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The camera going live. Good evening. All I hope you can see me and you can uh hear me. Welcome to the uh 15th episode of the very popular uh Master Techniques. My name is Manish Via. I'm a member of the education Committee of BOFA and on behalf of the education committee and the IT committee, which plays a big role in organizing these very educational um and and highly appreciated meetings. Um We are going to invite um our two guest speakers. The topic we have chosen for tonight is uh alternative options to joint fusion in Hallux. And like me, I think you, you, you would see patients in your clinics where patient has arthritis, which is such a common problem in the foot uh arthritis of the big toe. And they have got, you know, taboo about fusion. They don't want the joint to be fused and they want to know about the alternative options. So I think it's quite a relevant uh topic both for clinicians as well as for patients, but obviously, clinicians need to be educated first. And uh it's, it's a great honor that uh we managed to get to excellent speakers who are going to talk about different approaches for Hallux Rits, both would be, however, talking about avoiding joint vision surgery. So I would uh welcome our first uh speaker um Alessio. Um He is uh a, a good friend. Uh Alessio uh Bernasconi is practicing in Naples. Uh he's very active researcher. Uh He has just become the member of Scientific Committee of EA S and previously, he has chaired the Youth Committee of the, if A has written a number of publications and is an excellent speaker. And today Alico is going to give us hi his tips and techniques, what he does mainly with the first metatarsal osteotomy, the young osteotomy. So I will now um pass it on to Alicia so that he can take us through his um presentation, looking forward to it, Alicia. Thank you. Thank you, Manish. Good evening, everybody. So thanks again, Manish, thanks to the US educational Committee for inviting me and thanks to both of us in general for the opportunity to be here. So I'm gonna now share my screen. Give me just one second. OK. Can you see my screen? Manish? Just look back. All right. So my talk is gonna be yeah to me for Alex Ride. So just this is the way I have divided this talk just a bit disclosure. We are talking about alternatives to fusions and that's not a way to say that I do not perform fusions because essentially when you have a stack outlooks with like no motion at all probably doesn't make sense to think about osteotomy. But leaving this aside, we're gonna just discuss about Yang's week in general, we're gonna consider how to perform it and then just um reflect a bit ab about different points. So this is what we are talking about. That's just daily practice. Nothing very specific. What you can see in the clinic with whatever young lady coming and complaining of pain on the hall looks not really saying there is a bunion because there is not of course, saying that she has a um a sensation of rigidity and there is probably a dorsal bump that gives problems with the shoes. So this is probably a story that you all know very well. And when you go and try to classify, you know that there are many classifications for that. But generally speaking, the coin one is probably the most used one and there is agreement that for whatever is conservative. I when I say conservative, I mean, joint preserving, um we can consider grade one and grade two and grade two is like 10 to 30 degrees of motion. However, as a provocative thought, if you consider that in foot and ankle, in general, probably in orthopedics, but especially in foot and ankle, we're moving towards um the moment where uh we really consider less and less radiographs and we consider more and more the function like for example, for sma osteotomies or Z osteotomies are just two examples of, let's say bad radiographs, which can still bring us to good clinical outcome. So this could bring us to consider or other joint preserving procedures. Also for grade three and grade four, probably grade four is a bit too much. But for grade three, I think it's something that could be discussed. So we go back to radiographs. That's just another case. And this is just to highlight how something is some uh you always have to consider bilan or radiographs because like on dosa planner, you, it seems that there is no joint space at all. But if you look at the lateral view, the age of view, essentially a lot of of that space is occupied by osteophytes. And actually, there is still a joint you can see you can see in there and clinically speaking, that's the dorsal bump we we were talking about and you may discover that there is still some hope. Now there is still some motion in the Alex as in the picture on your right. And this is what we want to do. That's the hand of a young osteotomy. So ho let's see, how do we get there, so how to perform it? Uh probably different approach. Uh you know, that um our science is is not perfect and uh orthopedics, I mean, so um uh there are multiple ways to do a thing and this is just my way like uh patient supine with the um ankle tourniquet. And on the red line, you see how you place your incision is more or less the same place of a chevron osteotomy and of a scar for ostectomy, probably just slightly more, more dorsal. And this is how you perform your capsulotomy. And again, this is quite standard. Did you go into the joint? And when you do your dorsal capsulotomy? Probably compared to a Chevron or to a scarf, it's a bit more tricky just because you got osteophytes there. You got a lot of beat uh o of beats of bones that are in the way. Anyway, at the end, you are exposing the joint as you can see here in the video. And then the first thing is just do a cally. This seems quite I yeah, I can see your slights moving. What are, what, what are you now? We are on your uh basic slide with the classification. All right. But it, well, I think, I think there is a leg, they are moving but it's a leg. So. Ok. So which flight, which flight are you seeing? Now? May which slide are we seeing? I am still on the, the uh classification slide for me? It's not moved. That's weird. No, no, it's actually moving. Um But there is a slight lag which is normal. Ok. So tell me if I can go on or I mean, if you now do you see the X rays on the, on the, on the slide. Uh Yeah, so I see the previous slide but that yeah, I see the X rays, it's fine, the X rays and any at on these can please let us know if they can if they have any issue II can see it fine. And this is clinical pictures, you can see the clinical photos. OK, great. OK. And now the X ray and I go, so this is a video, just confirm you're seeing a capsulotomy. I see the video of mine. OK. OK. That's great. So I assume it's all right, you, you just stop me, I if needed. So that's again, the capsulotomy. And on the next slide here, there was the joint exposure with um essentially opening of the dorsal capsule, which as I, as I just said, I mean, can be a bit more deep because of the uh multiple dorsal osteophytes. And then you, you expose your joints and in the way you are seeing in the video you perform a dorsal colectomy, which is, I mean, I do normal colectomy, nothing really special about that. And then in this part, you can see the medial exostectomy essentially. And again, this is not probably described in all cases, but I do perform it just in order to have a more regular surface to perform than what I want to do. And that's just sort of a an X ray with a drawing on just to um show you, what, what is my intent? So I know that I want to do a B shape as for a Chevron, just in order to be a shortening, it needs to be in, in, it needs to be there a recut of the dorsal arm. And also remember that the lower arm is the one that is gonna um uh that is gonna um uh um help you to plan to flex of the metatarsal head. So the two targets of your osteotomy, let's just underline, this are number one shortening, I mean, the compressing the joint and number two planta flexing and this is the way you perform your upper cut. But again, also here nothing really special as compared to a normal shape or not. That's the lower cut and that's the V shape that you can see on the bone and then you go there for the recap. So about this, there will be a lot to say because if you look at um uh publications at, at literature, essentially, there is no real agreement about how much you have to remove. Like generally speaking, II would say 23 or four millimeters, but sometimes I must admit that I go at five, which is quite a lot. But if you consider that most of these alys, I have um um uh uh metator index plus, which means that first metatarsal is longer than the other than the second metarsal, you probably have room to go and shorten the compress a bit a bit more and then you remove the interposed bone, which is in the middle here and here you can, you can test your shortening and the movement of your metatarsal head and you can do the same also on the fluoroscopy. This is not something that I would do normally. It was just for the sake of um recording this presentation. And this is just a sort of before shortening and after shortening uh intra op fluoroscopy. Again, of course, I didn't touch the joint. You can still see the osteophyte on the medial part, but there is no evidence that going in there and having a better X ray will give you a better result from this point of view. And then there is just screw fixation here. You can use 2.5 or three millimeter, the standard that you would consider also for a sh or a scarf osteotomy. And this is already how you appreciate on your fluoroscopy what you have done. So with the, with those 22 lines I have just indicated um how much I have plan to flexed and shift that shifted uh from distal to proximal dermato head and there with multiple fluoroscopies, I'm gonna show you in terms of movement, how satisfactory can be. Now, this is with the, with an open capsule, we agree on that. So this is not never gonna be the final movement, but on the other side, it gives you, it gives you hope that the final movement again would be not so bad. And this is just the same radiographs just compared on the same screen to give you an idea of plant flexion and dorsiflexion. And that's the same thing just seen from a dynamic point of view. Like we know in order number one to test how stable is your screw and number two to check what is the movement and that's the final closure. So again, just for stitches is of course, it's standard, but it's not minimally invasive. But again, it's not, it's not generally problematic area for food issues. So just general considerations. Uh First thing, this is probably what you want to have. It's just one case. It's not evidence, it's not even expert based. It's just one example of what you can have. Um like in this um when I saw this lady, uh it, it, it struck me how her, her big toe was slightly dorsiflex, but this was something that I wanted uh going back in surgery because essentially I tried to let her gain a bit more of dorsiflexion and in the end, um uh she was very happy and this is the video, a video she sent me one year after the surgery, uh probably she would have been able to do that after five or six months already. But this, this video was quite satisfactory and that's another case just 10 months. Follow up. Why I picked up those regulars because this is, this is an example of metatarsal plus. This is the thing I was discussing earlier and there are, I've shortened a bit more, but I'm not, I'm, I'm not afraid about that. Like in this case, the parabola is still quite good. And on the such of you, you can really appreciate, I think what's the true power of this osteotomy? I mean, when you decompress and you plant a flex, you can really increa you can really improve the congruence of the joint. And this is what uh I try to show on the, on those images and these are just other, other radiographs again, index plus, which is quite common in my, in my practice. I don't know if there is um a relationship of co effect with uh uh um Alex rides, but it's something which um has never been really demonstrated to the best of my, all of my knowledge. So he'll start with evidence behind Yangs Week. There is evidence I don't know how good it is. Uh There are papers like this one that's an Italian group from Milan um showing that you can delay effusion uh at 13 years, which is not that bad. And uh you can also see here a picture II took in toulouse uh like 10 years ago when I was there as a fellow. And uh Nazim Medi was 11 of my mentors there and he has never been a big believer in ankle replacement. So um in these words, ankle replacement should have been presented to patients as a delayed arthrodesis. So I'm just borrowing that concept, maybe Y could be considered as a delayed fusion or delayed arthroplasty. Uh we will see is infusion a good option. Actually, it is a good option and there are also studies and also like this one which came out much of year. Also demonstrating that also in young patients results are good. Um Anyway, if you look at the literature a bit more in detail and you look at those papers, for example, in lines, you will find that you need a careful patient selection for your fusion. And also that uh outcomes are not so predictable, especially in in um athletes. So it's something that let, let's say is good but should be probably even more discussed alternative ger preserving uh osteotomies, probably the mob mob osteotomy. And about that, II really know um uh experience. So I I'm unable to, to, to, to add anything relevant about that. Can we, we, we go minimally invasive? Probably we can. Um That's the only paper I found published by uh George Delvecchio was published a lot on minimal invasive and essentially what he describes here. Uh uh And being called Shortening Palco is essentially a young, we oy just performed uh in a minimally invasive way. I must, I must tell you that I do perform minimally invasive surgery. I do Mica, I do Zade, I do Calcaneal osteotomy. However, considering the les with osteotomy, my personal thought is that in my hands, this wouldn't work. I mean, I haven't tried yet, so probably in, in a few months we could rediscuss that anyway. II think you probably need a, a really uh delicate control of the position of your bones to make it work. And when I do percutaneous surgery, I do control a lot of things but really not all of them, at least in my hands again, open questions for, for the future or also for this, for this webinar. If you want, what's the exact point where analys limited becomes analys rigidus? So this is something which has never been defined to the best of my knowledge. And it's something useful because if we do studies, we need to um include selected people, like we need to um define the population, we want to study. And sometimes if you look at the literature about those kind of osteotomies, there is a bit of confusion about this terminology. Second thing, the best direction of the cut, especially the lower arm, which is which is the one which is the plantar flexing your metatarsal head and also about the upper arm. Like how much do we need to shorten? Really how much we have to and how much we can shorten, which is a bit complementary. So just in conclusion yw technique as you have seen is not certainly a difficult procedure. I mean, anyone who has done 4 ft surgery will like an experiencing scar fect, I think can uh quite easily do that. Indications are probably getting wider. I don't know if wider, also minimally invasive. It's something that future will tell. Uh it could be presented as a delay that through this is so I must, I must admit to you that this is the way I do present this to most of my patients telling them, listen, if I can save your movement, I'm happy. But in case we feel like in one year you come back, you have movement, but you also have faith, you have to be aware that we may need to do a sort of stage to go in there and do a fusion. Thank you very much for your attention. Thank you so much. Um Alessio, if you can stop sharing now. Excellent. Thank you very much. That was a very concise and a very practical talk with very clear message. Uh And I'm sure there will be uh lots of questions um People would want to ask. So let's move on to the second speaker. Um Mister Clough, Tim Clough, um he's a consultant um in uh writing for a very long time. Uh doesn't need much introduction. His main interest is ankle arthroplasty. He has done a number of publications, but his second level I believe in foot and ankle is s fantastics. Uh So I look forward to hearing from Tim about how to avoid joint fusion surgery? Ok, thank you very much uh man, thank you uh for um inviting me. So I'm just trying to uh get to er, share my screen. So am I on, am I sharing screen? Yes, perfect. Ok, let's hope. Um it goes past the first slide or maybe not as the case may be. So I've been asked to talk about alternative options to joint fusion. Uh So obviously, you've heard now about the youngs with osteotomy. Um and I'm just gonna give you alternatives, cos not everything in life has to be fused. So obviously, you all know the epidemiology of haloid often age more than 56% are bilateral, more in female than male and most commonly primary oa and the management, you all know conservative injection surgical. So surgical early you could consider a chilomys, you could consider adding in a mob. We've heard the Youngswick and then end stage, you're talking fusion or replacement in my book. So Cheilectomy tends to be good for early disease, rapid recovery. The problem with a cheilectomy is 20% of them unpredictably progress and why have two operations when one will do. So. This is a recent um uh long term study on chom 100 and 69 cases from Stephen Rein in the US. So if you see 88% ie 90% of these are really early disease, 6.5 year average follow up only 70% satisfaction rate. So one in three are not satisfied at six years with this operation. And the question becomes, would they have been better being tickled along with a cortisone injection? So you can then do one operation, one good operation rather than give them two cracks at the whip. Ok. What happens if you add in a mo these are interesting cases here. Uh interesting papers both written and published in 2024 both published from hospital special surgery, New York. Not clear whether we're talking about the same cohort of patients written up by two separate groups of er registrars. And you'll see Scott Ellis is on, on them both. And the first one analyzes that data to say that adding in the Movo osteotomy doesn't change short to medium term outcome of a high chom. The second one gives a slightly different slant to what must be the same um set of figures to say that adding in a mo improves gives a greater change. And that's basically because that cohort of patients had a slightly worse preoperative score. So does a mob really work for the jury out, I'm not convinced it adds much to a, a standard colectomy personally. Ok. So then we're into fusion or replacement. Well, fusion is a great operation as is fusion of an ankle. So why would you consider replacement? Well, why have stiffness when you can have movement if you can get rid of pain. And this is what the ladies want to come in and see and this is what they want. They want to go back into the high heels and be pain free. And this is what you can expect if you do a joint replacement. At six months, this was done bilateral, same sitting and this is her at six months showing the range of movement you can expect with a joint replacement. So why have stiffness when you can have movement? We don't stiffen the hips anymore. We don't stiffen knees anymore. We've got good joint replacements. Um We've heard uh the skeptics view of an ankle replacement, an ankle fusion is good, but an ankle replacement also gives you a pain free range of mo uh range of movement. And what I'm gonna do is try and introduce you to a big toe joint replacement and show you that similarly, you get great results with it. So fusion, you all know, it gives excellent pain relief. 7% symptomatic nonunion. You've got a slow initial recovery cos you're waiting five weeks for the thing to fuse. It can limit high heel shoes afterwards and it can limit running particularly in, you know, long distance, half marathon, marathon runners. It can increase stress on adjacent joints, particularly if you get a slight malunion. The distal IP joint is unforgiving and it can go on to hyperextension and malpositions which we do not talk about for fusion cos we're only interested in union and then discharge is an extremely difficult problem to, to deal with uh as is uh excessive shortening following a fusion. So, what are you, what are your options for joint replacement? Well, historically, we had a few and one I'm gonna uh effectively introduce to you is now, there really is only one. So the mojo was out 20 years ago. It uh effectively has now been uh uh it was a ceramic joint replacement on both sides. It didn't do well. It sunk, it cracked and it failed. The Townley toe isn't ok. It's this uh steel one here. The problem with the Townley Toe in my book is it's replacing the wrong side of the joint. The diseased cartilage is on the head of the uh first metatarsal and this replaces the base of the proximal phalanx. So then we've got the Silastic, we've got the heap, which was out about 15 years ago, which was the precursor of the uh of the cartiva. So the heap is basically now withdrawn as is the cartiva. So that really just leaves you with the SAS as a viable option. So I'm gonna introduce that the Silastic is the best operation you can ever do. So let's go to the history because you don't know where you're going until you've seen where you come from. So Swanson introduced the er er cytic joint replacement now 60 years ago and it was originally introduced as a hemi arthroplasty. Then about 10 years later, he changed the silicone to make it a high performance Elastoma. And then in 1975 this is the one that you should be dealing with. It's a double standard hinge. So it's, the implant is not a new implant. It's been out 50 years. And then in 85 he introduced Titanium gros for the end. So it's been out 50 years. Why are we not all doing it? Well, just like you, I was introduced that it was a device of the devil. It didn't work. People catastrophically hated it and it you it would leave you with a short floppy big toe. And it, and because of that, we were introduced to historical reports of cyla synovitis, progressive cyst formation, loosening and failure. So why am I doing it? Well, I inherited a practice that my predecessor had put a lot in and I was seeing them in clinic because at writing, we never ever or certainly 30 years ago ever used to discharge patients and patients were coming in 15 years after having one put in. So I sent them off for X ray hoping that it would show catastrophic failure and the patients had come back and say it's great and the x rays would look OK, like a 15 year old hip replacement. And I was seeing more and more. So I went to the literature and there's only eight studies in the world literature. That are negative on a cymatic and yet that was enough to kill the joint replacement. And all those negative studies were on the single stemmed hemiarthroplasty like you see here. And they were in the late seventies and early eighties predominantly and they were put in for a mixture of hallux valgus and hallux rigidus and they reported what you traditionally hear. So what's the positive literature on it? Is there any? Well, yes, since those negative literatures and the double stem was introduced, there's been 17 subsequent studies in the world literature over the 30 years. So that's one every two years. They report the double stem slaty. They report them for predominantly hallux rigidus, but early studies were putting them in pex valgus and all. But one of those 17 studies report good or excellent results. So we've got a database in that study, a cumulative database of almost 1300 patients with follow up averaging totaling around 1400 months. So each paper averages there 81 patients with 86 month follow up and an 87% satisfaction rate which is not bad at all. So let's go to the papers. Swanson is early paper, 19 7900 and 65 ft average four year follow up, put them in for a mixture, rheumatoid osteo, some Hallux valgus, it was a mishmash of patients 20% revision surgery rate in rheumatoid because they got recurrent hallux valgus. But an 88% satisfaction rate in OA. Then 1980 a year later, similar uh outcomes. So the results are different for OA and ra and the results are certainly different for neutral OA and hallux valgus. So let's go to the negatives. These were quickly followed by a, a four negative papers in the 8 1987 ft. Not many. Um they got reported sinusitis of the wound. 71% revision rate, everyone had cystic formation. There's no other paper that's uh found that. But these are for the single stem implant. 1982 reactive sinusitis, 1989 single stent implant wear and osteolysis. 95 single stem implant, uh poor result and 93 granulomatous reaction. So, the hemiarthroplasty which has been withdrawn from the market now for a long time is where the bad results came from. So the conclusions of those five papers were that you get a lot of silicone wear debris, you get synovitis, you get bone erosions and cysts losing an implant fracture. And these all related to the hemi implant, which should not be used. You can't use it anymore. It's been withdrawn. So let's go to the positive results. The introduce then the doubles then and here we are 9100 and 6 ft, 2.5 year. Follow up. 88% good results. 19 9200 and 28 ft, 90% good results. 1% revision for pain, 2.5% wound inflammation rate and no implant failure. 92 37 ft, some rheumatoid. So again, a mismatch, 82% satisfaction rate, uh worse rate with rheumatoid. 92 67 ft six year average follow up 87% good results. 2003 42 ft. Again, a bit of a mishmash, 90% satisfaction rate. 2008 76 ft. 85% pain relief. Here's 2011 and 2013. So the re the reports still come out. Uh, here's 19 year average follow up 90% satisfaction on 43 cases. So I looked at mine, I'd been putting a lot in, I had 100 and eight consecutive cases. No case loss to follow up. Mean age implants. 61.5 years average 5.3% year follow up with 2 to 14 years. Vas scores reduced from 7 to 1.3. A mox FQ dropped from 80 to 10. We had a 97% survivorship at five years, which clinically is ex exactly the same as the best joint replacement in the body, which is a hip replacement. So it is a good joint replacement if put in for the right indication side. The conclusions from the literature is that the double sound implant has a high satisfaction rate with minimal implant failure, minimum synovitis, you do eventually get bone cysts, but they're clinically asymptomatic. You mustn't use it for a bunion for Hau Valgus because it will recur and the jury is out as to whether you should use it for rheumatoid and I would suggest you wouldn't. So, in those 30 years, there's been 17 studies which are backing the implant. Ok. So what would I consent them to then? So, it's day case surgery, both sides can be done at the same time. It's woolen crate bandage, you're immediate weight bearing and you can get a predictable, good result of 93% 10 year survival on the implant, two weeks in dressings and at two months, they're into their own shoes and potentially into higher heels. And the concern is stiffness, swelling and wear. So this is what you'll see. At three months, you can see that the wound is still a little red until early day, but that's how much movement you're gonna get through the joint that's on a hard floor. Oh, no. So what are the indications and contraindications? So, ladies do really well with this short procedure, over 55 potentially neutral, how much rigidus they want movement and the concern for heels on the shoe wear and they can be active in the gym. So your ideal patient lady, 61 wants to keep the joint flexible, wants to wear high heels, end stage rigidus. Don't do it for Hallux valgus. So if you've got a significant Hallux valgus with oa, then that's going to have to be fused and caution in the young active caution in the males and caution in the rheumatoids. So, the take home message on Silastic is it'll give you excellent pain relief, predictable, rapid recovery. It will preserve the arc of movement, er, that they currently have at the toe. There's a 93% 10 year survival. It is very reproducible. It gives excellent cosmetic results and there's a high patient satisfaction rate. So, here we go. Hall of Fame. 26 years. So yes or a fuss. But if you take an X ray of a hip at 26 years, you're not gonna get a perfect looking hip. So these, these are not uh any significant problem but have been over emphasized in the literature. So in my book, Fusion versus Replacement, why would you fuse it when replacement does everything and gives you the movement back replacement has a faster recovery. You're not waiting for bone effusion, it preserves movement. So there is zero issue with shoer minimal bone resection and it you get an excellent, predictable long term outcome. So summary, if you want to play with the joint and you want to give them an unpredictably painful and stiff joint, then offer them a colectomy. If you want a bulky fusion where you might need second surgery to remove the implant uh because of prominent hardware, then go ahead and fuse it with a dorsal plate, 15% further operation to remove the pro prominent metalwork. But if you wanna surf the Wave and Live The Dream. And in my book, give them a Silastic. OK. Thank you very much. I think you have sold the so stick very well. So we're going to have a discussion. Um So I let you if you can please uh switch on your camera as well and join the discussion. Thank you very much, very uh very entertaining as well as educational material here with both the talks and we have got some questions. So we'll let's kick start with uh a couple of questions uh for Alessio. So uh the thing for your questions is number one about people are asking about metatarsalgia. So do you get uh are you worried about uh introducing metatarsalgia if you are shortening? Um And the let, let's start with that. What are your thoughts about uh additional pressure on the lesser metatarsal of the young? Sw So I agree that's probably the most important concern even because every time I talk about week with someone who doesn't do that is the very first question. And I totally understand that. And my is the same is that for a reason that I ignore because I don't know why like 80% of all ri see are uh metatarsal plus. So actually, ii very rarely concerned about too much shing at the beginning. I was in theory concerned. But in the end, after five years of practice, I can tell you that I don't, but I don't know why because also I must tell you that talking to other colleagues uh from Brook Sales, I think they were telling me like the opposite, which is very curious from an epidemiological point of view. I don't know if there is the studies saying that ridge disease is more common or not based on the first metatarsal length. Anyway, this is how it is in my practice. Like 90% are plus and it's not a problem. Of course, like in the first say six months, like everyone gets a metatarsalgia, but there is not a true complication. It's just the adaptation. It's something I see also with me osteotomy, at least in my practice like it's an what I call normal reaction because you have had the procedure on your media column, you'd start walking again, but you still feel something is new. So you need to adapt to that. So you try, you tend to overload a bit, your central and lateral columns and this is why your metalia comes from. But like most of them at six months, they are sorted. It's very rare that at one year or two years, I see a meal. I never treat that during the first year. If there is a problem, I go with orthosis. So it starts from zero and it's rare that I have to go in there and do a DM mo like those cases are probably my mistakes either in indication because the first metatarsal was already too short and I was too aggressive in thinking about the shortening osteotomy mistake. Number one or mistake, number two, like a technical mistake because sometimes when you are there and engaging, like I have to remove four millimeters and you have to consider the uh the, the uh the width of the. So et cetera, sometimes you want to do something and you can get out with like one millimeter more or less if it's less, it's not a problem because you go for another recut. Like if, if it's more, you have to accept what you have done. So this is another thing and probably the just the last point for this question is that it's very important the plantar flexion of the metatarsal head. So it's not all about shortening but is about plantar flexion. This is where I think the problem in the future weight bearing CT could be helpful for us to understand things because in this moment, I am unable to assess the plantar flexion properly. Like I use radiographs of course, or I use unloaded CT s. But none of them could really tell me what I've done in terms of plantar flexion. So I can I ask you? So I mean, if I remember correctly. So when Barook introduced uh scar fit to me, I think the initial thoughts were to plantar flex the first metatarsal head. Um But then I think uh we talked a lot at that time, but we gradually moved away from plantar flexion. Then I think I heard Barook uh saying that he said no, you, you shouldn't be plantar flexing too much, maybe a millimeter or so. So that's where the confusion is that, you know? Um Yeah, yeah, yeah. But if I can interrupt you, that's, I mean, with the valgus, you're not concerned about metatarsal celeus. Like when you see that those plantar flexion was purely to try to unload the lateral column. But it was like starting from zero, going to minus five. OK. But with in all rigidus, normally you start from plus five because if you look at your lot of your sagittal X ray, you will see a dorsal movement of the first met dorsal. So I think it makes much more sense to planta flex. I think you, you, you cannot compare the planta flexion of a young week or whatever osteotomy for an Alex reach this to aex valgus. OK. Fair enough. No, no, that, that, that I absolutely get. And you have actually covered um uh another question which people are talking about index minus. So do you do it for index minus or you don't? That's a contraindication. No, I don't. No, I don't. I II don't, I don't think it's a for, I never found it in, in literature, but I don't, I wouldn't dare. OK. And thirdly, people have asked that, you know, if people, somebody has metatarsal developed after surgery or maybe had before the surgery do you do then? Uh do you have to do lesser metatarsal to make them short as well to maintain the? So I honestly don't, II must tell you, I tried, even for, for 4 ft re balancing, I try to touch the least I can uh uh at lateral uh metatarsals, at least in my hand. I mean, even in doing the MMO of 234 of five, I try not to do that much and that's the same for Alex region. So II tell them I'll try to compensate that. Just plan flexing the first ray and must most of the times I succeed for some reasons if I don't, I'm happy to go back there and say I'm gonna do just the DM M. OK. So what we uh I'm going to do now at this point um before we get Tim in um I will ask you, what is your algorithm for surgery? So do you do Colectomy? Um uh uh young switch you obviously do and joint fusion or, or any other procedures. So what is, do you have an algorithm? Yeah. So just very, very, very, very simply. That's not my algorithm. It's, it's I think it's borrowed from, from common literature like at the beginning orthosis with just Morton's bar. I mean, it, it works. Sometimes it works. I always start with that second step is injections, just steroids, injections, never yell uric acid or whatever else. Just that just once and if it works, ok. If it doesn't work, I'm never gonna repeat it. And then there is surgery. I mean, if, if the injection has worked and the duration is, uh, more than 12 months, I can repeat it, I can consider repeat it. But otherwise I don't. And then there is surgery and is generally a young week. II have done some colectomies, but in my hands, maybe I've never been so aggressive. I mean, at the EA S Congress in Brook Cells, I have seen images of very, very aggressive colectomies like one third of the joint. While in my training, I was trained not to touch the cartilage and those kind of things. Ok. So I'm, I'm not, probably, it's not, it's my fault but colectomies in my hand. Not very good. So I go for a young sw or if it's a stage four, it's a fusion and it's generally if, if it's a fusion, I generally do miss like percutaneous because I don't need to open and see it. Thank you very much. So, Tim coming to you. Um We have heard that Colectomy should not be performed. Do you ever do Colectomy? I, I probably do one every 35 years. Uh It's so, so II don't see early disease. I just don't see it. II think I can't remember AAA one, a one's normal in my book. I just don't see it. So um I, I'd see later disease. So I have a chat with the patients. You know, it ii, it's in my Armament Town. It's an operation. I don't like, only because, not because it's difficult, but I want an operation that predictably works for a long time. What I don't want to do is do an operation which unpredictably doesn't work. And they back knocking on the door within 18 months to two years to say it's worse, it's stiff, it's this or that. So I'd be more down the road of, I'm gonna keep on ticking along until they're ready for definitive surgery. So, by that, I mean, I'd inject them. Now, I'd inject them only once a year. Ok? And realistically, the injection might help for seven months, eight months. And then, um, you know, they suffer it for another two or three and then they come back the next year and I might get another 3 to 5 years out of that with an injection. I don't want repeat, I don't want multiple repeat injections. And then it's a case of they're either having def, they're usually having definitive surgery. So it's, I I'd only use Colectomy on, on fairly early disease with a prominent dorsal osteophytes, rubbing on shoes and they've got classical pain at the extremes of dorsiflexion. Certainly not on axial grind. Thank you. Um There are a few questions coming up. So let me just take some questions from audience. So, uh, first question is, uh, uh any experience with toe fit replacement. So, toe, I have no experience with. It's an implant that takes up the whole flipping toe. I mean, it's a big implant. So you've got to worry where if, and when that fails, how much bone have you got left and the bottom line is not very much. So, if, and when Silastic fails, then you think Crohn's, what am I gonna do? I'm gonna have a big cyst. I'm gonna have to fuse. No, you don't. It's no different from a failed hip replacement. OK. So you pull the implant out, you ream out, you fill up the uh stem because it's a contained defect. You put bone graft in DBM and you put in another cyotic. So I failed, I failed. My failed implants go from C elastic to X elastic just like they would uh you know, a failed knee or a failed hip. Can I ask you, can I ask you a question to? Yeah. Is, is a revision clastic more difficult than a primary one? It's an easy operation. That's why I love it. Predictable outcome, easy operation. And I classically say a blind, a baboon can do it. It is that easy. OK. But I was trained to do it by the associate specialist, you know, who's been doing it for 10 years. See one do one teach. One, it is exceptionally easy to do so. So the question was uh Tim about revision. Yeah. Is revision easier than primary No, what, what, what revision operation is easier than primary but no, no, that, that, that was the question I let you ask you not a difficult revision cos the implant you can just lift out, then you've got a hole, you just re you take out the biofilm uh from the, from the stem, uh r the stem back up and put in a slight uh the next, the next size implant up. OK. Um So another, another question is uh so you, you uh you, you heard your thoughts about dot How about, do you use grommet for the replacement? Oh, no. So uh Gromit, so again, why did gromit come in? So you've got to go to the literature. So Gromit didn't come in because great thing to do grams came in because the last negative paper out and then somebody, the writer hypothesized that the cysts were caused by the sharp bone ends rubbing on the implant. So Swanson then thought, right. I'll knock that on the head. So he created metal gromit. And then two years after they were introduced in 1985 a very dodgy paper came out to say are the results of that. There's much less cysts when you use grommet than when you don't. It was a really dodgy paper just to answer that question. Now, why don't I use grommets there? A grommet if you look at it has a very sharp metal back to it. So if anything is going to cut through a, a plastic implant. It's going to be the metal gromit. The metal grom has no binding on. It's just literally a dutch cap on the end of, you know, bone. It's just sitting there. Ok. So I don't use it. The chap who trained me never used it. All those 100 patients who I'd inherited didn't have a grommet in, they were all doing well. I saw no reason to use the grommet. So I've never used a grommet. They go straight in the bin. OK. Good. Thank you. You did talk about contraindication. Uh Helix valgus being a contraindication. So a question for audiences, you know, is there any degree, you know how, how much helix valgus? Can you accept five degrees, 10 degrees or nothing? So this is a real easy question and everybody gets concerned about it. OK. So um it, it's WW when people ask, ask me that they're looking at x rays and they're treating x-rays and they're drawing lines on the X ray. And what I say to the to, to those people is have a look at the patient. What is the diagnosis? And it's very easy, you know, the diagnosis is either hallux rigidus or it's a bunion or it's a bunion with arthritis. Now, if it's hallux rigidus, very, very rarely, almost always the toy stroke, it might have a minor degree of valgus. But the underlying problem is hallux rigidus. So I would use without any difficulty whatsoever, ac elastic on that. So I never measure angles. It won't be that vuls. If it's a bunion, it can't be, it cannot have. And that's your primary problem. It cannot have ac elastic. And certainly if it's a bunion, if it's a bad bunion with arthrosis that has to be fused. So I don't measure angles. I work out is the primary problem how it's rigidus. And if it is, then I can correct any minor valgus, radiological vuls either through my coat or through plicating the medial capsule and the toe goes beautifully straight. Good. Thank you. Um So what I'm thinking is, you know, we, we talk quite a lot that if the toe is very stiff and unless you also uh alluded that toe, if, if it is very stiff, then you're not able to gain movement. Is that right? Is it if, if you have hardly any movement, can you still get excellent range of movements as you have shown with the salt stick? Yes, cos you put it in sloppy, you don't put it in tight, the sloppier the better. So there is a bit of uh give. So your cut is just like, you know, if, if people were brought up doing knee replacements, when, when you did a knee replacement, your cut on, on both ends is a box shape. It's a rectangle. And similarly here on the big toe, you've got a rectangle which is a depth of, you know, maybe a centimeter, a centimeter and a half and the implant might only be in that hinge, might only be a centimeter. So you've got a bit of play and wobble. So it's moving. So even though you close a capsule and then you get some degree of fibrosis, it's moving. Um the pa that's why you need. There are different designs for this implant. I'm not got any financial gain on any of these designs, but there is an alternative design with a shorter stem. Now, the Silastic did have come out with a short stem device. Now, for me, I've seen some uh s short stem clastic that are painful and for, and you've gotta work out why when the longer stems aren't. And I think you need the longer stems to get adequate fixation in the bone and the shorter stem doesn't give you that because you're making it sloppy through the interface. So you want the stems tight. How about your postoperative protocol, weight bearing and all that straight away weight bearing, full weight bearing. This is, it's, it's, it's so easy. So into, into wooly bandage, immediate weight bearing is tolerated. So they're all done on the block. So they, you know, they wake up, there's no pain in the foot, they're, they're walking out of the hospital, no pain in the foot and then they're taking regular analgesia for the first two or three days then. So pain is gone. Ok. At two weeks, wound is healed, they then into a trainer. So Alessio saying, ok, it might take six months for his youngswick to calm down. They have a bit of metatarsalgia, they have a bit of transfer, they have some swelling. You saw my results at three months. Bilateral, you know, the foot. The great thing about this operation is like a knee replacement that you see at six weeks, the arthritic pain has gone, you've got rid of it, it is gone at two weeks and then you can get them going and they can load that big toe really quickly. So they, the, the, the time taken to get from A to B is fantastically fast. Great. You talked about your ideal patient as 55 years old, plus female, uh, with a straight toe. How about, um, 40 year old male who is very active? What do you do? So stick on him? So, males. So this is, this is the fine print males do not do as well. So, so I have that conversation with them so I can say, right. Ok. So the females want different things. They want you, uh, the male wants the pain to go away. Ok. So y you know, he's not normally varying the height of his heel at the weekend. He's not in high heels at the weekend. So what's the advantage of movement for him when he can have everything? With a good fusion pain relief? Er, er, and it's set to a standard heel height. So it, it, I don't think the joint is robust enough for an active male personally. So, in that sense, then, uh, it's very clear than what you have said for males, you will do a fusion for females. You'll do Xylo. Yes. If you look at my pa, if you look at that paper, I think what, what is it? 100 and 18 consecutive patients? Four males, 104 females. And that's just with discussion with the patients. OK. So this, this condition is four times more common in females to ma than, than males, if you look across the spectrum in terms of what people are having doing. So you will see more females for the first time two PJ OA uh end stage, but I tend to do much more fusions for males than, and virtually every lady is having AAA xyla. No, that, that doesn't make sense. Look, I think Tim, you have uh sold, I, I'm sure you've sold Xyla to a lot of people. Um I'm tempted to try, I haven't done one. But uh the way you've described, I think it's worthwhile uh to try. And again, Youngswick, uh u you very beautifully demonstrated uh you know, um uh what are the indications and why you do it? Uh And uh obviously, there is a role for, especially if you get an index plus dorsiflex. So you, that's an option one must think about it, which is underutilized, I must say. Um Oom is in general are underutilized. Uh I think we are bang on time and we had a good discussion and I thank you very much uh for giving your time and giving these excellent talks and educating. Um And thank you so much on behalf of both us and I'm sure we'll catch up very soon um to the listeners. Um You will get uh feedback um uh you uh so please fill, fill back the feedback and you will get this certificate uh automatically uh and uh uh look out for the next uh uh date for Master Techniques. We'll be holding it in a couple of months and suggestions are welcome. What you would like to hear. Thank you very much and goodnight everyone.