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CME Surgery

Plate Fixation in Forefoot and Midfoot Surgery

Lawrence DiDomenico, DPM

Lawrence DiDomenico, DPM, FACFAS discusses various techniques for the repair of forefoot and midfoot deformities and supports his discussion with case studies.

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Goals and Objectives
  1. Explain forefoot and midfoot plating
  2. Review surgical plating techniques for repairs of forefoot and midfoot
  3. Describe appropriate candidates for forefoot and midfoot plating
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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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  • Lecture Transcript
  • Male Speaker: Lapidus in weight-bearing status. So, we have done in our practice now it’s really we have been weight-bearing Lapidus procedures immediately the same day and a walk-in boots for a couple of years now, and it can be done very safely, and I can tell you, we are going out with a paper that is going to show a fair amount of patients without a significant risk to you and 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 patient’s hallux valgus deformity have some form of instability or hypermobility, frontal plane deformities are a part of hallux valgus deformities. 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 in sagittal, frontal, and also the transverse plane. So, as you can see here, this is the only procedure that does, and we must need to know that. The idea is to reestablish and correct the anatomical alignment in order to obtain a predictable long-term outcome. Otherwise, we have a chance of reoccurrence, which I have seen over the years, with other procedures, not that the 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 a much better long-term result. So, you have to look at yourself, why are they having these problems? It is muscle tendon imbalancing gaining mechanical advantage over unstable anatomy. It’s no different than hammertoes. Nobody is born with a bunion. It is a development of problem, it is a biomechanical imbalance occurs, and I always pose a question, is 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, but that there is really not much logic behind that thought process, and I’m not passionate about the procedures; however, though, when you start thinking about it, I think, it just makes much more sense long-term. So, if you’ve to look at the mechanical failures, malalignment, it’s a valgus rotation and ground reactive forces applied to medial great toe. It breaks down the soft tissues and the capsular structures. It’s an ongoing dynamic process. These are dynamic process. Why you don’t see newborns with bunions or hammertoes? Why you don’t see a 4-year-old or 6-year-old? That’s why we see a lot more older people because it’s a mechanical failure from a biomechanical imbalances and it’s a dynamic process that goes on overtime. We have external pressures such as shoes, we have ground reactive forces, we have mechanical wear shoes, we’ve biomechanics that causes failure over time. If the underlying problem is not repaired, then soft tissues will continue to break down as the forces remain. Most of the people into science are very young, but there are folks who have been out there practicing. If you have been taught to do all these different capsular repairs and you have done them, you have tightened them up, what happens after surgery, either one or two are stiff. They get neuritis or they reoccur typically if the underlying process isn’t repaired. If you get the underlying process repaired, it can work, but you still have the potential of a stiff joint and neuritis and different things like that. So does repairing the capsule really matter? In my hands, in my mind, it does not. In my mind, we shouldn’t even enter that capsule, not even invade that tissue in any form at all because there is nothing wrong with the joint itself, which will get to when it gets realigned. So you have to look at the dynamics contributing to the pathology. It’s EHL, the FHL. You have the malaligned pull, if you will, pointed laterally. You have your abductor because now it’s in frontal plane. It’s rotated. It loses its mechanical effects or the buttress effect if you will. The sesamoids glide laterally. They don’t really shift, I mean they rotate laterally. Everything rotates. It’s a frontal plane PROM 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. Here’s a lady who has been operated on twice by very well-trained foot and ankle surgeon, and you could see not good results, sub-two lesions, recurrence, I believed, and one foot was operated on twice and the other one was operated once and just not good results with hammertoe corrections, sub-two lesions and also hallux valgus deformities, and I am not saying it’s bad procedure selection, but you can call what it is. Just didn’t work out, and this is what you want to try avoid in your practice having people come back unhappy. So, if you don’t believe in hypermobility, I don’t know. I think every hallux valgus deformity has a degree of hypermobility. Question is we can’t quantify it, and if you look through literature, which I did at one time, the last I looked was several years ago, it was about 88 articles, if I remember, that I found, and there is no systematic appreciable way to be able to measure hypermobility. It is a clinical finding if you will, and if you look at TMT-1, it causes forefoot pressures. It’s been talked about in the literature from Morton and Root for a long time, and Morton’s foot is abnormal weight transfer to the second metatarsal due to hypermobility of the first ray, which results in lesser metatarsal pain or lesions, alternation in normal balance of the foot. So, we are not creating anything new.

    [05:05]

    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 like locking plates to get people walking much quicker, taking away the chance of nonunion, much better for us than it was 70 years ago. In the 30s, Lapidus has recognized it. The problem is he had cracker and he had a leather shoe to mobilize people, but the bottom line is addressing the underlying pathology at the point in time. And Root made this comment years ago -- hypermobility of the first metatarsal segment is responsible for the widest range of foot trouble, and I believe that. Not only hallux valgus, but in multiple foot pathologies both the forefoot, hind foot and the midfoot as well. I’m sorry about that. And so Jack Schubert [phonetic] said this when looking at juvenile rheumatoid feet. Once the metatarsal is relocated over the sesamoid apparatus by correction of the hallux valgus and inherent stability, the first ray is restored. I believe that’s very true with that. I had a lecture with Kye [Indecipherable] [06:00]. Kye’s dad was an engineer, and Kye’s dad created this. This is the only device I know that can measure hypermobility. If it’s only if they 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. So, it’s really a clinical diagnosis, and again like they said, there are multiple articles suggesting what hypermobility is. I will let you read in for yourself, but there are so many different variations; it’s a very personally interpreted based on what it is, and it’s really a clinical diagnosis. So, as we know, if you looked through to orthopedic and a podiatric literature because over 130 different procedures listed for hallux valgus, and they all work, don’t get me wrong. Which one works best, which one works longest, which one is going to make your patients more satisfied is what you have to ask yourself, and there is inherent risk with doing more complicated surgeries and certainly, the Lapidus procedure, I think, is more complicated to do, but like anybody else, 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 is for me, it has to be a large IMA angle. When I took my boards and say when you folks take your boards, that answer is true, but in practicality, in my practice, that is false. Increased convalescence -- senior care probably still is today at this time, although it has changed and I believe, long-term immobilization of 6-8 weeks in a cast. Today, I think that’s going to continue to change, that’s false. Technically challenging, it’s very true. It’s a very hard procedure to get in all three planes. Anybody can get one plane over or one plane down, but to get 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 ray stability, it is very necessary to get in order to get rid of these lesions such as a sub-two lesions. This sub-two lesion is not from the metatarsal; it is from the instability TMT-1, posterior muscle group, hammertoe deformities, culmination 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 the first ray. If you follow Ted Hansen’s work, 35% of the body’s weight runs to the first metatarsal and the two sesamoids. If you look at the first ray, some lecture says 60%; so really where is the weight-bearing on these patients, sub-two lesions. Is the first ray doing its job? The bigger metatarsals why they are for a reason, is to bear that load, and oftentimes in 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, an inability of the first ray to plantarflex adequately leads to subluxation of the first metatarsal phalangeal joint leading to problems and typically this is done from the peroneal longus and the mechanical way so you have to look more and the hind foot sometimes is associated with this, so it’s not just a forefoot problem, oftentimes it’s a hind foot problem associate with this, and you need to look at that when you are addressing these patients. So, the anatomy to hallux, here’s our conjoint tendon that we all know about from doing a modified McBride’s. I was taught to do all these procedures, and now I tell you, you do not need to do a modified McBride, you do not need to release the adductor tendon in order to get a severely or significantly dislocated or subluxed joint back into alignment or moderate bunion back in alignment. This is 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 AVN from an 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 you do in surgery, if you perform in surgery, eventually over time, you are going to have certain amount of complications, no matter who you are, were you trained, what you do, it’s just a numbers game. There are so many accidents up and down the major freeway outside here. It’s going to occur on a given year, so many accidents occur, and no matter how good previous speakers are, it’s going to happen, everybody has complications. So your goal is try to reduce the amount of complications you have, and so if you can avoid one more area by non-invading periosteum, by not invading the vascular supply of the bone, why would you if you can avoid it. It eliminates one set of problems for you from obtaining an AVM possibly.

    [10:10]

    So traditional Lapidus indications are for first ray deformities, high IMA angles, arthrosis of the TMT-1, ligamentous laxity, reoccur hallux valgus or first ray insufficiency hypermobility. Again, what is hypermobility, it’s really subjective. I will show you the couple of ideas what I think it is, and the goals are to reestablish the congruence first metatarsal phalangeal joint, reduce the IMA angles closer to zero or below 8 for sure, but somewhere it is possible to number 2, realign the sesamoids as best we can, restore the weight-bearing function of the first ray. Maintain the range of motion of the first metatarsophalangeal joint without entering it, so we don’t have the adhesions, that scar tissue, that neuritis and different things. And you can’t get a varus if you don’t go in that joint. We want to reposition the hallux to erect this alignment, and again, I use this procedure in conjunction with a lot of hind foot procedures too to get that tripod effect to bring that first ray down. So it’s not just used for hallux valgus forays, but a lot for mid foot and hind foot 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 ray so the great toe can glide over top of it. Mild-to-moderate IMA angles, that’s what I perform for my bunions, lesser metatarsalgia or sub-two lesions or callus lesions that we already talked about in conjunction with hind foot and mid foot procedures. And in [Indecipherable] [11:31] and his articles stated that it should be emphasized that in patients with HAV deformity, the decision to perform a Lapidus bunionectomy frequently is based on the hypermobility present, 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 criterion for my hands is not necessarily a large IMA angle, but certainly that is one criteria, hallux limitus and rigidus, neo-column stabilization, rheumatoid patients, exostosis of the TMT-1. If you just do a bumpectomy eventually, they are going to get that back because you haven’t adjusted the hypermobility, lesser metatarsalgia, hypermobility of the first ray is a prime indicator for doing this and you could see in this patient if you look at the lateral x-ray, the first ray dorsal cortex is elevated relative to the second, and this joint is going to be jamming overtime. So, the idea is to bring the first ray down so that great toe gets mechanical advantage over 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 what it is. Here’s another example of it. Where it is unstable between one and two, and you get a sort of feel for it, and again, it’s all relative to the person who is examining. Radiographs, some people say, you can see increased cortices of the second metatarsal, I can’t, but the key thing I look for is relative elevation between one and two on the lateral, arthrosis at the TMT-1, first metatarsal length, I think, that’s also another myth that we are taught because if we look at a long first metatarsal, typically those feet whereas first rays are flatter to the ground or more parallel to the ground with a flat foot, so when you have a flat foot deformity, it is more parallel to the ground, it is flatter, the first metatarsal is going to look longer. When you have a cavus foot or a high-arch foot that will be a higher declination where the metatarsal is going to look shorter radiographically. So, I don’t think that you really get a long or short metatarsal as you get these brachymetatarsals relative to the positioning that you have, and so I could promise you on patients in CMT; patients who I have changed foot structure and have them touch the metatarsals and lengths look tremendously different 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 lengths, so I think that’s again something you really have to look at and the IMA angle certainly is something to consider. Complications are the same as any. I put in here surgeon failure because one thing is, I realized, a lot of people when paying attention to lot of details about fixation and that is the key. If you want weight-bear your patients early, it’s not just putting a locking plate, it’s hyperlocking plate on and the size of plate and where you put on, who you put it on, 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 weight-bearing earlier, sesamoiditis, if you ever plantarflexed the first ray, certainly you can go and obtain that. So if you look at internal fixation, the pull out strength is equal to cortical screws versus solid cortical screws. That’s cortical screw compared to cortical screw and has a better pull out strength than cancellous screws. The pull out strength of a cortical screw is superior to cancellous screws. So if you are using a cortical screw, you are going to get much better strength and stability, if you will, and with two cortices purchase versus a one cortex purchase.

    [0:14:59.4]

    Fatigue analysis reveals cortical screws superior to cancellous screws because the core diameter would be a principle determining factor. So, it’s your hardware selection that you chose is part of the answer for how you can wake your people earlier. So, here you can see this, we called the whole monster, typically I like the screw to be 50-60 mm in length, is closer parallel to the ground, and think about this like a teeter-tooter, think about the ground reactive forces, I’m really close to the joint, I’m coming down to this angle, it doesn’t have as much as resistance, I have all these vulnaries resisting indepth forces, the ground reactive forces here, and spit it onto the ground. Because you had sort of beam effect and its two cortsis compression, impressive. Also I have this screw who is about 38 to 42 mm in length coming from the spur proximal as I can distally on the second courtesy and you can pick your 3rd screw transversally or if you want to keep it as a sedge of plan. So, we don’t resect medo unless we don’t get a stiff joint for that matter because we are not bathing the soft tissues, you are not going to get scar tissue, you are not going to get varus. You can’t get stake in metastarsal because you can’t get a varus deformity because you can’t over correct it. You leave that natural large medo answers don’t really occur, if they do have one of the [indiscernible 0:16:07.7] large medo on this, I can tell you clinically it doesn’t want if you realigned the first metatarsal, so just don’t go into the joints and there’s no other reason to go into these joints . So, here is the patient, we didn’t do a lateral release, we didn’t do large large medo [indiscernible 0:16:22.2] on this patient and so it can get reversed. If you look at the sesamoids and look at the toe, the toe rotated in valgus, you can see the preop nonweight bearing and some people may say this has a large medo on this and may or may not, [indiscernible 0:16:38.2] sesamoids but you can get this realigned, the great toe underneath and if the first ray looks short because planted a flex to it, relative to the pre-op x-ray and therefore you may say well they are going to get a substitute of this, but I can promise you if you planter flex it and stabilize it they will not, and there’s nice, the group at Seattle Jeff Cursion and Sea Johnson, they were nice serioes, literally 2000s, I think it’s like series of 3 or 4 about the tripod effect in lapro procedure itself, stabilize the whole area. And if you look the sesasmoid displacements, there are lot of literature saying that you can move the metatarsal back over, and actually it’s not really moving back over to rotating, and I’ll show you that live picture, it’s about rotating it and you get the sesamoids directly underneath the first metatarsal. So, here’s the patient, weight-baring, hallux valgus deformity, as you can see the toes deviated, the first metatarsals are open, the sesamoids in the space and the great toe is valgus. I would tell you all those rotations, if you rotate this all around, this can be reduced if get into alignment without going onto the joints. You can correct this hallux valgus deformity without doing that. Here the patient is on the table, quite large [indiscernible 0:17:47.6] quite large bump, was all about malalignment and here are his chest x-rays after destabilizing CMT-1 nerve soft tissue dissection and look at the toes, in valgus you have seen a lateral portion of the great toe, now you are seeing nuchal with the toe is rotated, the first metatarsal has been moved over, because this is rotating and you haven’t destabilized the first metatarsophalangeal joint your whole complex has been rotated as one. So, the first metatarsal is going on a verge, so what may look like a large indiscernible 0:18:18.6] now doesn’t look like a large [indiscernible 0:18:23.3] because this is rotated on the varus and the positive changes relatively speaking because it’s a radiographic orientation if you will that you’ve seen when these people are having or not weight-bearing x-rays. So, by destabilizing this you are allowing to control the entire first ray, and you can do this on the table with patient once you have him destabilized. Here is another patient and you can see my hand stressing the foot, destabilize and rotating the toe to more nuchal position. Although relatively minor case, you can see that you get the sesamoids back in the position very very nicely and getting alignment. Here is a cadaver lab, not destabilize the first metatarsophalangeal joint, but I typically don’t take down this much dissection but you see rotation of the first metatarsal by rotating just a great toe by leaving ligaments intact. Then once you leave the soft tissue intact, the whole thing rotating in that much better if you will with that. Pearse Seagal came back to me for revision surgery; she had a distal metatarsal osteotomy done several years ago. You can see I think it was a [indiscernible 0:19:25.5] type procedure, she has a valgus deformity sesamoids medo line, there’s instability here, the first resolving. All the first resolved, she had a metatarsal osteotomy, so couple of millimeters of bone has been gone, but the first metatarsal looks long. So, tell you again, this looks long because it’s more elevated, this is more parallel to the ground. That’s the reason why this looks long. So, here she is in surgery, look at the rotation, I destabilized the CMT-1, look the great toe getting to nuchal position, you can rotate this in sagittal plane, the transverse plane, you can anything you want with it and put it where you want, and I don’t worry about this because I backed for your all these procedures bone-graft and I put it where I want. Now, I have got a planter flex, the first metatarsal looks little bit shorter and of course you are going to lose some millimeters but I can promise you are not going to get a sub-toe because it is relatively planter flex or stabilize if you will into the nuchal position where you need to put it and you can see that mal motion that you have, control the entire first grade by destabilizing CMT-1, and have that great toe and the whole complex as one together and leave it together.

    [0:20:31.1]

    Here she is with my stabilization, I will use a large home run screw and fried screw 50 and 60 mm and then I put a [indiscernible 0:20:38.8] plate over top of it, stabilize to get [indiscernible 0:20:41.3] down to zero, joint space opens up, nothing was done to the first metatarsophalangeal, no incisions were made by discreet positioning, I have now much better range of motion, the pitches functions much better, stabilizes the saggital plane, it shouldn’t come back in a transverse plane, we are to follow plane again because of our position and our fixation. Those who say that you need to take off the lateral flare here, here’s no need to take off the lateral flare if you correct off and follow plane, if you see the follow up plane, it says [indiscernible 0:21:10.5] are corrected in that lateral flare and so first metatarsals that are rotated in valgus where you a large lateral flare, there is no need to go back there and have to do the extra dissection in that space because if you just rotate the first metatarsal, you will maintain your alignment without have to do that extra procedure. So, the key is in a [indiscernible 0:21:29.5] hit that first ray down, 5th ray in the calcaneus, and in often time you may need to do [indiscernible 0:21:36.6] along with these procedures but it’s been acquired to form for a long period of time. I have your home-run screw while using screw technique or screw and plating technique, that’s same screw that we want to have [indiscernible 0:21:47.3] long home-run screw if you will parallel to the ground as close as possible, and so this is what we are based to do is leave incision enough to enough to get screws and plates in there, using between 4 or 5 or maybe even 6 cm over CMT-1 making incision, watch out for neurovascular bundles, retracted soft tissues and write down in there down to the bone. Do not invade the peristomal, there’s no need to. All you need to do is take down the ligaments with the rigors of the CMT-1 and you can use a [indiscernible 0:22:18.0] does not matter. The new form is convex, the metatarsal is concave, so you may be a little more after the first metatarsal and take it off perpendicular to the long axis of first metatarsal, and you leave it square to the long axis first metatarsal and don’t worry about getting done-to-bone together because I always back these and that’s the key, put the bone where you want, get your position and back to bone graft, each one of these cases, so put it where you want, and you have a lot of room in there, so 3.2 cm on average deep, 2 cm wide, that’s a relatively big joint, you can get a lot of hardware and you get the people often moving quicker. The key thing is it’s been lot of time preparing your joint, take down the medial aspect of second metatarsal, I spend the most of my time preparing my new form of first metatarsal there using drills, fix, triats, whatever you need to do, use these [indiscernible 0:23:10.8] on the middle aspect of the second metatarsal base as well open it up and you are going to see a lot bundle brunch not even going to near to that [indiscernible 0:23:15.2] area, no need to invade out that area. Get some large K-wires, I typically like to use .6 or 2.0 K-wires, put them to bone where you want, don’t worry about these gaping here, don’t worry about getting in the end sagittal plane, just leave it where you need to keep some bone contact and fill the gaps of bone graft leaving to space, go from 1 to 2, so you are not over planter flexing or under planter flexing or dorsiflexing, if you will, making sure that this alignment down this closest possible to parallel, and then you get screw hole for [indiscernible 0:23:49.0], nice vents for putting angulations near screws in there and typically if I’m using [indiscernible 0:23:56.4] cortical and noncannnulated. There’s a difference in the screws and there are fatigue analysis of those screws. So, cortical screws typical like these 2 in saggital plane and one from medial lateral, is typically to do or your home-run screws, your biggest thing, if you want a plate over the top of it then home-run screw then walk your plate medially, that’s how I like to go with it. So, here is my home-run screw, here’s my middle base lucky plate, and here’s my home-run screw 2 or 3 saggital plane screws. And again the home-run screw is a beam effect, by cortical purchase away from the [indiscernible 0:24:30.1] you won’t have any effect on that area. As I said, I don’t worry about any gapping till I go back, I always get autopsies graft in the calcaneus, his back floors will create sheer strains and practicing very very nice tightly which I have in my lapros procedures. This is how I do that. Just go to the lateralized aspect of calcaneus with an erosion skin line inferior to the

    [ 0:25:00.2]

    sural nerve the perial tens make the stab incision and just make that it get a free elevator right down the lateral wall make sure your not too far inferior or posterior to cause stressurizer put a Dural either 2-5 or 3-5 whatever you feel like you need to a small—start up the small thread you have a large thread so you can harvest a lot of fresh skin cells on touch bone graft and pack it right back safe and again it is a key thing you want to do so my post op course with a weight lock key plates immediate weight training with protective weight during boot and if I am using two screws right now we are performance two weeks and I think I can even do this immediately as a possibility but anyway in long term these boots they will thrust six straight weeks until they show periodic consolidation at the sight. So, to take you through a bunch of cases patient's sub two lesion and sub TMT-1 hallux valgus deformity and here at base we are doing destabilize TMT 1 and basically open a sub [indiscernible 0:25:55.6] spreader to breach down the [indiscernible 0:25:56.3] tarsal base and prepare these joints i spent a lot of time adequately get my K-wire in there to stabilize it and getting prepared for my home-run screw bicortical purchase as long as possible. Go to the calcaneus showing you how minimally invasive this is a little stab incision and you can see you are not taking a whole lot of bone out of there we have a paper look at couple hundred cases showing you that you do not have anything really to worry about except leaving some bone in there and you may get some associate small issues but a very very small amount of potential complications with the procedure very friendly. Here is our incision what I’m grabbing here is my hands and grabbing an excessive tissue from the bursa and showing you how much that is. So it looks like on the table the bunion may still be there and we are all used to go in there take out the capsule tissue and get rid of that bunion but you don't need to trust it, it’s like somebody going into gastric bypass where stomach conventionally strings up so this soft tissue adapt over time. So here is a preop x ray, here is the intra op x-ray. Here i am holding that excessive soft tissue you just see how much that excessive soft tissue there is. you don't need to take that down that eventually shrink up over time as you see or you should case with no sub valous rotation in this gentleman [indiscernible 0:27:10.4] nothing was done around there to get it. It’s all about positioning the whole complex out of valgus to neutral position and Varus traction can stabilize it and nothing needs to be done around there as you can see. Here is a range of motion post operatively so the range of motion much more freely much more easier for patients not getting any stiff joints post op with that. Here is another gallery you can see a pre op and a post op ... post lab tests. Here is a revision this patient have previous bunion, I commit mcbride orthoplasty on this [indiscernible 0:27:43.1] toes and here I did my modified hips, it’s a little gruesome procedure and did a laprous procedure no [indiscernible 0:27:47.8] rotation of valgus. Here I’am intra operatively as you can see changing realignment of sesamoid complex just by manipulating with my hands intra operatively to destabilize TMT 1. Here she is long term the second toe I didn't do orthoplasty if you go back and look this is already done up here so basically just put a K-wire through did my tila girdlestone in my modified hips procedure cut the toe back down out the alingement cut the first metatarsal stabilize everything functions as one solid unit now in that area. So here is another pre op how its valgus elevated for firstly to mild degree to increase stress second metatarsal homerun screw with an immediate base locking plate holding everything in place again nothing done in first metatarso phalangeal joint. Here is cross over 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 these in your office try so much correction you can get without anesthesia. Here she is post operatively everything lays down flat again maintain alignment and again you can see the alignment [indiscernible 0:28:55.0] case but you can see the functionality of this foot long term the toe stays down and there is nothing really done from cosmetic point that really bars the patient. Here is another patient post operatively you can see maintenance these patents cann’t get a reoccurrence because you got a nice solid fusion at the TMT 1. Here is another patient with revision had previously had surgery done on the second toe had lastor metatarsal procedure done, I’m sorry first metatarsal procedure done with distal metatarsal area valgus rotation even with the staking done you can still get these back in place and you can maintain them in a nice alignment by getting them in position and another case of pre and post and you notice again the valgus rotation to much more neutral position without having touch this area. So I have showed you multiple cases where you can achieve this very useful. This is a tremendous cases show this is a that was done multiple years ago and I’m thinking about I don’t think any surgeon had did distal metatarsal osteotomy for this large [indiscernible 0:29:53.2] many years. So I wonder if that ongoing pathology continued to occur and just continue to widen after what that surgeon thought did a pretty good job with distal metatarsal osteotomy.

    [0:30:04.3]

    I would think so but this is done like tissues closely twenty years ago or fifteen years ago so she was scared to come back and have the procedure done and basically we did as you can see we did a lap, we didn't do anything to the first metatarsal phalangeal joint. If you look at the pre op looks like you need to do something here and there it’s like total posture can change but it’s a visual misnormer on x ray based on what you are seeing, so you see we took down the TMT1, we spun the toe around fell everything to neutral position, you can see that the alignment maintains much better once you get the foot hold in the neutral position. Look she has a very short first metatarsal planterflexed, I promise you there is no sub 2 leision. You can see it lays flat very nicely there is no incisions from this foot pre op to post op you can tremendous corrections with this procedure as you see there and you can get tremendous stability along this without getting sub 2 lesions. 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 here but it’s a very challenging work we do with these procedures, but that can be done with anything else like I said a good practice, I think you can get some fantastic results with this.