Male Speaker: He is another very good friend of mine, Larry DiDomenico, who comes from Ohio. He is a brilliant foot and ankle surgeon. He’s an excellent speaker. His picture slides are superb and he is going to talk for about an hour, maybe a little more, on three topics. So we’re gonna start right off now with soft tissue balancing for hammer toe deformities and then move on into more extensive surgical procedures. So please welcome, Dr. Larry DiDomenico.

Dr. Larry DiDomenico: Thank you and Harold, thank you for inviting me back. After Dr. Fello’s lectures I’ve always been a fan of his – I have followed his work for the last 20 years and given him tremendous amount of credit, keeps going and does really nice stuff. So Harold asked me to talk about soft tissue balance in hammertoe procedure. So for me, I changed the way I do my hammertoe procedures probably about 10, 12 years ago now to my neighborhood. I rarely ever do an arthroplasty or arthrodesis anymore. I was taught to do that most of the time and I learned how to do soft tissue balancing. And if you think about the underlying pathology of hammertoe deformities, it’s the tendon that is a problem, it’s not the bone. So as I said, my Lapidus procedure, why we’ve taken the straight bone in terms of hallux valgus deformity in a virgin foot and cutting it, make it crooked to get rid of the bunion. So I pose the same question for the hammertoe procedure. If you look at each segment of the toe, the proximal phalanx, the middle phalanx and distal phalanx, they’re normal bone, normal architecture. They’re just contracting. So why are we addressing the bone? If you inherently sit back and think about it, to me it makes sense. And so if you’ve had been doing hammertoes long enough and doing arthrodesis, arthroplasties in long term, you eventually wind up some bad deformities. I’m not saying the soft tissue balancing doesn’t provide you bad outcomes either but to me it’s a lot more predictable and a lot less complicated for me in terms of my hands and for my patient population. So again, why destroy or alter the normal segments of the digits? The three phalanx individually have no deformity within them. The deformity is within the soft tissue imbalance, not in the bone itself. So that’s the genesis of this whole topic. If you look at this list, there’s a whole bunch of complications in the curved hammertoes and hammertoes are quite difficult to get done perfectly for you and your patients. If you look at this x-ray, this arthroplasty is across two through five. Inherently that’s just not the way – it’s not supposed to look that way. Eventually what happens is you lose that cubic volume in the bone and you get some destabilization overtime in some cases, not always again. So certainly I’ve done enough arthroplasties and arthrodesis that occur and that they are done very, very well. But again what’s most predictable long term outcomes that you can provide. I really like to spend time in going over who has hammertoes but we know we tend to see more females than males but again, it’s altered biomechanics that cause hammertoe deformities. There’s a lot of neuromuscular disease. There’s lots of systemic disease process that occur with hammertoes. It’s listed there as you can see for yourself. Then for your boards, you need another pathomechanics of why these hammertoes do develop. I’m really going to talk about why actually these procedures can apply for all three. I’m going to look at two different runs mainly for you to look at later on in the lecture here. So I’m not going to again spend time going over the pathomechanics but I would note the stuff for your board examination, knowing the difference between flexor stabilization, substitution and extensive recruitment or substitution, however you want to call it. There’s a difference in how you address these patients with each deformity. In our radiographic findings, I think everybody sure knows how to look at an x-ray, on a hammertoe deformity that you’ll see but certainly something you want to include in your workup in your examination. And then I think everybody in this room also knows the difference between a hammertoe, a claw toe, a mallet toe. And really I use these soft tissue balancings for overlapping toes, crossover toes, for HT5s, [holo malaise] [04:05], you name it, distal clavi lesion which I’ll go through several different examples and it works for all different hammertoe deformities in my hands again. You look at this patient. We’ll come back and go through his case. This patient was a diabetic, had osteomyelitis secondary to flexion contracture and hammertoes and just chronic ulceration from this area from increased amount of pressures on the distal aspect of toe. So whether it’s a distal clavi, a callus lesion or whether it’s an ulceration, you can fix these deformities long term for these patients by removing the underlying pathology. Again, here’s a list of ideologies which is not really the region that we’re gonna discuss this. I’m really here to show you the surgical techniques and who to apply it to when we look at. Prior to going under surgery, you must know your normal anatomy. So you have to go back and review the little intricacies of anatomy in order to really be able to fix it.

[05:00]

So you must know all the normal anatomy around the toes including a long tendon or shortest tendons in the soft tissue capsulars and the extensor hood, all those different types of anatomical landmarks that we are taught. So clearly it needs to be known before embarking on these surgical procedures and just going through about the plantar plates and the soft tissues surrounding all the digits in the metatarsophalangeal joints. So again you look at this patient sitting in an exam chair. You can see callus tissues two, three, four. You have to actually solve it. Is it really a deformed metatarsal that caused it? Some of the skeletal maturity developed a deformed metatarsal? Does it really become plantar flexed? s These are the things I was taught and I joke around called podiatric myth number 39 I was taught because it doesn’t occur. It’s really the external pressures that are placed upon these metatarsal heads. It’s an imbalance that occurs. Certainly the hammertoes have a contributing factor with these patients. So if you look at this patient in the chair, the toes are curled back. They’re caught back. The extensors have a tremendous mechanical advantage and also in conjunction with these patients oftentimes there’s a tight posterior muscle group. Significantly hallux valgus deformities. So you have the instability of TMT1 and the way it get shifted laterally. There is not a plantar flexor metatarsal that occurs. There is not a lengthening of the metatarsal that occurs after skeleton maturity. I could see in a very unusual brachymetatarsal case far in between that you may have some like this. I don’t even see that with those cases. So I really beg you to sit back and challenge yourself and look at the underlying ideologies rather than going ahead. And performing other procedures such as maybe arthrodesis, arthroplasties, and lesser metatarsal osteotomies and different things such as that when really it’s the external forces or dynamic effects if you will or the soft tissues around the metatarsal heads that’s causing the effects. By the way, everything I’m telling you here, it’s nothing that I’ve invented or created. This is all old information in the books. It goes back about hundred years with the modified Hibbs and Girdlestones about 60 years or so that it was listed. So really we’re gonna talk about doing a modified Hibbs procedure and the Taylor Girdlestone procedures. Again, this is not my work or creation. It just really taught me from Ted Henson and then I’m trying to expand it because I think it really has a great place for forefoot surgeon. And actually it makes it more interesting. I think it’s more fun type of surgery do hammertoe repairs. So again the PIPJ and DIPJ and the medial lateral collateral ligaments are intact. So the patient cannot get a frontal plane or transverse plane deformity or instability if you will after performing the surgeries whereas, if you’re doing arthrodesis or arthroplasty, it certainly can happen. No bone resection. So there’s less postoperative edema. There’s no shortening. There’s no instability. There’s no rotation, no translation that can occur. It’s much more predictable for you. It gives at least in my mind a better cosmesis for patients and particular for the females who want to wear open-toed shoes. Their toe can actually get longer because if they’re curled up or hammered, they become longer. But relatively you’re not gonna add anything more than the normal anatomy that they have. They’re gonna go back out to normal length. As you’ll see with our scars, particular to Taylor Girdlestones are hitting their medial and lateral scars on the toes so they’re not even visibly seen when wearing open-toes shoes. So from a cosmetic standpoint, your female population certainly works much better in my hands. And then Hibbs as I said, this has been around since I believe 1914. It really initially describe for neuromuscular disease patients and really is for our patients who are like diabetic and neuropathic patients, intrinsic minus the rheumatoid patients, people with neuromuscular disease, CMTs, different patients like that. Whether this really cocked up toes and just really balance out the soft tissues is what we’re gonna really do this for. Here you can see the date was 1914 when Hibbs originally described this. Again, so nothing new. The goal was the decrease of buckling at the metatarsophalangeal joint. Hence offload in the lesser metatarsophalangeal or metatarsal heads. Increase the ankle dorsiflexion because that’s one of the problems with these patient’s neuromuscular disease they have a lack of ankle joint dorsiflexion. So we’re going to enhance that, the procedure for hammertoe deformities due to extensor substitution. And typically with the Hibbs we’re also doing a Taylor Girdlestone or a flexor type of work as well. Not necessarily the offset when you’re doing a Taylor Girdlestone or a flexor tendon transfer. You have to do that modified Hibbs with it. So the modified Hibbs the way it was cut is really it’s one incision at the second metatarsal head going down to the fourth metatarsal base. It’s an oblique incision. Most people look at that and say, “Oh my gosh. There’s a lot of neurovascular sections.” There are. You have to be careful when you make your incision and you just make the full thickness incision. There’s a very thin skin there so you have to be careful. You avoid your neurovascular structures. They’re running longitudinally. All you want to do as a surgeon is find the tendon tracks. All you want to do is work within those tendon tracks while you’re performing these surgeries.

[10:04]

What you want to get to is in EDB two, three, four, and there’s only and EDL five. You get EDL 5 through here and I’ll take you through it. Again, most of these patients are Charcot-Marie-Tooth type of patients, polio patients, diabetic patients, rheumatoid patients, or anybody who has an extensor substitution or recruitment type of problems. Again, these patients have a weak tibial muscle. They use the EDL for recruitment, for hyperextension of the toes. They dorsiflex at the MPJ, get that buckling if you will. This dorsiflexion overpowers the intrinsics and this is how we see with our diabetics, as intrinsic minus. They get more clawing of the toes and again the contractions, the MPJ, PIPJ, sometimes the DIPJ, and they get lesser metatarsalgia or callus tissues or even ulcerations for these types of patients. So the idea of this is what we’re going to do is really weaken the muscles. I have a diagram of an anatomy in my office, in each room. I showed the patients a long EDL muscle. It’s a big muscle and it comes on these tendons of the midfoot and to the toes. I show them the small EDB muscle and I show them the tendon goes to the toes. I said really I want to do is transfer. I’m going to weaken those toe muscles because those toes are really overpowering and our goal is just to balance out. All the patients need to do is dorsiflex and plantarflex. They don’t need to be grabbing things with their toes. If you explain to them, they understand it. So the idea is to weaken or balance out these long extensors if you will to offload the pressures that the patient is having from that big muscle over that little muscle belly. So here’s a case. You can see that more clawing to the toes and extensor recruitment. Basically what we’re doing is making the incision at the second metatarsal head to the fourth by tarsal base obliquely. Once we get to that point, what we want to do is just find the EDL tracks and EDB tracks at two, three, four, and there’s EDL track of five. Leave all the other neuromuscular structures intact. Don’t touch them. There’s no need to. And it run longitudinally or longwise so you will not interfere with any neurovascular structures at that point in time. And basically I used a fine skin tooth retractors with my assistants here to hold the soft tissues the other way and pull it very gently while I use a 15 blade and a one two pickup. I find my long EDL two and I find my short EDB two. The EDB always comes from lateral. It’s much smaller. Isolate those and I’ll continue going. I then continue to retract that laterally and then I find EDB in the EDL three and continue retracting laterally EDL four and EDB four and eventually over to EDL five to find that. You can do this with all one utility incision without undermining full thickness incision and leave the neurovascular structures intact. Now this is hard to follow through this lecture because we’re limited on time. This really should be like an hour-long talk by itself but basically I use a Hemi set as far as proximal as I can to find EDL two. I clamp with a hemostat at the most proximal portion of that incision for EDL two. And then I go as far distal as I can and find EDB two. I cut my EDL and I put – EDL two and I put an Alice clamp in the first sub space that’s at the distal portion of EDL two in the first sub space. Then what I do is look for EDB two distally and basically what I’m going to do is cut this and have an Alice clamp on EDB two here. You want to do the same thing up and down the line. So again, EDL distal stump is in Alice clamp. EDB proximal stump is in the Alice clamp. EDL proximal stump is in the hemostat. There’s a reason for marking them in different ways like they are labeled because you’re going to see we have a lot of hemostats and Alice clamps here so we don’t get them mixed up. At this point in time, you can get complete exposure to the metatarsophalangeal joint. You get the McGlamry elevator in there. If you have a lateral deviation for example in the rheumatoid patient, you can really release his lateral collateral ligaments at the metatarsophalangeal joint. As far as the plantar contractures, you can go underneath that and you can really free up that joint and a great visibility to it. Then what the surgeon wants to do is move one to number three. Again EDL three, EDB three, and laying the same way that we did before. So that’s why we want an Alice clamp and hemostats on the respected EDLs two and three, four and EDB two, three and four. Then we want to get to EDL five because there’s not an EDB five. You want to perform a Z lengthening procedure. And then after I said, you want to go through each metatarsophalangeal joint and completely get complete freedom of the metatarsophalangeal so you can take off all the soft tissue contractures from that area. Then we’ll have to fast forward and come back. We do our Taylor Girdlestone procedures before we can fix these Hibbs but I can only show you one segment at a time.

[15:01]

We do our Taylor Girdlestones, pin our toes, put them where we want, and then basically what the surgeon wants to do is put the toe or the tendon transfer under physiological tension with the toe where the surgeon wants to put it. So when you’re done with the surgery, before you put the K-wire in, you should be able to put the toe where you want to put it. Then what you want to do is rebuild and do your tendon transfers so that the toe is in the position you want and you want to perform it under physiological tension so it has nice tension. So it has nice movement to the toes when we’re done. So what we’re gonna do here is take the proximal stump of EDB into the distal stump and use a vasectomy clamp here, into EDL two and put a weave graft in there. So now the small muscle, the EDB, is transferred into the distal stump of the EDL two, three, and four. That’s now gonna function dorsiflexion of the toes. Go up and down the line and do that with each one, do a tendon transfer. I use four Monocryl. And then after that, I get the long stumps of two, three, four and go underneath the neurovascular structures and the tendons and pull them up. I use an O Vicryl and have the foot at dorsiflex at 90 degrees. And I put them into the peroneal tarsus or intercuneiform and the periosteum because now this stump of EDL two, three, four are gonna now aid in dorsiflexion because remember, we have a weakness there. We’re going to try to aid in our dorsiflexion at the midfoot. Gives more of a direct line pull. This is what it looks like when we’re done. So you could see each segment of the bones. You can see each joint at the metatarsophalangeal joint, proximal phalangeal joint, distal phalangeal joint. Of all the toes across, you could see there’s no buckling occurring anymore. The flat surface there, the fat pad comes back down underneath the plantar aspect of the foot. Here’s a case with the patients on hammertoes. Sub two lesions, sub five lesion, hallux valgus deformity, same type of procedure that was done. Really balancing out the foot. Here we can see again the dorsiflex in the foot. I use these long extensors in dorsiflexion. Here you could see the toes laying down flat. All the soft tissue lesions done. Nothing is on the left metatarsals and the toes at the more normal length. They perches the ground very nicely because they’re done in a physiological tension and they look more natural because you don’t have that edema, that swelling, that translation or rotation especially that we often see with hammertoes. Here’s another patient. This patient is a rheumatoid patient and a diabetic patient. You can see the firing and the extension of the toes. Here we dig at the stress fraction of the metatarsals but avoiding that you could see the toes, all the joints are lying. Even though you have a significant arthrosis at the joint from a rheumatoid disease, if you realign these patients they function fine and the pain goes away. Here’s the patient’s other foot. We came back. This patient got admitted at the hospital with an abscess and [indecipherable] [17:52] because all of the abnormal pressures. Once the infection was cleared up, we brought her back in and did reconstruction. This was done like seven years ago. I see this patient every couple months for regular diabetic foot care. Here’s her x-rays. As you can see, significant dislocations, subluxations at the joints of the toes. We did some medial column stabilization as well as a gastroc recession. Then we took down the toes with a modified Hibbs and Taylor Girdlestone type procedures. Not the prettiest looking foot but the bottom line you could see the x-rays. You could see all the segments of the joints. The joints are maintained in well alignment and there’s no plantar sores there. The toes now cannot recontract because there’s nothing there to make it reoccur. The long term outcome is much better. The foot’s balance, the lesser metatarsal area is free of any infection or ulceration from occurring. Here’s something more simpler if you will. Somebody had a crossover hammertoe with the isolated toe on the second and the plantar plate rupture. To me this is very simple. Really performed the tendon balancing without getting into all of the metatarsophalangeal joint or metatarsal osteotomies or any caps or repair or plantar plate repairs. Just put the toe where you need it put it under physiological tension. Here we did a Lapidus with this patient along with the gastroc. Stabilize the toe and you could see there’s nothing to hold it down. It maintains balance because we put the toe on a physiological tension with the tendon transfers and maintains this position very, very nicely. Here’s that lady. You could see significant hammertoe recruitment. Sores on the toes and then the PIPJs. We performed the arthrodesis of the first metatarsophalangeal joint. Again, you look at all the toes. You got the length. Nice alignment and there’s nothing holding them down. There’s no special devices or foreign objects in the foot and they are very a predictable. Patient, you could see the very – I’ve done this area. Plantar plate tear two or three. You can see there’s dorsi dislocation or you could see the swelling there. Here you’ll see the dorsi dislocation. Note it on two and partially on three. So it’s a complete plantar plate tear. Again, in my opinion based on my experience in doing this, there’s no need to get into doing lesser metatarsal osteotomies. Did any plantar plate repairs, plantar incisions, and all the extra hard work that’s needed. Put any extra suture in there that caused any kind of potential reaction.

[20:02]

Basically what we did is the tendon transfers, K-wires in the toes for a short period of time. Pull the K-wires. Here you can see in long term these hold out very nicely because now they cannot come back because the deformity force is removed and it’s stabilized with the tendon transfer itself, holding the toes into position. Here’s another patient with a significant hammertoe deformity. Crossover toe. Significant hallux valgus deformity. Same type of approach. We performed the gastroc recession. We’ve performed a Lapidus arthrodesis. We did a little modified Hibbs with the second toe only and the Taylor Girdlestone procedure to the second toe base. Stabilizing that toe, holding down, maintain the position. And again, the joint is free, kind of a significant pathology. Here you could see the small modified area to the Hibbs. You can use this for one toe or all five or four, I’m sorry, if you like. It really depends. You could see there’s no lesions plantarly. There’s no incisions. A very predictable results and much easier on your patients postoperatively. Here’s a patient with the varus deformities of the toes. Sort of crossover toes if you will. You could see it caught up quite a bit. So again, this is all done by – here she is clinically all done by soft tissue balancing. Just put our K-wires in it. The key thing is all the joints, all the lengthened toes, everything is maintained. All the ligaments are intact and they maintained much more functional ability. Here she is – this is a different patient. I’m sorry. The scar is not the prettiest looking scar but you can see the toes lay down flat. They perch in the ground. They maintain length. They look much more natural to me than when my – when I was performing arthrodesis and arthroplasties. Here’s a patient postop on the left, his left. And preop on his right. So you could see some different patients here. Here’s another one postoperatively. Again, the toes perched in the ground. No rotation or translation from a cosmetic standpoint they gets much better. Here’s another patient postop on this patient’s left. Preop on the patient’s right. So you can see what it looks from one toe to another. Here’s another patient. Same thing. Postop right. I left this toe up a little bit. That’s my fault. That’s not a procedure fault. Patient wasn’t dissatisfied with that although. She was pretty happy but you could see the toes lay down very nicely. One of the things you can do is overcorrect these. You can over straighten them and that’s one thing we’re wondering about when we get to the Taylor Girdlestone portion. Here’s another procedure. You could see the incision. But again the toes lay down very nicely. Maintain alignment and integrity of perched in the ground. Here’s another rheumatoid patient. Bilateral feet. This is done probably about eight years ago. I still see this patient routinely. So there’s no reoccurrence in eight years, postop. This patient sees significant sublux dislocation. Signification arthrosis but if you follow Paley’s work, you can realign an arthritic join. They still function fine and their pain typically goes away. Not in every case but most cases. So what we do with this patient, as you can see, rheumatoid arthritis through the joints, the hindfoot, midfoot. We performed a medial column fusion on the right and a tarsal arthrodesis on the left. We did the hammertoe corrections. I believe a Talar navicular fusion on the one. But you can see the toes lay down very nicely. Maintain alignment. Because when you perform these a Joplin and Clayton’s when you perform these arthroplasties, you lose that cubic volume of bone. Eventually destabilization will set in overtime. The predictability, the long term effects of these are not merely as good. Here’s a pre-op on your left and a postop on your right, demonstration how the toes look from one to another. Here’s a patient of the simple sub two but no sub toes are very curled and flexed out. It is a not a low metatarsal claws. That’s a fallacy. So it’s instability in TMT one. Forefoot overload. Tight posterior muscle group and extensor recruitment on the toes. After performing the hammertoe procedure you can see as well as the gastroc recession stabilization, TMT one. Sub two lesion goes away with nothing being done on the second metatarsal. Here’s that diabetic patient I’ve talked to you about. The osteomyelitis on third toe. He got consult in the hospital, debrided and got him on IV in a bag. Once his sed rates and reactive proteins were down to normal and his wound healed, we took him in and did surgery. Did this about six or seven years ago. This is what the gentlemen looks like. I see him every two months for diabetic routine care. I promise you he has no other recurrence in the last six years or so. All his toes are at length. Natural looking. The space of them. The joints are maintained very nicely and they perched the ground very nicely and there’s no de-arrangement with it. Wound complications because it’s a thin dorsal skin with the Hibbs. You have to be careful of. Use a full thickness approach with it. Now the other part of this is for flexor transfer. So really the PIPJ and a DIPJ or a combination of both. This is typically done for flexible toes. I do it for rigid toes as well. It does work for rigid toes. I’m going to try to speed up because we only have about five to six more minutes left. But really the idea is the flexor tendon transfer enables the flexor digitorum longus to assume the function of intrinsics when those patients lose their ability to bring the toes down. So what we’re going to do is extend and grab the flexor tendon and put in an extensor hood so it can plantar flex to bring that toe down if you will.

[25:02]

There’s many more modifications. I’m just going to fly through this real quickly. But the idea is really taking the tendons transfer from the distal phalanx and transfer it to the extensor hood and cutting the FDB, the medial and lateral slopes. This is basically the way I do it now. I just do it through one incision and typically it’s medially. If you want to go lateral, if you have a varus deformity, you might want to go lateral. Incisions two, three, four but stay medial on five from a cosmetic standpoint. If they’re laterally deviate, you want to make your incisions two, three, four and five and bring the toes more medially. There’s been many modifications. You can drill holes through the bone. You can do split discs wrap around both sides. Just do it. I just do it one simple approach. I find that it works very well. Make sure you cut the FDB medial and lateral head and realize there’s two heads off the middle phalanx. Put the K-wire in. Leave the plantar flexed slightly to a neutral position if you will. Now this is lower slotted line. If I’m just doing isolated Taylor Girdlestone, I keep the K-wire in seven days. That’s all. Seven days. So the push of the course is much, much easier. For my patient it’s much more friendlier. Complications. Any other hammertoe repair, the biggest I can tell you, when you get a hammertoe, that’s really significant. You want to overcorrect it. Try not to overcorrect it because you can give the mechanical vantage to the extensors. So leave it to neutral slight plantar flexion when you put your K-wire in. This is essentially what we perform here is we release the distal phalanx, the FDL from the distal phalanx, cut the medial lateral slips of the FDB and bring the long FDL into the extensor hood. Put the K-wire. Put the toe where you want and then put the tendon under physiological tension. So take it through cases. There’s a lateral approach to the great toe from a cosmetic standpoint and you can do this for a great toe as well. Just pull the FHL tendon and put it right in the extensor hood. These are all the slides. Today would have my K-wires in first before doing that. I used to put my K-wires after doing the transfers but I would do it first my K-wire and then do a physiological tension. Then you go up and down the line to the toes as you see here from a lateral standpoint or medial standpoint, whatever you like. You can midline. Watch out for your neurovascular structures and find your FDL and the FDB tendon and you pull them out very nicely and you can transfer tendons and put your K-wires. So the fifth toe again to medial approach from a cosmetic standpoint. So this is what your toes look like. That’s what your scars look like postoperatively much easier for patients with toes nice and straight. So here, again, same type of approach. Here are some patients. Flexion contractions of the digit joints. Not the metatarsophalangeal joints. As you can see there’s a pretty significant buckling if you noticed. Again, these are all the slides. So I apologize today. We’re not going to go through the metatarsophalangeal joints. I would just put my K-wires into the base of the phalanx like I have here. But you notice the contractures. No contractures here but all contractures are distally. Here you could see all your joint spaces and all your bones anatomically. Here’s a patient with a simple flexion contracture callous tissue at the tip of the great toe, from secondary to flexion contracture. With your lateral approach, one simple K-wire, you can see the joint space very nicely. K-wire today comes out seven days post op and that’s it. Your suture and this is usually about two to three weeks, whatever you like to keep it in. Here you can see the toe perched in the ground very nicely and cosmetically to me is much better. A lot less postop edema. You don’t get the sausage digit effect that you often times or can often times get during arthroplasties or arthrodesis type procedures. Here are more flexion contractions as you can see. So again, the same type of approach. Look at all the joint spaces that are open here at the metatarsophalangeal joints. All the distal toes are contracted. So as you can see, here’s my Alice clamp with my flexor hallucis longus tendon before I transfer. So I put my K-wire in and then do the transfer under physiological tension and go up and down the line and you could fix each toe. Here’s what the patient looks like with the perched to the ground, all that great toe right there. Another patient, all these joints are open. All these are contractures right occur here. You can see all the flexion contractures. Here you can see my K-wires in. Seven days, take them out, and you can see there’s no re-contractures and you get your natural length of your toes and they maintain position very nicely without any kind of internal object in there or foreign device. Here this patient is pre-op, right postop. So postop, pre-op. You could see the difference how the toes lay. Here’s the other foot on the same patient. No flexion contracture of the great toe but the lesser toes at the DI and PIPJ. Nothing at the MPJ. So again here’s out x-rays showing all the segments of the bones, all the joints. K-wires intact. They come out seven days. All my incisions are medially based or laterally based, however you want to put them. From the cosmetics standpoint you have your natural length of your toes. So here it is again. Postop, showing the toes perched in the ground with natural length. Another flexion contracture quite significant to these toes. Here you can see a pre-op and postop on the right and left.

[30:01]

More hammertoe showing contractures via right foot, as you can see right there. K-wires in, same approach. Each time K-wires come out, the toes maintain their position very nicely by themselves. You can perform this procedure for an isolated second toe or isolated fifth toe or AD flat, adductus varus deformity of the fifth toe. It doesn’t matter. It works for all procedures. There’s nothing but a flexion contracture at the PIPJ. Very simple as you can see. There’s nothing more going on. Here’s your x-rays pre-op. You can see quite a significant contracture. Here’s our K-wire. Here’s my incision cosmetically. I think it’s really hard to beat this because the length is there and they get the integrity of the joints. Here you can see each segment of the bones. There’s nothing done to the bone. K-wire’s in very nicely. K-wire comes out seven days to the postop. Of course it’s much more friendlier. Pre-op, you can see a lot of contractures. Post-op, much straighter and nice alignment. So I think I’ll move on we’ll do questions down here or just keep moving onto the next top –