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Michael Trepal, DPM
Vice President for Academic Affairs
Dean and Professor
Department of Surgery
New York College of Podiatric Medicine
New York, NY
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Male Speaker: Everyone, we’re going to begin the last session of this seminar which I hope all of you have enjoyed. We certainly enjoyed putting it on. Our first speaker this morning is Dr. Michael Trepal. Most of you know Michael or should know Michael. He is a professor of Surgery at the New York College of Podiatric Medicine and serves as vice president for Academic Affairs at that institution. In addition, he is a clinical assistant professor in the Department of Surgery at New York Medical College and a clinical assistant professor in the Department of Orthopedic Surgery at SUNY Downstate where he also serves as director of the residency. Dr. Trepal will be presenting two topics, repair of the plantar plate and geriatric bunion deformity. Please welcome Dr. Trepal.
Michael Trepal: Hello. Good morning, everyone. It’s a pleasure for me to be here because I think that this is one of the best things for residents. It gives you the opportunity to hear a bunch of really good talks. It gives you the opportunity to catch up with some of your colleagues and classmates who you may have not seen for a period of time. I came in on the tail end of the rumble last night and that seems like always a lot of fun. Get to look at the exhibitors. All around, it’s a great opportunity and I’m so happy to see so many of you taking advantage of it. Okay. Okay, my topic that I’ve been asked to talk on today was lesser metatarsal surgery, specifically, as it relates to plantar plate tears. This is a problem that I guarantee every one of you has seen and well seen. It is a difficult, extremely difficult area to manage. It seems like it should be a simple straightforward thing. You got a floating toe. You got a crossover toe that we can fix that one, two, three. But those of you who are in the upper years of your residency, I’ve certainly noticed that if you get to follow the patients that this is really a very difficult problem to get longstanding results. In terms of disclosures, I am a consultant for Vilex. And let’s get going now. Metatarsalgia is kind of a wastebasket term. We just use it, obviously. It means pain under the metatarsals. It can have many etiologies on it. The one that we’re interested right now is that which is attributable to pain, ultimately, rupture of the plantar plate. It stores out, generally, with plantar inflammation. This is what you want to avoid. This is one of the areas where you want to get it early. We see this all too frequently where patients come in with just some pain and tenderness about the second metatarsophalangeal joints. If you do a careful analysis, you’ll see that they are really ripe for this deformity to occur because of a host of the associate structural and functional factors that we’ll be talking about. But this is where it ends up and this is really what you want to avoid and particularly when you tell someone you know, you don’t want to end up with your grandmother’s foot. That kind of resonates with them because many people know people who have feet that look like this and that they’re terrified for that to happen. So this is the structure that we’re interested in. This, I guess, I can point. But, if you look at it, the MRI images that quite nicely up on the top and then when it ruptures you can see down on the bottom there on the T2 weighted image that the distal attachment of the plantar plate has severed itself from the base of the proximal phalanx resulting in that inflammation, edema and pain in the area. Now this plantar plate, and I don’t want to go into great detail on the anatomy, you should all remember that. It is a trapezoidal structure underneath the metatarsal head and that consist of the joint capsule thickening of it. So it’s a collagen and add an extra type one, two and three collagen. It also takes investiture of the plantar aponeurosis. The distal attachment goes into the base of the proximal phalanx. It attenuates somewhat this which is reason why that is the most frequent place that it ruptures. That also makes it more difficult to repair it, primarily, because you don’t have much to work with right there. Many of the repairs, as you’ll see later on, generally involved reattaching it into bone rather than direct repair of it.
Medial and laterally, it gives off expansions into the intermetatarsal and the collateral ligaments. Of course, the function of this, everything has a reason as to why it allows the metatarsal to glide during the propulsive phase of gait. It has a surface for the flexor tendons so they don’t rub on the inferior surface of the bone. And really, it’s a stabilizer to prevent hyperextension of the metatarsophalangeal joints. Of course we know that’s indeed what we see, that hyperextension when it ruptures. Also addition, it causes some cushioning there particularly in the older foot where you have attenuation of the fat pad. Now, generally what you’ll see in the crossover toe, transverse deviation of the toe usually it’s medially over the hallux. There is an abnormal position of the long and the short flexes, again it’s one of those things which came first, the chicken or the egg. Certainly we know that there is inflammation and pain submetatarsal head in the area or the plantar plate. This can be attributable to overloading. There’s a whole variety of functional and structural abnormalities that occur in the foot that will result in the overloading underneath the second metatarsal. We’ll look at some of these in greater detail. Mike Coughlin and Doty did an analysis and categorized this. I don’t know if that it’s so much clinically relevant for you to write in your chart, whether it’s a grade one, two, or three, but it certainly has import to you to understand the level of the pathology that you are working with. Clearly we want to get this in the early stages. If you understand these various stages, you understand the pathology and the sequential pathology which is occurring. The earlier in the process that you can get at these, the better chance you have of a better longstanding outcome. And again that’s true for most of the things that we treat. There can be other etiologies other than biomechanical, an overloading in the area. It can be a result of a trauma. It can be a variety of rheumatological conditions. It can be due to neurologic conditions where you have muscles imbalances particularly of the intrinsic. Again, you don’t want to be treating something biomechanic. Well, biomechanically certainly has a role on this but clearly you want to be going and attacking the etiology of it if possible and if known. But your job is really incomplete and improper if you don’t really look at what the underlying etiological factor is. So this is really the pathologic anatomy which is occurring here. What’s happening here, biomechanically, when you get the rupture or the tear of that plantar plate, you get a loss of the plantarflectory pull of the plantar structures on the proximal phalanx, which results in then secondary overpull of the extensor tendon and the extensive structures by virtue of that extensor hood mechanism which is where they have their effect on the proximal phalanx. This then increases the retrograde force. You get a buckling of the attenuation of the plantar structures, extension or contracture of the dorsal structures and this deformity gets worse with time as it goes. So, it’s a progressive deformity. You can actually track patients if you look back at your old x-rays. When they come in you can see frequently the progressive stages of it. Here’s a patient that certainly is right for a plantar plate tear. You can see that they have a fairly significant bunion deformity, relatively long second metatarsal, overloading of the second metatarsal due to structural and functional problems. You can see that the second MTPJ there in 2011 is slightly narrowed compared to the third, fourth, or fifth. What you’re seeing is there’s dorsiflexion of it. And then you look a year later, Frank dislocation. These things go in a snap relatively quick. Patients will come in and then they’re almost tell you to the day when that toe dislocated because of the acute pain exacerbation and then clinically what they see and then dorsal subluxation or dislocation becomes rigid and fixed, and it significantly increases the difficulty level in repairing that. Again, April 2000 to August 2000, okay. Only a period of a couple of months, that joint went from predislocation to Frank dislocation. Again, March 28 to July 2008. You can see clearly the progressive dislocation. In this particular case, it was lateral rather than medial. Most of the time it is going to be medial. Once again, take a look at these foot structures that’s occurring here.
Short first ray, hypermobile, you can see previous attempt at bunion surgery here, a biomechanical dysfunction. These patients are all right for it. Then this is ultimately where it ends up with. When these patients come in, they got a hell of a problem. Not only is the bunion difficult there but you can see the dorsal dislocation, the increased retrograde force. As patients age, the attenuation of the plantar fat pad, they are literally walking on skin and bones there. You can just palpate that right through the skin. Clinically, as in all cases of lesser metatarsalgia we need to be fairly precise as to where we’re palpating in the location of the pain. There are lots of conditions that can cause forefoot pain, arthralgias, nerve entrapments, neuromas. I think in our profession are the best adept because we understand the anatomy and we understand the function, to really pinpoint the location of the pain. It’s not uncommon that this will frequently start dorsally. As the joint becomes inflamed, you can exacerbate the pain by palpating it because you don’t have the thick plantar skin which may attenuate some of the palpation and the force that you’re doing when you’re palpating these on the plantar aspects. Again, if you just use the tip of a finger and palpate along the dorsal aspect of the foot, you will almost invariably find that it hurts right there in the dorsal aspect of the foot. The Kelikian push-up test can be helpful. If patient is sitting in the chair, push up on the metatarsals. If you want to, you’ll just have the patient stand up and look if the patient stands up in weight base, that’s essentially what you’re doing is the Kelikian push-up test. But loading under the metatarsal head in a normal to slight hand and toe deformity, when the collateral ligaments or the plantar plate has attenuated a toe and you’ll start to see transverse plane deviation of the foot as well. This so-called Lachman test can be of benefit as well where one hand stabilize the metatarsal and the other hand try to dorsally lift up, or dorsiflex on the proximal phalanx. Depending upon the degree of tear, if any, you will see relative movement of the proximal phalanx on it. Again, depending upon which stage you are in that [indecipherable] [12:31] scale, stage two, they’ll have little movement all the way up to stage three. You’ll see the phalangeal base in the fixed dorsal position. I think, this video, I guess the video is not working. Okay, well, if that video was working, what you would see is the Lachman test being performed where you can see with the right hand there that the proximal phalanx is able to be significantly dorsiflexed on the metatarsal head. X-rays are a help to us in looking at the etiological factors, certainly they're going to tell you if the MTPJ is dislocated like we saw on some of the previous ones. Generally, I’d like to take x-rays with lesion markers where the patient’s symptoms are, to try to attribute somehow that painful spot or callosity with structure in the foot. If you’re going to use a lesion marker, it should be as small as possible encompassing just a keratotic lesion or just the area of pain. Remember when you’re taking the x-ray beam, well we would normally angle the beam 15 degrees to go perpendicular to the declination of the metatarsals. If you’re utilizing a lesion marker, you want to go 90 degree to the weightbearing ground because otherwise, you’re going to get distortion of the lesion marks, where it is in relationship to the metatarsal head. So, you need to take two views there, one at the normal 15 degrees, and the other to get the appropriate position of the lesion marker at 90 degrees to the foot. Then that will tell you, hopefully, a lot of information. It’ll tell you whether you have a relatively long second metatarsal. It may tell you that the second metatarsal is fine. It’s the first metatarsal that’s short, or maybe one of the lateral metatarsals which is short. Okay, again, everything is relevant. We just don’t always assume it’s the second metatarsals. It could be the ones next to it. So in these particular cases, if you’re going to do something to address the etiological factor, that would be addressed to these neighboring metatarsals, which are short. The plantar flex, this is difficult to determine, really, because there is variation on how the view was taken, the position of the foot. Does it really replicate what would happen during gait?
There is some sagittal plane bounce in the metatarsals that’s occurring back at the metatarsal cuneiform joint. So this view here doesn’t truly replicate any of the phases of gait. So while in severe cases it might give you some useful information, I don’t rely on this all that much. The lateral view will not only show you the congruency of the lesser metatarsophalangeal joint but the position of the first metatarsal, whether it is dorsiflexed. Again, remember this is just a snapshot in time. Taking of an x-ray in the angle base of gait this is replicating midstance phase of gait. But remember, these metatarsals are functionable throughout the entire phase of gait. Therefore, not only do we have to look at the structural components, you want to make sure that functionally you’re trying to evaluate it to the extent that we can put the first ray for its range of motion to determine each relative hypermobility is useful. Also, looking at x-rays you can look at the cortex of the second metatarsal, bone does respond to [indecipherable] [16:10] as we know. And in cases where there is hypermobility or overloading of the second ray for whatever reason you will usually notice that there is indeed cortical hypertrophy. So you’re getting a pressure analysis just by looking at the x-ray. And I always look at the thickness of the cortex because that gives you a lot of information as to terms of function. Etiology may be iatrogenic. Someone may have been in there and shortened a metatarsal as part of a bunionectomy, which resulted in a relatively long second metatarsal. Again, in cases on the shortening of the third metatarsal they are leaving the second metatarsal abnormally long. What’s happening here is, again, functional, that retrograde force. When you have subluxation for sure or dorsiflexion of it during the stance phase of gait and particularly in the propulsive phase of gait, that pull of the extensor tendon is going to recreate or create a functional retrograde force that only exacerbates the problem which is occurring. Remember, the x-rays also going to show you of other systemic disorders going on here, any of the arthropathies, rheumatoids, psoriatic, or any of its variance and that needs to be managed as well. You can have other osteochondritis occurring in the area which will only be shown up by x-rays. Other little tests that we can do to help us determine what’s happening in that foot as it functions, because remember, most of the time the foot is functional and when we examined this as the patient sitting in the chair we may not be getting the full information. Relative inexpensive way to do this is to have the patient walk on a pressure mat. There are a number of these different systems which are available. They don’t quantify so much or you can see the increased loading underneath the second metatarsal head there. You can tell how the arch is loading there. So they can give you some real useful information as to what’s happening on the foot. I find these are particularly beneficial in trying to explain to the patient what’s going on, take the x-ray and say, look here Mrs. Jones. Look at this. Your metatarsal is long, you got this bunion deformity, you’re not getting weight on to the medial side of the foot. And look here, when you walked on this, and this takes seconds to do, when you look at that you could see how this is loading underneath the second metatarsal. Yeah, this is all your pressure is going. Whatever therapy we’re looking to offer to the patient, its intent is going to be to offload that area and create a more diffuse walking area. You can do sonograms of the foot. As you know, when you’re doing sonograms you have two ways of doing it, the longitudinal plane and the transverse plane. Usually, when looking at plantar plates it is the longitudinal that’s going to be most useful to you right underneath the second metatarsal head. Sonography, diagnostic sonography is a very useful tool but the person doing it really has to be the doctor. You can’t really too much certainly the podiatric practice perhaps at a hospital, the techs are good at it. This is something that you can’t rely on an assistant. You need to do it yourself. You can get a fairly good imaging of the plantar plate as you see there in the top screen on the right hand side. We fill that in with green there so that basically is the area where that green is in the lower that we’re looking at on the plantar plate. Again, good imaging with sonography can show a tear as we see on the left hand side there where there is a front tear within the substance of the plate, or where the plate is intact, attenuated and you can see more joint fusion surrounding the plate.
Other more sophisticated modalities which the average practice may not have but at the college we try to do this as frequently as possible. We got a guy there who can really do this computer-assisted gait, Dr. Cusack is really great at this. I will routinely, on any patient on contemplating lesser metatarsal surgery, have him do a pressure scan on this to try to get an idea as to what is going on functionally in that foot. Now we’re interested here in how the foot is loading, how long it is loading, not just peak pressures but we’re interested from a temporal perspective as well as to what’s going on underneath each of those metatarsals. You can see the pictures on the left, the nice colored codes as to how it’s looked at. Using our senses, we can pick out depending upon how we place them each of the areas of the foot and see how it is loading. Not only are we looking at the peak pressure points but really importance here is how long the foot is loading percentage wise during various phases of gait. In this particular patient here on the left hand side, you see that the midstance phase of gait is significantly prolonged as compared to the contralateral foot. So when we look at these pressures and the timing of these pressures that can help us formulate our surgical plan as well as that would buy a mechanical followup as to how we’re going to manage the etiological factors for those particular patients. Again, what we’re looking at is everyone assumes that you just wanted to look at the peak pressure. And yes, that is important to look at the peak pressure, say, the second metatarsal here. And we look at the peak force over period of time. So in this is particular hypothetical scenario, you would see a metatarsal that is loading to a very high rate but for a relatively short period of time as compared to, say, another patient with second metatarsal which may be not reaching the same peak pressure but for a longer period of time. So, think back to calculus and then the area under the curve. That’s the total force of that metatarsal is loading with. It may not be as a peak as high, but it’s occurring for a longer period of time. We can look at this in the pressure codes on the F-Scan analysis. We can look at it on the peak pressure curves on it. You can also look at this in terms of the percentage that the foot is loading. So, if you have a foot for a midstance, it’s a prolonged midstance phase of gait. You’re going to see more of a red curve there than you would in the yellow curve. The MRI can be, again, pretty definitive in determining exactly what’s happening here. Here you see a very nice image of it. Also, you see where the tear occurs. Most of the time, it is going to be occurring just proximal to the proximal phalanx. The plate is as thin as there. It attenuates there, and that’s the place which you’re going to see a tearing. Your two sequencing on the top, a T1, you can see the bone marrow light up so you know that’s a T1. If you look at it real close, you’ll see just again proximal to the insertion at the base of the proximal phalanx, the tear there. On the T2, also you’ll see the tear of it but you’ll see the marked inflammation which is occurring, the bursitis, the inflammation, the joint effusion, which is coming, which is in many cases it’s quite pronounced. I mean, that thing there is a very high signal intensity on the T2 indicative of significant effusion, periarticular inflammation, and needless to say, quite significant symptoms occurring for the patient. We’ll just very briefly going to touch on the nonsurgical treatment of this. Not everybody is a surgical candidate, not everybody wants surgery. But there’s not too much once that plantar plate occurs that you’re going to do nonsurgically to realign that joint. So you accommodate it with shoes, offloading, metatarsal pads, dispersing pads. You can treat them pharmacologically with certain anti-inflammatories that may get them over a particularly bad hump on it but it’s not going to solve them long term. Periarticular injections can be useful for short-term relief of the pain. You’re going to need to be careful in utilizing a steroid around it. I do it but in the early phases of it, if you give a periarticular steroid, it’s really important that you plantarflex the toe for a period of time.
You splint it down. You just don’t want to give the injection and send the patient off. You want to give the injection, you want to offload the area as best as you can, depending upon what the etiological factor is of the overloading, even putting in your electropads to take more weight within in the midfoot. And offloading the second metatarsal and utilizing whatever way you like to plantarflex that toe and hold it down can work wonders for the short period of time of offloading this and carry the patient over a particularly painful period of time. If you’re going to then approach this surgically as many of the patients do require, we have several options in which we can treat these patients. We can repair the plate. We can work on the hammertoe, which usually includes reducing the metatarsophalangeal joint. There are a variety of osteotomies on either the associated MTPJ or the neighboring ones, depending upon the pathology that you have. So, there’s more than one way to skin a cat here. Basically, what we’re looking to do, certainly, is to release the dorsal contractures which are holding the joint dorsiflexed or subluxed. We want to decompress and relocate that joint. We need to be able to restore the flexor power of it by even repairing a plantar plate, flexor transfers, digital fusions, whatever technique you’re going to do it. But these three things need to be relocate the joint, release the dorsal contractures, and restore the flexor power to the joint. The thing that’s involved right now is the scorpion technique. One of the problems of repairing plantar plates directly is anatomy doesn’t always cooperate here because you got to get to it. So, you have two choices, you can’t go medial or lateral. You’re going to go either dorsal or plantar. There are relative advantages and disadvantages to it. One of the disadvantages of making a dorsal approach is you got the metatarsal head on the way. So you’re going to get that out of the way. This particular technique involves doing an osteotomy or Weil type osteotomy sliding that metatarsal head back so that you can directly visualize the plantar plate, first of all inspect it. Most of the time you’re going to have an MRI. You should have an MRI or some time type of imaging to know at least that you do have a tear there. This will confirm it on your visual inspection. So an osteotomy which is performed to approximately relocate the head temporarily to give you direct visual access to the plantar plate is performed. The plantar plate is then harvested, sutured with a fiber wire or other nonabsorbable suture and reattached back into the proximal phalanx. On the rare occasion that you do encounter, midsubstance tear of the plantar plate, you can do a direct repair there. But again, those patients are going to be few and far between. Most of them are going to the distal location where it’s pretty much impossible to repair it. Again, the dorsal approach has been discussed in the literature. Here, you see the exposure of it, grabbing that plantar plate, reattaching it to the proximal phalanx. Here is a patient that recently was done here at the institution. Again, classic bunion deformity, relatively long second metatarsal confirmed by MRI, plantar plate tear. The bunion was taken cared of as well but that’s not the purpose of this talk. The osteotomy is performed. The metatarsal head is approximately relocated. If you look carefully where it’s torn, the plantar plate is harvested, sutured, reattached back to the proximal phalanx, and then the toe is splinted and K-wired in plantar flexion. So you see relocations of the joint and repair of the bunion as well. Plantar approach can be done as well. The advantages of the plantar approach is the direct visualization. The collateral ligaments are undisturbed. When you’re doing the osteotomy from the dorsal approach, obviously, you need to sever the collateral ligaments if they’re not severed already to retract the head proximally so you'd get access plantarly. If you’re doing the plantar approach, you don’t need to do that. So they’re undisturbed and the osteotomy, therefore, is unnecessary. Disadvantages, theoretically, a painful plantar scar, increased risk of vascular compromise if you’re also doing a dorsal approach.
Remember, many of these or most of them are also associated with digital contractures that you need to do something dorsally. So, it’s rare that you’re going to get away solely with a plantar approach here without having to do something of the dorsal aspect of the toe. Therefore, a dorsal and plantar incision can increase the risk of vascular compromise. In addition to repairing the plantar plate, the dorsal contractures need to be released in the structures that are there, the hood, the capsule, ligaments and tendon. Dorsal capsulotomy needs to be complete. That means not only the dorsal but the medial and lateral aspects of it as well. In order to get to that, you need to proximally retract that extensor tendon. The extensor hood release also needs to be complete because the action of the extensor tendon is through the mechanism of that extensor hood expansion so that needs to be severed in its entirety. So you need to get that extensor tendon all the way back. Again, complete extensor hood release than in some cases just a digital arthroplasty to restore the digital structure. Flexor tendon transfers, also a very viable option. We harvest the flexor tendon, wrap it around the proximal phalanx and plantarflex it. Capsular reefing on the medial and lateral side, this is difficult to do. The capsule is fairly attenuated there and it’s like suturing a tissue paper together but you can make an attempt at it. PIPJ fusions are also that I tend to prefer the digital fusion over a straight arthroplasty in these particular patients. There are a variety of ways to do it. If you can do a fusion with an implant as well, there are a bunch of digital implants which are on the market now. You can see there in the third toe a pretty good fusion with one of the makers of it. But what a fusion does is it creates a single digital unit which can no longer buckle. So what you're doing is you’re taking those three bones. And essentially, if you’re doing both joints, you convert it into a single unit that again would require PIPJ and a DIPJ fusion. But even just doing the PIPJ, what you’re doing is preventing the buckling of the toe at it. When there are long flexor pulls now what you’re doing is you’re plantarflexing that toe as a unit. That’s a rigid lever. When you have more global pathology involving all of the toes, flexor tendon transfers into the midfoot, also in conjunction with digital fusions are an effective way. A variety of osteotomies are available. We mentioned the Weil, the V is kind of falling out of favor. We certainly did a lot of these back in the day. The osteotomies, you never knew how much to raise it. They were associated with their own healing perturbations. The Weil osteotomies seems to be the one that is most frequently utilized today. The Weil osteotomy is a fairly easy osteotomy to do. I think it’s been shown but I think it’s been reported that a 20-degree osteotomy with a five millimeter displacement decreases loading in the forefoot, foot flat at 36% and as much as 65 degrees during heel rise. So that’s significant numbers in doing it. The Weil osteotomy, you will know how to do it, several examples of preop, postop of it. However, with the Weil, clearly you will see floating toes. I mean, that’s one of the detriments of that procedure. Floating toe is clearly associated with it [indecipherable] [34:00] now I am depending, regardless of what I do on the digit, I’m K-wiring all these, keeping it in the plantarflexed position, trying to get as much scarring and fibrosis in a rectus position to minimize the chances of the floating toe associated with it. The literature shows there’s not a lot of good studies out there. There’s not a lot of long studies. There’s not a lot of highly powered studies in it. We have relatively sparse data and most of it is done in retrospective fashion. Here's one that’s done in 2008 showing a retrospective study of plantar plate in hammertoe. Through a plantar approach, the plantar plate was repaired either midsubstance or at the distal aspect where it’s reinserted into the proximal phalanx. Again, fairly respectable, and again, limited study retrospective. AOFA score of 83.2 average, again, not highly powered retrospective in nature but from limited data showed fairly good.
Nery, in foot and ankle in 2012, in this particular case did a prospective study in patients with direct repair of plantar plates in conjunction with the Weil osteotomy. Again, not highly powered. This was done through a dorsal approach, much of the same technique we just managed. Again, looking at relatively small numbers of 17-month followup, third of them still has a little bit of a floating toe and which is about what we see. All the 63% had digital purchase. Again, the AOFA score was 92 and 77% of the patients reported progress. This Weil boys, father and son did again postoperative visual analog pain scale based upon their series of patients. Again, the pain score is decreased from a 7.3 to a 1.7. Implants resurfacing is an option. One other thing that I’m going to leave you with before we move on to the next talk as I'm over is there are times in which severe subluxation of this is restoring the function of that joint, at least in my hands, is virtually impossible. What I've kind of opted for in these particular cases is stabilizing the medial column through effusion and partial metatarsal head resections. Again, for a limited or all of them, here is a particular patient who did repairing, stabilizing the medial column, doing partial metatarsal head resection, and of K-wiring of it. So, summary, in dealing with these difficult patients, we really need to identify the etiology of what’s going on here, try to address it if possible and then reduce that retrograde force and offload the metatarsal to try to get the best results possible. Thank you.