as shoes, we have ground reactive forces, we have mechanical issues, we have biomechanics that causes failure overtime. If the underlying problem is not repaired, the soft tissue will continue to break down as the forces remain. Most of the people in the science are young, but the folks who are been out there practicing, if you have taught to do all those different cap repairs and you have done and you have tightened them up, what happens after surgery, you either are too stiff, that you get arthrodesis or they reoccur typically if the underlying process isn't repaired.

    And if you get the underlying process repaired, it can't work, but you still have the potential of the stiff joint and arthrodesis and different things like that. So it doesn't repair or capture really matter, in my hands, in my mind it does not. In my mind, we shouldn�t even enter that capsule, I am not even wade that tissue in any form at all, because there is nothing wrong with the joint itself, which we will get to when it gets realigned. So you have to look at the dynamics contributes to pathology, it's EHL, the FHL, you have the mal-aligned [Indiscernible] [0:03:24] laterally, you have your abductor, because now it's in frontal plane it's rotated, it loses its mechanical effects or the [Indiscernible] [0:03:30] effect if you will, that says let's glide laterally, they don�t really shift laterally, they rotate laterally.

    Everything rotates, it�s frontal plane prompt that rotates and this may help prevent reduction in the transverse plane and then you get this dynamic pushback in the valgus that occurs because of the soft tissue changes. Now the lady who has been operating on twice by very well trained foot and ankle surgeon and you can see, not good results, two lesions, reoccurrence, believe that one foot was operated twice and then one was operated once. And just not good results of hammer toe corrections, sub two lesions and also hallux valgus has formed in this.

    And you know, I am not saying it's bad procedure selection, but you can call what it is, it just didn�t work out and this is what you want to try to avoid in your practice to having people come back unhappy. So if you don't believe in hypermobility, no, no, I think every hallux valgus deformity has a degree of hypermobility, the question is we can't quantify it. And if you look through the literature, which I did at one time, the last I looked was several years ago was about 88 articles if I remember that I found and there was no systematic appreciable way to be able to measure hypermobility, it's a clinical finding, if you will. And if you look at TMT 1 and it causes forefoot pressures, it's been talked about in the literature more than long, for a long time and Morton's Foot is abnormal weight transfer to the second metatarsal to the hypermobility of the first rate, which results in lesser metatarsal pain or lesions, alterations or the balance of the foot.

    So we are not creating anything new, this has been around for a long time, just going back to literature and now we have better material, better tools to work with in terms of like locking plates, to get people walking much quicker, taking away the chance of doing that much better for us and it was, you know 70 years ago. In the 30s Lapidus recognized it [Indiscernible] [0:05:21] and he had another shoe to mobilize people.

    But the bottomline was addressing the underlying pathology at the point in time. And Root made this comment years ago, hypermobility, the metatarsal segment is responsible for the widest range of foot trouble and I believe that. And don�t believe hallux valgus, but multiple foot pathologies, both the forefoot, hindfoot and the midfoot as well. And so we said, I was looking now at the rheumatoid feet. Once the metatarsal is relocated over the sesamoid apparatus by correction of hallux valgus. And here, stability, the first stage is restored and I believe that�s very true with that. I have a lecture with Kai Klaue [Phonetic] [0:06:02] Kai�s dad was an engineer and Kai�s dad created this, it's the only device I know that can measure hypermobility.

    It's the only thing to quantify, but it's not really practical, but I don't think there is anything else out there that I know of, that can measure it. So it's really a clinical diagnosis and again like they said, there is multiple articles suggesting what hypermobility is, I will let you read it for yourself. But there is so many different variations, it�s very personal the way we interpreted, based on what it is and it's really a clinical diagnosis. So as we know, if you look through the orthopedic and a podiatric literature, there is over a 130 different procedures listed for hallux valgus and they all worked, don't get me wrong.

    And which one works best, which one works the longest, which one is going to make your patients most satisfied is what you have to ask yourself. And as in here, rest were doing more complicated surgeries and certainly the Lapidus procedure I think is more complicated too. But like anybody else if you can get good at it, if you practice anything hard enough and really concentrate on it and put your mind to it, you can accomplish those skill levels.

    So common thoughts about Lapidus procedure, it just formally has to be large IMA thing. When I took my boards and say when you folks take your boards, that answer is true, but in practicality and in my practice that is false. Increased convalescence, center care probably still is today at this time, although it's changing I believe long-term mobilization six straight weeks in a cast. Today I think that's going to continue to change that, that�s false. Technically challenging, it is very true, it's a very hard procedure to get all three planes, anybody can get one plane over or one plane down, but if your all three planes is very technically challenging, it's hard.

    But with experience, you can get it and you can get a very nice result for your patients. So you have to look at first rate stability as very necessary to get, in order to get rid of these lesions, such as subtoe [Phonetic] lesions. This subtoe lesions is not from a metatarsal, it is from the instability TMT 1, it puts your muscle group hammer toe deformities, [Indiscernible] [0:07:54] and nobody knows how much each one of those segments plays into, but it is and you have to look at the weight-bearing, insufficiency is a big part of that.

    So our goal is to stabilize it first rate, if you fall, and your hands work, 35% the body weight runs to the first metatarsal and two sesamoids. If you look at the first rate, some literature says 60%, so really what's the weight bearing on these patients, subtoe lesions, is the first rate doing it�s job, it's a bigger metatarsal, it's a wider for a reason, to bear that load and often times, these patients, it's not, so you have to start thinking outside the box and look at the leg globally when you look at these hallux valgus deformities. So, the ability is the first rate of plantar flex adequately leads to subluxation of the first metatarsophalangeal joint leading to prompts and typically this is done from the peroneus longus and the mechanical advantage, so you get to look more in a hindfoot sometimes associated with this.

    So it's not just a forefoot prompt, oftentimes it's the hindfoot prompt and associated with this and you need to look at that, when you are addressing these patients. So anatomy to hallux, here is conjoined tendon that we all know about from doing modified debride, I was taught to do all these procedures. And now I will tell you, you do not need to do a modified debride, you do not need to release the adductor tendon in order to get a severely or significantly dislocated or sublux joint back into alignment or a moderate bunion back into alignment.

    And it�s just really like relocating a dislocated joint to some degree. If you look at the anatomy of the metatarsal, the vascular supply, I just saw a case of AVM from Austin being done in our local community. Not that it happens often, but it does happen and it's a numbers game, everything we do, if we are doing surgery, if you are performing surgery, eventually over time, you're going to have certain amount of complications, no matter who you are, where you train, what you do, it's just a numbers game.

    There are so many accidents up and down in the major freeway outside here, it�s going to occur on a given year, there are so many accidents are going to occur. And no matter how good the previous speakers are, it's going to happen, everybody has complications. So your goal is to try to reduce the amount of complications you do, you have and so if you can avoid one more area, by invading the periosteum by to say non-invading periosteum, but not invading the vascular supply of the bones, why would you, if you can do avoid it.

    It eliminates one set of proms for you from obtaining an AVM possibly. So traditional Lapidus indications are for first-rate deformities, high [Indiscernible] [0:10:17] arthrodesis of TMT 1, ligaments will actually reoccur in hallux valgus with first-rate insufficiency and hypermobility. Again, what is hypermobility, it's really subjective, I will show you a couple of ideas of what I think it is. And the goals are to re-establish a congruous first metatarsophalangeal joint, reduce the IMA, go close as to 0 or below, you know 8 for sure. But somewhere it parallels possible to number two.

    Realign the sesamoids as the best we can, we restore the weight-bearing function at the first rate, maintain the range of motion in the first metatarsophalangeal joint without entering it. So we don't have that adhesion, that scar tissue, that arthrodesis in different things and you can't get a veris [Phonetic] [0:10:54] if you don't go in that joint. We want to reposition the hallux into a rectus alignment and again, I use this procedure in conjunction with a lot of hybrid procedures too, to get that tripod effect to bring the first-rate down.

    So it's not just used for hallux valgus, but a lot for a midfoot and hindfoot procedures. Other procedures are augmentations if you will, I use this procedure for hallux limitus when the joint is not destroyed to stabilize the first-rate, so the great toe can glide over the top of it. [Indiscernible] [0:11:22] perform for my bunions, metatarsal or subtoe lesions or callus lesions like we already talked about, in conjunction with a hindfoot and midfoot procedures. And in Neal [Phonetic] [0:11:35] in his articles say that it should be emphasized that in patients with HAV deformity, the decision to perform Lapidus Bunionectomy frequently is based on the hypermobility present and not the degree of intermetatarsal angle present.

    So again at least in my hands, I believe all these patients have a degree of hypermobility and it's all relative to how you interpret it. So the Lapidus right from my hands is not necessarily a large IM angle, but certainly that is one criteria. Hallux limitus ridges, [Indiscernible] [0:12:03] stabilization, rheumatoid patients. Actually that is a TMT 1, if you just do a Lumpectomy, eventually they are going to get that back, because you have addressed the hypermobility, less metatarsalgia, hypermobility at first rate is a prime indicator for doing this.

    And you could in this patient, if you look at the lateral x-ray, the first-rate dorsal [Indiscernible] [0:12:22] is elevated relative to the second and this joint is going to be jamming over time. So the idea is to bring that first-rate down, so that great toe gets mechanical advantage over the stabilized area. So this is what I consider to be hypermobility, some people in this audience may agree, some may disagree, but that's my opinion. And then, here is another example of it and it was unstable, between one and two and you get a sort of feel for it. And again it's all relative to the person who has examined it. Radiographs, some people say, you can see increased courtesy, the second metatarsal, I can't, but the key thing I look for was relatively the elevation between one and two on the lateral, arthrodesis at the TMT 1, the first metatarsal length, I think that's also another myth that we were taught.

    Because if you look at a long first metatarsal, typically does feet or does first rate or flatter to the ground or more parallel to the ground with a flat foot. So when you have a flatfoot deformity, it's more parallel to the ground, it�s flatter, the first metatarsal is going to look longer. When you have a cavus foot or a high-arch foot, that�s should be a higher declination or the metatarsal will look shorter radiographically. So I don't think that you really get a long or short metatarsal unless you get these breaking metatarsals relative to positioning that you have.

    And so I could promise you on patients on � patients who have changed their foot structure and I haven't touched a metatarsal and the length look tremendously different in pre-op and post-op. So you have to think about that, the bone doesn't really generate or degenerate one way or another for length. So I think that's again something you really have to look at and the IM angle certainly is something to consider. Complication is same as any, I put in here surgeon failure, because one thing is, I realized a lot of people don�t pay attention to a lot of detail about fixation.

    And that is a key, if you want to weight-bear your patients early, it's not just putting a locking plate, it�s how you put a locking plate on and then the size of plate and where you put it on, who you put it on there. You have to look at your patient, your host, that's a key thing. And how sick your patient is or how healthy they are, how big they are, how active they are, you have to really build your plate and screw fixation around them, assuming you want to get them to weight bearing earlier. Sesamoid arthrodesis, if you ever plan on flex to first rate, certainly you can go ahead and obtain that.

    So if you look at the internal fixation, the pull on straight is equal for cortical screws versus solid cortical screws and that's a cortical screw to compare to cortical screw. And it has a better to pullout strength than cancellous screw, the pullout strength of a cortical screw is superior to cancellous screw. So if you are using a cortical screw, you're going to get much better strength or stability if you will over to courtesy purchase versus a one courtesy purchase. Fatigue analysis reveals cortical screws superior to cannulated screws because the core diameter will be in a principal determining factor. So it�s hardware selection that you choose is part of the answer for how you can weight-bear people earlier.

    So here you can see this is what we call the homerun screw. Typically I like this screw to be 50 to 60 millimeters of length and it�s close or parallel to the ground. And think about this like a teeter tatter, think about the ground reactive forces, if I'm really close to the joint, I am coming down this angle. It doesn't have as much as resistance. If I have all these bone-resisting net forces, the ground reactive forces here and just put it all to the ground. Because you had that sort of beam effect and it's cortical compression.

    And also I have this group, usually about 38 to 42 millimeters in length, coming from as far as proximal as I can, especially in the second courtesy and then, you could put your third screw transversely or if you want to keep in that sagittal plane. So we don't reset the meter on this, we don't get as shift joint for that matter, because we are not invading the soft tissues. You're not going to get scarred tissue, you're not going to get veris, you can't get stake in metatarsal because you can't get the veris formed because you can't overcorrect it.

    You need that natural large [Indiscernible] [0:16:06] don't really occurred and if they do have, one interprets to be a large [Indiscernible] I can tell you clinically it doesn't bother people if you realigned the first metatarsal. So just don't go into the joints and there is no reason to go into these joints. So here is a patient, we do not do a lateral release, we did not do a large [Indiscernible] [0:16:24] on this patient. And so we can't get a veris, if you look at the sesamoids, and look at the toe, the toe is rotated in valgus. You could see the pre-op, non-weight-bearing and some people may say this has a large [Indiscernible] [0:16:38] elements and maybe not and may not and they have fibular sesamoids.

    But you can get this realigned, the great toe underneath and the first rate looks short because we plantar flexed relative to the pre-op X-ray and therefore you may say well, they are going to get a subtoe lesion, I can promise you if you plantar flex it, and stabilize it they will not and there is a nice, the group out of Seattle is Jeff Corsan and Chris Johnson [Phonetic] [0:17:00] they were [Indiscernible] yeah in the early 2000s I think it�s like a series of three or four about the tripod effect in Lapidus procedure itself, stabilizing that whole area.

    And then if you looked at sesamoids displacements, there is a lot of literature out there saying that you can move the metatarsal back over and actually it's not really moving it back over, it's rotating. And I will show you, that live pictures, it's about rotating it and you get the sesamoids directly at the first metatarsal. So here is a patient weight bearing, hallux valgus for me as you can see, the toe is deviated, the first metatarsal is open, there is sesamoids in the space, and the great toe is valgus. Now we will tell you all this rotation, if you rotate this all around, this can be reduced if you get into alignment without [Indiscernible] [0:17:44] joints and you can correct this hallux valgus for me without doing that.

    Here the patient is on the table, quite large IMA angle and quite large bump, that's all about malalignment and here our stress x-rays after destabilizing TMT 1, no soft tissue dissection. And look at the toe, it's in valgus you're seeing a lateral portion of the great toe, now you are seeing a neutral width of the toe, it's rotated, the first metatarsal is being moved over, because this is rotating and you haven�t destabilized the first metatarsophalangeal joint, the whole complex is being rotated as one. So the first metatarsal is going in to varus, so what may look like a large medial [Phonetic] [0:18:21] now it does not look like a large medial [Indiscernible] as much because it's rotated on the varus.

    And the process of changes relatively speaking because it's a radiographic orientation if you will that you are seeing when these people are having a weight-bearing x-rays. So by destabilizing this you're allowing to control the entire first rate and you can do this on the table with your patients once you have them destabilized. Here is another patient and you can see my hands stressing the foot, destabilize there and rotating the toe into a more neutral position, although relatively minor case. You could see that you get the sesamoids back in to position, very, very nicely and get an alignment.

    Here is in a cadaver lab, not destabilize the first metatarsophalangeal joint, but I typically don't take the down this much dissection. But you could see the rotation of the first metatarsal by rotating just a great toe, by leaving the ligaments intact. And once you leave that soft tissue intact the whole thing rotates even that much more better if you will with that. And here is the girl that came back to me for revision, so here you see she has a distal metatarsal osteotomy done several years ago. You could see I think it was a reverent type procedure, she has a valgus deformity, sesamoids may align, there is instability here, the first rate is elevated.

    And when the first rate is elevated, sure you had a metatarsal osteotomy, so a couple of millimeters of hone had to be gone, but the first metatarsal looks long. So to tell you again, this looks long, because it's more elevated, it's more parallel to the ground, that's the reason why this looks long. So here she is and surgery look at the rotation here, by destabilizing TMT 1, look at the great toe getting into neutral position, you can rotate the sagittal plane, that transverse plane, you can do anything you want with it and put it where you want.

    And I don't worry about this because I backfill all these procedures about bone graft and I put it where I want. Now I have got a plantar flex, the first metatarsal looks a little bit shorter. And of course, you're going to lose some millimeters but I can promise you, you're not going to get a subtoe, because it's relatively plantar flex or stabilized, if you will into a neutral position where you need to put it. And you can see that motion that you have, control of the entire first rate by destabilizing TMT 1 and have that great toe, and the whole complex is one together and leave it together.

    Here is she is with my stabilization, I will use that large [Indiscernible] [0:20:38] screw between 50 and 60 millimeters screw and then I put locking plate over the top of it to stabilize and get my angle down to zero, my joint space opens up, nothing was done to the first metatarsophalangeal joint. No incisions were made by just repositioning, I have now much better range of motion, the picture functions much better, it stabilizes the sagittal plane, it shouldn't come back in a transverse plane or the frontal plane again, because of our position in our fixation.

    Those who say that you need to take off this lateral flair here, there is no need to take off the lateral flair, if you correct it off for the frontal plane. If you see the frontal plane, the sesamoids are corrected and that lateral flair and so the first metatarsals that are rotated in valgus where you see a large lateral flair there, there is no need to go back there and have to do that extra dissection in that space, because if you just rotate the first metatarsal, you will maintain your alignment without having to do that extra procedure.

    So the key is you got a three-legged stool concept, get that first rate down, 5th rate in calcaneus. And oftentimes, you may need to do gastric resection along with these procedures, if it's been acquired to form over a long period of time. Yeah I have your home run screw, whether your using the screw technique or screw plating technique, that same screw that we want to have, bicortical purchased long home run screw if you will parallel to the ground as close as possible.

    And so this is what we basically do is leave incision enough to get the screws and plates in there usually between four or five or maybe even 6 cms over in TMT 1, make an incision, watch out for neurovascular bundles, tracking the soft tissues, they are there and then right down there, you download a bone. Do not invade the periosteum, there is no need to. All you need to do is take the down the ligaments with the [Indiscernible] [0:22:17] at the TMT 1 and then you can use a power [Indiscernible] [0:22:21] it doesn't matter, the [Indiscernible] [0:22:22] is convex, the metatarsal is concave. So you're going to get a little bit more of the first metatarsal and take it off perpendicular to the long axis of the first metatarsal.

    And you leave it square to the long axis of the first metatarsal and don't worry about getting bone to bone and together because I always backfill these and that's the key. You put the bone where you want, fill your position and then backfill the bone graft in each one of these cases. So put it where you want and you have a lot of room in there, so it�s 3.2 cms on average deep, about 2 cms wide, so it�s a relatively big joint, you can get a lot of hardware here in getting these people up and moving quicker.

    The key thing is to spend a lot of time preparing your joint, take down the medial aspect of second metatarsal, I spend most of my time preparing my cuneiform in the first metatarsal there using drills, picks, cravats, whatever you need to do, use it on the pituitary rongeur on the medial aspect of second metatarsal base as well, open that up and you can see a large bunion, but we are not even going near that bunion or no need to invade that area.

    You get some large K-wire, so typically I like to use 1.6 or 2.0 K-wires, put them to bone where you want, don't worry about this gap in here, don�t worry about getting [Indiscernible] [0:23:30], just leave it where you need to get some bone contact and fill the gaps here with bone graft, leave into space, go from point one to two. So you know you're not over planning flexing or under planning flexing or dorsiflexing if you will, making sure this is in alignment, get this down as close as possible to parallel.

    And then to get your [Indiscernible] [0:23:50] written by [Indiscernible] Hansen, it gives you a nice way for putting your angulations and your screws in there and typically if I'm using solid screws like [Indiscernible] [0:23:58] solid cortical screws, not cancellous screw � cortical and non-cannulated. There is a difference in the screws and the fatigue analysis of those screws. So cortical screws, typical activities two in sagittal plane and one for medial lateral, it�s typical I like to do. But your home run screw is big, your biggest thing. If you want to put a plate over the top of it, then the one home run screw and the locking plate medially is where I like to go with it.

    So here is my home run screw, here is my medial base locking plate and here is my home run screw 2 or 3 sagittal plane screws. And again the home run screw use the beam effect, by cortical purchase, you know away from the tendon navicular joint or the knee form joint I am sorry, and C joint, you won't have any affect on that area. Don't worry about, as I said I don't worry about any gapping, because I go back, I always get all touches graft in the calcaneus.

    And then backfill it and create sheer strains and pack this in a very, very nice tightly to fill in the voids I have in my Lapidus procedures. And this is how I do that, I just go to the lateral aspect of calcaneus within resting skin line, inferior to the [Indiscernible] make a stab incision and just make it a get free elevator, get it right down to the lateral wall, make sure you are not too far inferior or post this, you don't cause a stress riser, put a drill, either 2.5 or 3.5, whatever you feel like you need to, sort of the small crutch.

    You get a larger crutch, you can harvest a lot of fresh calcaneus autogenous bone graft and pack it right back in the site and again this is a key thing you want to do. So my post-operative course with a weight locking plates, immediate weight-bearing with a protective weight-bearing boots, if I am using two screws, so right now we are doing or performance at two week. And I think I can even do this immediate as a possibility. But anyway, long term, these boots stay on for about six or eight weeks, until they serve a period of consolidation at the site. So to thinking about a bunch of cases, especially subtoe lesion, instability TMT 1, hallux valgus deformity. And here basically what we are doing is destabilize in TMT 1, and basically open a stuff [Indiscernible] [0:25:57] to breed the second metatarsal base and prepare these joints.

    I spend a lot of time medically, get my K-wire in there to stabilize it and getting it prepared for my home run screw, bicortical purchase as long as possible. Go the calcaneus, show you how minimally invasive this is, that little stab incision and you can see you are not taking a whole lot of bone out of there and we have a paper looking at a couple of hundreds I have shown you, that you do not have anything really to worry about, except leaving some bone in there. And you may get some associated small issues with that, but very, very, small amount potential complications with the procedure, very friendly.

    Here is our incision, when I am grabbing here is my hands I am grabbing an excessive tissue from the [Indiscernible] [0:26:39] and showing that how much that is, so it looks like on the table, the bunion may still be there. And well we all used to go in there and take out the capsor tissue and getting rid of bunion. But you don�t need to, truss it, it�s like somebody that goes on a gastric bypass or some of the [Indiscernible] [0:26:53] strings up. So does this soft tissue adapt over time. So here is the pre-op x-ray, here is the inter-op x-ray, here I am holding that excessive soft tissue, you can here how many excessive soft tissue there is there.

    And you don�t need to go ahead and take that down, that will everything shrink up over time, as you see it. And I showed you this case, but no hallux valgus rotation in this gentleman, no post-op, nothing was done around there to get it. It�s all about positioning the whole complex out of valgus to neutral position in a veris direction and stabilize it and nothing needs to be done, around there as you can see. And here is a range of motion post-operative release that a range of motions much more freely, much more easier for patients who are not going to get a stiff joint, post-op with that. Here is another gallery, you can see a pre-op and a post-op, post Lapidus.

    Here is a revision, this patient has a previous bunion, like a McBride [Phonetic] [0:27:43] in Arthroplasty and a dislocated toe. So here I did my [Indiscernible] [0:27:47] procedure and did a Lapidus procedure and no rotation, this great toe in valgus. Here I am intraoperatively as you can see, change in the realignment of the sesamoid complex, just by manipulating with my hands intraoperatively after destabilizing TMT 1. Here she is long term, the second toe, I didn�t do the Arthroplasty, if you go back and look. This is already done, up here, so basically just put a K-wire, through did my [Indiscernible] [0:28:13] and my modified hips procedure, got the toe back down, out of that alignment, got the first metatarsal stabilized, every flexion is one, so I will do it now in that area.

    So here is another pre-op hallux valgus, elevated first rate to a mild degree, increased stress second metatarsal, home run screw with a medial base locking plate, holding everything in place, again nothing done at the first metatarsophalangeal joint. Here is a crossover hammer toe, hallux valgus, you see the toe up and you can see the reduction this is in my office, without anesthesia, you can reduce this in your office to try and see as much correction you can get without anesthesia.

    Here she is post-operatively, everything lays down flat, they again maintain alignment and again you can see the alignment [Indiscernible] [0:28:57] case, but you can see the functionality of this foot, long term to toss this down and there is nothing really done there from like a cosmetic standpoint that really is positive for the patient. Here is another patient post-operatively, you can see maintains, these patients cannot get a reoccurrence, because you got a nice old fusion at the TMT 1, here is another patient with a revision. Had a privacy, had surgery done on the second toe, had a last metatarsal procedure done, I am sorry, first metatarsal procedure done with a distal metatarsal area, valgus rotation. Even with the stake in done, you can still get these back in the place, and you can maintain them in a nice alignment, by getting them in position. And another type of [Indiscernible] [0:29:33] pre-impose and you notice again the valgus rotation of this too much more neutral position without having to touch this area.

    So I am showing you multiple cases that you can achieve this, very easily. And this is a tremendous case to show because this was a case that was done multiple years ago, and I am thinking about I don�t think any surgeon really did a distal metatarsal osteotomy for this large IMA [Indiscernible] [0:29:55] however as many years. So I wonder if that ongoing pathology continued to occur and it just continued to widen afterwards, that surgeon thought, did a pretty good job with doing a distal metatarsal osteotomy. I would think so, but this is done like tissues close to 20 years ago or 15 years ago.

    So she was scared to come back and have their procedure done and basically what we did, as you can see, we did our Lapidus, we didn�t do anything to the first metatarsophalangeal joint. If you look at the pre-op, it looks like you need to do something here and as I told you the posture can change, but it�s a visual misnomer on the x-ray based on where you are seeing. So you could see we took that to TMT 1, we spun the toe around, put everything to neutral position, you could see the alignment. Our maintenance is much better and once you get the foot, the whole rein of first position, it looks like she has a very short first metatarsal plantar flex. I promise you that there is no subtoe lesion. And you can see that it�s very flat, very nice, that there is no incisions from this foot pre-op to post-op.

    You can get tremendous corrections with this procedure as you see there, and you can get stability along with these people without getting subtoe lesions there. And here you can see the range of motion, is much better because again there is nothing invading the soft tissue once you are done. So I think there is a lot to take in there, but it�s a very challenging work that we do with these procedures, but that can be done, with anything else, like said, with good practice. I think you can get some fantastic results with this. I think we have one more.