← The AOFAS Orthopod-Cast
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- [00:01]
A
Welcome to AOFAS Ortho Podcast, where leaders in foot and ankle orthopedic surgery discuss the issues that affect you and your practice. Please note that the views expressed on this podcast do not necessarily represent the views of the AOFAS or its members.
- [00:26]
B
Welcome to to another episode of the AOFAS Ortho podcast. I'm Matt Conti. I'm a foot and ankle orthopedic surgeon at the Hospital for Special Surgery. And today we're talking about minimally invasive surgery and complications. I'm joined by two people that I respect and listen to a lot on this topic and just foot and ankle topics in general. Dr. Becky Serrato from Mercy Medical center and Dr. Holly Johnson from the Hospital for Special Surgery. And so thank you both for joining us. I really appreciate it. I'm sure everyone who's listening is gonna appreciate your insight on this as you gu leaders in this.
- [01:00]
A
Well, thanks for having us.
- [01:03]
B
Of course. Well, so I want to start by saying that while I think the three of us all do minimally invasive surgery and we're all maybe a little bit biased here, but for all of us, it's really changed our practice. And I think for a lot of people that I think as it gets more and more popular, it's changed foot and ankle practices across the country and world. And as we know, nothing we do is free from complications, unfortunately. And so I think MIS sounds scary to some people because if you haven't seen a lot of it and you dip your toe into it and then you start having complications or you do a lot of it and then you start to have complications and you just don't know how to manage those complications, especially if you're not familiar with them, it's a little bit scary. So that's kind of what I want to talk to both of you today about. Like, how do we manage complications? What are things to avoid? And so we're just looking for your insight on that.
- [01:53]
A
Can I just make one sort of comment in chat?
- [01:56]
B
Yeah, of course.
- [01:57]
A
Obviously, the more surgery you do, the more complications you're going to have. So if you start to do more MIS surgery, unfortunately, you are going to have some complications. But I think that the MIS world, and especially the people who started doing it kind of right around the time when the brrrrs came out, we're all kind of fanatics about it, and we love to help and give advice. And I think that's true of anybody who's a specialist in anything really in foot and ankle. And they do a lot of It So say, I'm so happy to give my thoughts and opinions here, but I'm always available. And I would. I'm sure Becky is, too. If anybody has any questions or they see a complication they haven't seen before, probably between the two of us, we have seen it. And I'm always open to texts and shout outs for people who need help. And I. I would say that's the great thing about our society, is that we're all pretty available and when we do a lot of something that we love to share our insights to. So if anybody ever has a question, I'm always available to answer.
- [02:53]
B
Perfect. Well, okay, so let's just jump into this. This is my first question, and I'm here to learn. So are there any minimally invasive surgeries that you started doing and then you found out this doesn't work or. I'm very hesitant to do this now because I found that I had a high complication rate and I wasn't expecting it. Maybe, Becky, you could start.
- [03:16]
A
Yeah.
- [03:16]
C
And I talked to some of my, certainly North American colleagues as we all were adopting all of these new techniques. I would say the one that. And Holly will speak on it as well. We discuss it at length when we're with each other is probably the dmmo, which is interesting because that is actually the first osteotomy that was extensively studied and described when a lot of the percutaneous stuff was being kind of learned in the early 2000s and stuff like that. And I think it's the technique and stuff like that is not what we debate about. I think it's the true indications, because the outcome of those osteotomies, even in somebody with skilled hands, is not the same as some of the other percutaneous osteotomies that we do. Holly, you can speak on that if you feel differently.
- [04:14]
A
Yeah, I totally agree. It's one of the first things you do. Because metatarsalgia is so hard to treat, and DMMOs are actually technically kind of easy when you start. They're one of the easier things. So I was so excited to try them, and I tried them every which way. And I would say I pretty much never do them now except in very specific cases, but never. It's always in a case like that famous case you have of that guy with a TC fusion or a pan tailor fusion who has a rigid forefoot as a result. And Becky had basically changed this guy's world doing TMMOs. But we're not doing it for, like, a woman with metatarsalgia. The second met. You fix the bunion. That's what you do. Yeah. So very sparingly doing DMMO's.
- [04:59]
B
I was hoping both of you would say that because that's the one thing I haven't done. And I'm just scared. It seems so easy and it seems like, yeah, it's just a while, but you just can do it percutaneously. How hard could it be? But it does seem like people have reported problems. And when I was abroad and I met with Barbara Piclay and I learned a lot from her, minimally invasively. But what's interesting, I think she only will do them if the patients and I think they do a lot more in Europe. But she'll only do them if the patients can weight bear through their forefoot. Well, right away she doesn't do very many big toe fusions, but even in a big toe fusion where she feels like people are walking on the outside of their foot more, she won't do them. And I don't know, maybe in the US we're just more conservative. It seems like they let them weight bear a little bit earlier in Europe than we do here. So we keep people non weight bearing. And it seems like that's a real problem for the dmmo. People need to be weight bearing and able to put weight through their foot. But I don't know if that's the only problem.
- [05:52]
A
I don't know. I've done it and I'm in the school of Barbara P. Clay as well. Here's what I think. First of all, she's a phenomenal mis surgeon and that makes her stand out, number one. But the other thing is that in Europe, I think we've talked about this, they often see their patients back every week. And they have, they have a setup in their office where the patients come in, they have these orthoplasts, molds, they're doing taping. And really in my office, we see the patient at two weeks, we take off the bandages, we tape their foot, we have them videotape it, and I don't see them for four weeks. And so they're on their own. And I think that's probably the biggest difference. If I had the bandwidth and the personnel to have patients come back every week, then you can really follow the DMMOs. I don't think it's a weight bearing issue. I just think it's a matter of keeping the foot strapped because naturally the metatarsal heads really want to shift laterally and so they can make Your bunion recur, they can float dorsally. If you don't do them right. They. They can shift too much, shift too little. They can go on to non union if you burn the bone, I mean, there's a million different complications. But I would just say, unless you're in a situation where you can have a patient come back every week and you can strap their foot, I would not recommend doing 2, 3, and 4.
- [07:06]
C
I also think the patient has to be invested in this. You know, sometimes I look at a patient, I had one that I did a revision MP fusion, who had a non union and terrible metatarsalgia, windswept toes. Technically, this sounds great, but she's a pediatric cardiac nurse who she's not going to be in a boot for three months because her foot has swelling. She needs to get up and be moving around and stuff like that. And so, yeah, I think when you factor all of those things in, patient investment, what they have to do, what we have to do, and how we have to see them, and some of the less predictable results, we get predictable results with our MIS bunion surgeries. That's why you see most of us North American surgeons, I don't know if you ask a bunch of the Europeans, but the North American surgeons, what is the one MIS surgery we don't necessarily jump to is probably the DMMO for that reason.
- [08:03]
B
Yeah.
- [08:04]
A
Yeah.
- [08:05]
B
All right. Yeah. And I think that's helpful for people to hear because I think that's where a lot of people want to start. Because like you said, like, it sounds easy, but.
- [08:12]
A
And it solves.
- [08:15]
C
If you're doing it for a bunionette, that's different. That is absolutely different. That should be where they start. That is a home run.
- [08:21]
A
Yeah, totally.
- [08:22]
B
Okay, I agree with that. I guess I didn't think of a DMO for five, but yes, I agree the bunion nets have been pretty good. All right, so how about stepping away from dmmos? Are there any MIS surgeries that you thought would be technically very easy? And then you've come to realize that there's a technique or tip or trick that you found has really helped you because it was actually harder than you thought.
- [08:45]
C
I would say at the very beginning, when Holly and I were training on this, we would teach and graded. These are the easy ones. And then you move to this. And it was always the bunion that was the last and lesser toes. And one of the ones that they would put in the beginning. As far as one of the easier ones to do was the calcaneal Osteotomy. And I would disagree that that is necessarily one of the easier ones to do when you're learning how to cut this bone and get the tactile feel and make sure that you're doing it appropriately without creating too much heat. The calcaneus is not where you start. Wouldn't you agree, Hal?
- [09:25]
A
Yes and no. I think that it's the. It's certainly the easiest thing to do in the lab. But you're right, you have to know the nuances of it. I find personally that when I teach my fellows, once they can do it in the lab, they can kind of do it on the patient, whereas the osteotomies, I'm still just completely hands on with. But I hear what you're saying. You don't want to oversimplify it. And knowing the principles for the calc osteotomy are so critical at the beginning.
- [09:53]
C
Some of my colleagues who jump to doing, even if they didn't do a lot of bunions, they jumped to doing one or two of these perk osteotomies. They would send pictures of non unions. And how many nonunions did you see prior to mis but calcaneal osteotomy? I didn't see any of them. And so it was very frightening for them in that sense. And again, I think it's because it's just the calcaneus is a different bone than the first metatarsal. It's especially if you're doing it in a young individual with good bone stock. You have to be very diligent and slow and deliberate in your technique. Otherwise a complication you never saw before you're staring at.
- [10:38]
A
Yeah, it's interesting that you say that too, because a lot of my partners have had non unions from bunionette, which I also have not seen. But sort of newer MIS surgeons are just like surgeons who sort of dabble in mis. They maybe do a calc and they do some bunionettes. Matt, some of our partners. Yeah, we're getting non unions in bunion. I've done hundreds. I haven't seen that. But I think you're right. I think it's more to the point. Not that calc or bunionettes are easy because I think that technically do it in the lab and you can do it, but if you haven't been trained on MIS principles, that's where you run into trouble. So you need to know that you need to copiously irrigate. You need to have the tourniquet down, you need to go slow, just like said, making sure. You're cutting with the cutting flutes and not with the smooth part of the bur. There's all these little nuances. And so I think that it's not so much math that these are more technically challenging. It's just that these are things that people jump to that they get complications with, that if they just really understood the principles of mis, they could probably avoid those complications. And by the way, I would add colectomy to that, too. And because colectomy is also a surgery that should be really benign. Chiralectomy should be the do no harm. Right. The worst thing that should happen with a colectomy is that the patient doesn't get better. They should never get worse. And so I've seen a lot of cases come to me where too much of the metatarsal head's been taken, the ehl has been been lacerated, the nerves injured, like all these complications. And again, I don't think it's necessarily because the colectomy is particularly difficult. It's just that people who dabble in MIS without knowing the basics do it. And it can be a dangerous operation in that regard.
- [12:19]
B
Yeah, I mean, I think it's interesting that we started with calc osteotomy, because I think just like anything, if you don't respect the fact that all surgery is hard and you just go into the calc osteotomy, you're like, how hard could it be? You just take in the burn, you cut the bone, but it's a wide bone, and there's a lot of bones you have to cut through. And if you get lost and you just keep making different tracks, I've had that, or I've had also teaching the fellow. They get lost or they don't go all the way through, and they're making multiple passes to go through, it can become really hard. And then they're in there and they're probably cutting. You think that you've cut the near side, and then now the smooth side is against the cut bone. But maybe they're pushing really hard. So I think just like anywhere, no matter what, nothing is easy. Nothing is just like you. You should always practice in a lab, I guess, right before you go and you practice on a human being. And things that are seemingly easy can be really hard. So, yeah, I really like that, that. That answer, because I think that's. I think that's 100% true. What about, like, when both of you are teaching fellows, where do you start? I know this is not really a complication. It just made Me think, like, where do you start teaching the fellows? I know when I did fellowship, like, we did a lot of. Did a lot of akins. We didn't do a ton of mis, but a lot of Aikens is a good place to start. Other osteotomies that are good places to start.
- [13:28]
A
Go ahead, Beck.
- [13:29]
C
Yeah, I try my hardest at the very early part of their fellowship to get cadavers on their hands even before they go to the me fast course, which I know that Holly and I are pretty adamant that all of our fellows go to that, which is a perk for both programs, because it is.
- [13:47]
A
It's true.
- [13:47]
C
I mean, that's one of the biggest challenges with this, is in training in this technique, as Holly mentioned, giving up that bur for some of these strategic osteotomies. And this is not an easy thing for us to just give up. We can't sit here and physically stare at what they're doing. And so it's usually putting that in their hands. I get them set up with saw bones. I actually set them up with. I actually buy an Amazon, a device that they do to file nails down and stuff like that. It actually fits the burs. And so we sterilize them, and they practice and stuff like that. And then once I feel like they've got just some basic practice, I think the first ones I start with, if it's not a colectomy, achan. Absolutely. And then I'll show them a DMMO for the fifth, and they're at it for the dmmo. Like I said, I kind of learned in the beginning a calcosteotomy, you need to have that familiar feeling with your hand on how the bur is cutting bone. The calcaneus is not where you start. That is not where you start. I mean, you can start on a cadaver. That is not where you start when you're giving that case to one of your fellows. But once they've had one or two of those other osteotomies, I think just like Holly said, it's a calcaneal osteotomy is a pretty forgiving bone. So I will do that. And then usually I follow up with that. They get another cadaver in their hand, and they don't realize it. But I am looking over them. They don't realize how much I'm judging them. But depending upon how they perform, the very next week, if they're with me, they can do the entire bunion. And many of them have and stuff like that. So that's the Sort of graduated evolution in my practice, and they get tons of exposure. And even if they're not doing the osteotomy of the chevron, I mean, I literally spend so much time speaking to them about what I'm doing. So, again, that, I think is one of the biggest challenges, us as educators in mis, how to safely give that burr to your fellow.
- [15:56]
A
Well, in my practice, it's a little different. I agree. For me, it's the Aiken, because I can fix. So far, I've been able to fix every single screw up that someone can do in an akin. They can make a bad cut as long as they don't go into the joint. They can put the screw in the wrong place, they can break the bridge, and I can figure out a way to fix it. But the FHL rupture that I have not had, you're right. Becky's had an FHL laceration. So, look, I practice in New York City, and I take people back to the operating room because their scar where I put in the screw is a little bit inflamed. Anybody who has a nerve injury, it's catastrophic. And so with my patient population, I honestly, if I had an FHL rupture, I'd get sued. Somebody lacerated the fhl, I'm getting sued. And so it's a different. It's a really different environment. And so I'm very. I hate to say it, and I feel bad for the fellows, but you got to show me in the lab that you really know what you're doing. And some of that, I put the onus on. We have a ton of lab time, and I say I will literally do any day during the week, I will come up and do a lab with you. And so if they can do it, then I'll graduate them. But if I don't see them do it in the lab, and I'm just like you. I'm watching like a hawk, and they struggle for me. You put two. Two guide wires in the lateral cortex or three. Three or four holes, that bone's going to collapse. In an osteoporotic patient, that's on me. That's not on the fellow. So I don't know. I just. I've seen too many complications, so I'm very hands on. But you're a better teacher, clearly.
- [17:30]
B
I want to hear about Becky. I want to hear, since we're this mis complication. So when you had the FHL tended Roger, what did you do?
- [17:38]
C
Nothing. So I've had 2.2fhl lacerations from ACHE and osteotomies, of which both of those cases, I did not do the achy, nasty atomies. My fellow did. Both super skilled fellows. Again, it's. This is the challenge that we have when we're in that case with them and just sort of. You don't have that feel you can't see. I mean, you could tell if they're totally. The burr is way too deep or whatever, but if it's subtly too deep and stuff like that, it can be difficult. So, yeah, I had two patients. The first, when chief brought it up to me, she was like, hey, I can't really flex my toe down. And I got an mri. And I'm like, oh, my gosh, yes, look at that thing. And she was perfectly fine with it. She was like, well, she joked around about the inability to flex her IP joint and stuff like that, and she didn't really care about it. The second patient, I didn't get an MRI because I knew exactly what it was. We have a MEFAS talk group, like a WhatsApp group that we chat all of our stuff. I'll throw it out there. Some people will be like, I have a ehl. I have this, I have whatever. And someone brought up the FHL because it's actually for achin osteotomy. If you're not careful. It's not. We always say it's difficult for these burrs to cut soft tissue. It can cut a tendon, it can cut the fhl. And some other surgeons showed these reconstructions that involved like 8 inches of incision on the bottom of the big toe. But the majority of the other surgeons all kind of conferred with me that they would just let it go. And, I mean, we grab the FHL for other procedures all the time and stuff like that. And so, yes, I didn't do anything about it. But, yeah, that was eye opening, and it absolutely was a result of the otomy that was done at the proximal phalanx.
- [19:28]
B
I didn't even think that could happen. So now I'm more terrified now when I. On Friday I have one and I'm going to be tailored. So I didn't even think about that.
- [19:37]
C
My fellows always laugh. They're like, whenever they're with me, they're like, I know, flex the ip. Flex the ip.
- [19:43]
B
Yeah. Now I'm going to be thinking about that all Friday, so. All right. Well, I mean, but surgery is hard. So I don't know if either of you, I think Holly, have asked you this, because every time I do an Mis Bunion. To be honest, being in New York, I also worry that I'm going to accidentally injure the dorsal medial cutaneous nerve. Not with the bur. But when I'm pulling out that stupid medial cortex thing, the cut from the first metatarsal, I am just terrified. Any tips to avoid that? I mean, I tried to take that soft tissue off with a periosteal elevator as much as I can, so it's not caught. But any thoughts on that or have had any problems with that?
- [20:18]
A
So the one thing I always. I tell every patient when I go through the risks of the surgery, I have my this and this. I have my whole speech. I say to them, you will have some numbness along the medial. You know. And I show them along the medial aspect of the first metatarsal for three to six months. And the vast majority of patients, that completely resolves. And that's the truth. And it's probably about 20% of patients have some numbness there. But I don't worry about it from pulling the piece out. I worry about it from cutting that. And so you have that sort of dorsal shelf of bone. And as I've done more and more of these, of course, I'm trying to take more and more bone, and I always take more bone dorsally, but that's right under the nerve. And I think that's when you get it. That's something I can tell you. I wouldn't give up to anybody. That, to me, is the hardest part of the case, is taking off the medial shelf, which is why you see many surgeons. I see a lot of patients who come and they haven't had that spike removed. But that's why you got to keep your screws proximal, the whole thing, because you want to take that bone. So if you warn patients about it, that's a little more forgiving, as long as you don't get an aroma. And you warn them, and because most of the time, the sensation comes back. So just tell them they'll have some numbness there. That's kind of the way to get around it, to be honest.
- [21:34]
C
Yeah. Agree.
- [21:35]
A
And if it's a huge piece, cut it in half. You just cut it. You just split it. Because you do it the way I do. Right where you take it from the proximal wound, you can just cut it in half. But I don't think I've had any issues with that. And I take some pretty big pieces out.
- [21:50]
B
Okay.
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A
Okay.
- [21:52]
B
I'm just gonna go through my complications that I can think of, and Then
- [21:56]
A
guarantee Becky and I have definitely had them, too. Don't worry.
- [22:01]
B
Well, I don't want it to be, though, that there's just so many complications, because the reason why I've done more and more mis, and I believe both of you is because patients do really well. Right? So that's the takeaway. I hope the takeaway for people is not that MIS is scary, but it's that, I mean, no matter what I do, whether I do a lapidus and they can't move their big toe afterwards because they're really stiff in their IP joint or whatever, people have complications no matter what I do. But. So I was doing a lot of minimally invasive distal metatarsal osteotomies for bunions, and I was getting kind of cavalier about it, which is, again, the problem. And. And so I did it in a. I did a Hallux MP fusion on one side of this lady, and she said she didn't want to fuse her other side, and she had a really bad bunion. I said, okay, I'll do a. She was like 75, 80 years old. So I said, I'll do an MIS. So I did it and came back. It just totally collapsed. The screws pulled out of the metatarsal head. And.
- [22:50]
A
Yeah.
- [22:51]
B
And you know what's really crazy is. And I tell you this. I know, Holly, you know this, but I keep my patients not weight bearing for the first two weeks, which is. I know it's a debate, but it's fine. It's been working out. I just. I've had people weight bear. I had one lady way bearing. She did one side and weight bearing. She hated weight bearing, so, I mean, whatever. So I just kept in that. But anyway, so she was non weight bearing for the first two weeks, and I think she was pretty compliant. And the screws still broke through, so it wasn't like she was walking around. Screws broke and. And then, Holly, I texted you and called you in a panic, and you said to just leave it, and she's doing fine.
- [23:21]
A
Wait, did the screws break or did the head just collapse?
- [23:23]
B
Oh, no, the heads collapse. Well, the screw.
- [23:25]
A
Yeah, the screws broke through the lateral cortex.
- [23:28]
B
Yes.
- [23:29]
C
Type 1 metatarsal explosion.
- [23:31]
A
Don't even use that terminology. It's so stupid. The lateral cortex breaks because these people are osteopenic. And it may have. This lady was. That's like your 80 year old with osteoporosis. That's the classic. But amazingly, they actually do quite well. You just have to go take the screws.
- [23:49]
B
Out.
- [23:49]
A
I probably have five or six of those. I just saw ladyback. I saw Lady Back. She's the pianist for the New York Ballet. And I let it go. She couldn't take any time off. I let it go. And now I'm going to take her screws out. But they're so prominent. It'll be so easy.
- [24:04]
C
I mean, I think that if you're trying to select the person to do that technique for a bunion correction surgery, you have to be mindful of the bone strength, the bone density in the patient. Not all of us have DEXA scans and I don't even know if I would interpret osteopenia versus osteoporosis or whatever, but I actually use X rays and just the relative thickness of that lateral
- [24:27]
A
cortex to tell me, yeah, you can see it. Yeah.
- [24:30]
C
And it's a woman. I mean, it's usually the seven year old woman coming in. Am I a candidate for mis bunion surgery? And they've got an eggshell of that cortex. I'm like, you know what, you can have it, but then you can't walk for two months because otherwise it's going to break. And so those are the things that we have absolutely heard. But Kali said if it does break, usually the head rotates back over. Oddly enough, the hallux valgus angle. Still well maintained. Short, but it's well maintained. But yeah, it's something that obviously I'm going to try to avoid just by selecting the right patient for it. Yeah.
- [25:08]
A
But it happens when you see it. So let's talk about when you see it. So usually it's going to happen at the first visit. So you've sent them out. I let my patients weight bear, but I put them in a short boot. But if I'm in the operating room and their bone is absolute crap, then I tell them, I'm like, you're literally putting your foot down to sit on the toilet, otherwise you need to get a knee scooter. So I'm essentially in those patients making them non weight bearing and they can get up and go to the bathroom and that's it. But then even still with some of those patients, either they're non compliant or like your patient Matt, like they should, probably took one step and the thing collapsed. You see them back and what you should do immediately is make them non weight bearing because what you don't want. And I just had this happen. I've got an 82 year old who's this typical Upper east side lady. She won't stop walking. She's awesome. But I saw her metatarsal do this and do this and it's just getting shorter and shorter every time I see her. I actually put her in a cast at the last appointments. But generally speaking, if you can see it right away, you keep them non weight bearing and then I keep them non weight bearing until four or six weeks. And then I let them weight bear on it and it's usually fine. And then what happens is the bottom bone, now that it's broken, it heals like crazy. So it's awesome. But you get this big bony response and then typically you get a CAT scan somewhere around eight to 10 weeks and they're more healed than any of your other patients. And then you just wait for everything to consolidate and then you take the screws out because inevitably it'll swell for six months. And then when the swelling goes down, then they feel the screws because. Because usually the screws stay fixed in the head and they sort of piston down and so they become prominent at the base and then you just go and you make a little incision. At some point down the line you take the screws out. So I mean, knock on wood, I haven't had no. It feels terrible. Yeah, it feels terrible also, but it's part of my pre op discussion. One of the catastrophic things that can happen if you have bad bone and you're non compliant is the bone can collapse over the screws. And I tell people, if it's a 25 year old woman, I'm like, this isn't going to happen to you. But in my 80 year old lady I was like, look, you're at really high risk for this. So at least you inform them ahead of time. And I think that that's the risk they take. Or you're Becky and you're like, look, I'm going to do a scarf. Or is that what that's your alternative, Beck?
- [27:28]
C
Yep. Yeah, I don't want to do amica and tell them they can't walk on it for two months. I do a scarf.
- [27:34]
B
So what about. I've seen mis calc, non unions, but not my own. But I've seen someone come in with a infected calcaneus. Actually it was terrible. She got a little shell of bone. So going back to the calc osteotomy, I don't know who did it, but imagine they just burned the entire bone, then it died and then it got infected and I had to go back in. I take out the. They had put in screws. I took out the screws and I had a bone graft and I was like so worried because the Achilles was attached to this very small sliver of bone. But that ended up working out for her. But what for the two of you, other kind of catastrophic things or really difficult things that you've seen and you're like, and then you've learned that maybe not the most catastrophic things, but things that you've seen, like the lateral cortex breaking the first metatarsal and you learn, okay, this is how I treat it. It's not the end of the world. Whereas the rest of us who haven't seen it before immediately call you and say, this is the end of the world. This is going to be terrible.
- [28:27]
A
Well, I would say one other thing I would mention away from the bunion is on a zadig. For those of you who do zadix, I think that patient selection is probably most important. And so for me personally, I won't do the zadig on, say, someone who's a runner. I've been burned. Or an, oh, I shouldn't even say a young runner is a good candidate. An older runner who just has crummy tendon. So some of this is patient selection. Kind of like Becky, when she sees that patient with the really thin cortex, she's going to do a scarf for me. My hard stop with a zadig is somebody, it's like you're a 50 year old runner, because I don't mind you're a 50 year old obese golfer. But I don't want the 50 year old runner whose entire tendon's disease, because you're not going to make that person better, even if it's primarily at the insertion. So there's something around patient selection, I guess, that I would think about. But one other thing here, I can think of one sort of complication. But people often freak out when the bridge breaks on the Aiken, I don't know, does that because Jensen was reaching out to me and she said, I keep breaking the bridge. And I'm like, that's not a big deal though. You break the bridge, you just have to be careful that you don't overcorrect it when you put your screw in. But a of times be creative. And if you're, if, say you don't feel, for whatever reason like you, you don't have to put your screws in the exact way that it looks like in the book. And so like for an Aiken, for instance, say you feel like it's unstable just with one screw. If you've Broken the bridge. Throw a second screw in. Just do one distal to proximal X them. I've done that in the perk bunion, where in the, in the mica where I felt like I needed another screw. I actually put one through the head into the shaft. You can get creative and don't lose sight of the fact that you're a surgeon. Think outside the box. Number one, you might come up with a really cool technique, but number two, you just first and foremost just remember your principles. So, so don't freak out. Just go, just take a step back and say, okay, that broke. What would I do if this was open? Well, I'd probably put more hardware in.
- [30:30]
C
So I think the follow up on Holly's comments. When we talk about complications in mis, there's a couple of ones that are unique to mis, that if you do enough surgery, as Holly said, you're going to see complications. But there are some that are unique to using a bur, and that is skin damage. And again, that does not happen if you have good and careful technique. But it happens if it does happen. Typically, thankfully, usually all you need to do is ellipse that and it declares itself typically at the time of surgery, but you ellipse it out at the time. Don't be afraid to do it and please do it because you will have a wound complication if you don't ellipse that out. I think one of the ones that is so hard to treat, and as Matt, you commented on, is avn. And so if surgeons are not conscious of how much heat they're creating with it, not only are they killing off the skin, they're killing the bone. And that's something. Not that you can't do it with a saw, but I think it's a little harder because it's widen your face and it's being irrigated by two assistants and stuff like that. But the bur, they don't notice how much heat they're creating. And then also, like we mentioned, the bur is in there. And if you're not paying attention to your anatomy and what you're doing, you can do things like cut tendons. It's hard to do, but it's unique to the bur. But then there are other, what they call complications in MIS that aren't really complications. Like, for instance, we just talked about the fact that we don't do a lot of DMMOs. But if you do prepare those patients, they're going to be swollen for three months and six months.
- [32:09]
A
I tell them Six months.
- [32:11]
C
And tell the radiologist please don't call this a non union, which they will do and stuff like that. These, some of the things that you see with like the non fixed osteotomies, these are not complications, they're just consequences of unfixed osteotomies. And just be patient, let them heal. But you have to prepare these patients for those, prepare the radiologist, prepare your partners, everything for it and stuff like that.
- [32:37]
A
Yeah, yeah.
- [32:38]
B
Nice. And then last question is, as we were thinking about complications, Holly, you had talked about some of the. Our partners have had mis bunyanet non unions. And I've seen that too, not, not so much in my own patients. But I don't do, I don't do a ton of them. So maybe it's just a numbers thing and eventually I'll get one. But what do you tell people? What do you do in those cases? Have you just taken out the metatar dorsal head? Because that's not a terrible surgery depending on the age of the patient. Or do you go in and fix them?
- [33:04]
A
Yeah. So the problem is when you take out the head, the little toe cocks up and it's not great. I think that's good salvage. But a couple things. Number one is I don't call a bunionette a non union unless it's been at least probably nine months and it's painful. So if somebody comes back at their six month visit and there's some callus there, but it's not completely consolidated, but they're running and jumping and doing their thing, I don't care. And so maybe there are a few of those what I would call delayed unions. I'm sure if I saw that patient back in another year, we'd see bony consolidation. So for me it's really the symptomatic nonunion that you're seeing. And I've seen two. I had one in this very elderly patient, maybe in my. Probably in 2018, a long time ago, right when I started doing mis. And then I most recently took care of one of our partners and I just re. Cut the bone and I put a pin in it like a Bosch. Do you know what a Bosch is? The technique where you basically just put a pin down the shaft and it kind of holds the toe over. I was prepared to pin the little toe, but I didn't need. Ended up need to do that. And I think I put some bone graft in there. I probably put some. I can't remember what I put in. Probably a sliver of infuse, but that's how I would treat it. Kind of like I would treat a base of the, like a Jones fracture, non union. I'm not going to open that whole thing up and put a big plate on it the first time around. I'm going to try to treat it. I'm going to stimulate the bone. I'm going to put some good bone graft in there, put a dowel of icbg. So. But just remember, just to Becky's point, a lot of these are just, they're delayed unions. They're not non unions. So. And don't. If the patient is asymptomatic, you just show them the X ray and you're like, look, you're on your way to healing. Everything looks great. And be positive about it because if they're not symptomatic, they're going to be fine.
- [34:55]
B
Yeah. Well, I think this is a good overview. I mean, I'm sure everyone sees. Can't talk about every single complication that anyone has ever seen. Right. We always see weird stuff. Multiple weird things showed up in my office today of my own and other people's complications. So you can't talk about every. You can't talk about everything. But. But I mean, I think this is a good overview and I hope that for people who are listening gives you a little bit more confidence that we all see problems when we're doing mis, but there's good salvage and also maybe a good pre op. I mean, a lot of it was like pre op discussion too about talking to patients about swelling and numbness and those types of things. And then I'll remember on Friday to flex the toe so I don't cut the FHL because now I'm going to have nightmares. Oh my gosh.
- [35:35]
A
One, one other thing, Matt, I want to mention is the rare non union for the distal osteotomy. Yeah. Just really quickly, the first. Again, I jumped right when I first started. I remember I had two delayed unions that again, probably would have healed. But I was kind of freaking out because I didn't know what the X rays looked like and there was nobody to ask. And I remember I ended up open plating them and then they took forever to heal. But I have. First of all, it's really rare that I see non unions, but even when they come in from the outside, I haven't opened a non union in years for at least five or six years. And so what I do is I take out the screws, I just re. Cut the bone. I put bone graft in, I shoot bone, graft up the old screw holes, and then I put in new screws and knock on wood. I've had 100 success with that, so I don't think. Yeah, so don't freak out if that happens either. I'll show you a couple images of that, if that ever happens, or anybody else. You don't have to convert it to open because that just creates a beast of a recovery and everything else for the patient, so.
- [36:41]
B
Oh, yeah, that's a good point. I mean, I didn't even think about that, so. All right, well, thank you both. Yeah, I know, I know I'm going to end well. Thanks for jinxing me, but. Yeah, no, I will. So. But thank you both for joining me tonight. I thought it was a great discussion. I really appreciate your insight.
- [36:58]
C
Thanks for inviting me, Matt.
- [37:00]
A
Yeah, any excuse to hang out with Becky. Anyways, I'll be there. Thank you for listening to the AOFAS Ortho Podcast, a Convey Med production. To learn more about joining our dynamic community of highly skilled orthopedic specialists, visit aofas.org.