Treazzze Medical AdductaLapiSpotWeld CME case :)

[Feli]

So, what do you do on this one, and why?
...no significant equinus, moderate-to-low flexibility/hypermobility. 65F in good health, MPJ1 moves ok but highly track-bound. Opposite foot is 90% similar.

I know what I will do (did the boarding slip just now), but definitely not exactly the 15degree IM that we usually have. This one is not minor leagues... I'd probably rather do a rheumatoid forefoot. Seems rare to get to adulthood with that level of adductus not being casted or UCBLs or surgery.

---

Members don't see this ad.

 

[Pronation]

What do: McBride

Why: it’s all I know how to do

 

[Scrantonicity]

If you're into Lapiplasty, could do that and adductoplasty on mets 2 and 3 (that's 4 Treace plates and a happy rep!). That doesn't really help with the sag in the longitudinal arch though, unless you fused more of the midfoot I suppose...

Nah, punt this to ortho for BKA

 

[heybrother]

Its a good case. If you put a gun to my head and told me "do the next case perfectly or I'll kill you" - then yeah, I'd rather do a rheumatoid slam because it walks sooner and the satisfaction is so high.

I get Treace ads on my facebook feed and all of the original adductoplasty example cases ads I saw were in my opinion - inappropriate cases. There were at least 2 ads that featured virtually no correction through the 2nd/3rd. The patient had essentially experienced a brutal, high cost, long rehab case when they could simply have had a lapidus. A friend of mine once wrote to me saying he didn't think he'd ever seen a metatarsus adductus case that was appropriate for a 1-3 realignment. They exist. I think the above is a potential example though I'm also open to the idea that someone out there might be able to achieve the correction through the 2nd/3rd metatarsal without touching the midfoot.

My residency would have viewed that as a 1-3 TMTJ fusion with realignment. I've offered that to a few patients with x-rays that look like the above. When they hear the rehab they thank me for my time.

I've fused a few 1st MPJs on patients with moderate adductus who just wanted hallux correction/positioning. I don't think it would work on the above since the foot will still be enormous prominently medially. I also will do lapidus on metatarsus adductus cases as long as there is a reasonable amount of correction to achieve in the first interspace. The additional correct is seldom required - the above case is a rarity. They are out there but most patients won't have that much deformity.

 

[Feli]

What do: McBride

Why: it’s all I know how to do

Oh for sure.

Given what I usually see in the area, can't believe she didn't already have bilateral McBrides or bilateral Austins "to fix it." Maybe a McBride + MBA?

...I get Treace ads on my facebook feed and all of the original adductoplasty example cases ads I saw were in my opinion - inappropriate cases...

I love how they are all in - or headed fast into - hallux varus, esp the one on the right.
And those are the "good" results? The ones they choose to advertise for all to see??? Crazy.

 

[heybrother]

Oh for sure.

Given what I usually see in the area, can't believe she didn't already have bilateral McBrides or bilateral Austins "to fix it." Maybe a McBride + MBA?


I love how they are all in - or headed fast into - hallux varus, esp the one on the right. And those are the "good" results? The ones they want to advertise???

I knew exactly what you were talking about before I even clicked the link.

 

[SouthPod7]

My vote is 1st MTPJ fusion +/- lesser met weils depending on callous formation and pain. Not sure if you have enough room for a plate so maybe crossing screws?

Curious what procedure you selected.

 

[dtrack22]

So, what do you do on this one, and why?
...no significant equinus, moderate-to-low flexibility/hypermobility. 65F in good health, MPJ1 moves ok but highly track-bound. Opposite foot is 90% similar.

I know what I will do (did the boarding slip just now), but definitely not exactly the 15degree IM that we usually have. This one is not minor leagues... I'd probably rather do a rheumatoid forefoot. Seems rare to get to adulthood with that level of adductus not being casted or UCBLs or surgery.

View attachment 358785View attachment 358786

I refer that to a foot and ankle ortho where I live, not where I work, that I don’t like. I usually think the met adductus treatments of central mets I see are unnecessary. I would have loved to say 1st MPJ fusion and nothing else but then I opened the image…

I’m not gonna answer either way but patients actual complaints/symptoms are going to dramatically change what I would theoretically recommend. Medial bump pain with no other symptoms is different than joint pain, diffuse forefoot or midfoot pain, etc. I’m doing as little as possible to treat the painful area. Just have a feeling it requires pretty extensive proximal work at the level of the TMTJ. Yuck.

 

[Shiyuan]

Isn’t it obvious?

Low-dye strapping.

💪🏻

 

[Jummy Biffett]

I think the only way to 'fix' this would be 1-3 TMTJ arthrodesis...what 'should' be done obviously depends on symptoms/complaint

 

[air bud]

Would refer to my friendly big time fellowship foot and ankle surgeon - not touching. Don't have the experience with this level of deformity. Not afraid to refer. But going to try and refer to someone I think can help them.

 

[air bud]

Oh for sure.

Given what I usually see in the area, can't believe she didn't already have bilateral McBrides or bilateral Austins "to fix it." Maybe a McBride + MBA?


I love how they are all in - or headed fast into - hallux varus, esp the one on the right.
And those are the "good" results? The ones they choose to advertise for all to see??? Crazy.
View attachment 358789

yeah but that sesamoid position...

 

[wakaflocka88]

I would refer without hesitation.

 

[Pronation]

This is clearly a case for ABFAS certified and not for ABPM with CAQ in total toenail replacement surgery

 

[heybrother]

Always interesting to hear other people say what they'd pass on.

I was at ACFAS a few years ago and someone had attempted to do a case like that with an Austin / Akin (this was a few years ago but it was something woefully insufficient). It had ended up with I believe the residency director for Inova who had revised it with a fairly perfect looking 1-3 TMTJ fusion. I remember thinking at the time that I thought very few people could have pulled it off. I saw zero of these done during 4th year. My residency director did a few (sub-5) with some degree of realignment as opposed to just in-situ fusion.

Limited survey of people above, but I think Treace is wasting their time advertising their set. I won't fault them for "inventing" it but I have a hard time believing anyone is really doing these for as much as it gets talked about. My lapiplasty rep did this thing for awhile where he'd look at my pre-ops trying to measure for adductus that needed to be corrected. Screw that.

To make matters more annoying. Old ladies and fusions is a recipe for eternal complaining about swelling. I spoke to the Arthrex rep the other day and then printed every article I could get access to about Bosch, SERI, etc

 

[heybrother]

39. Female. Nurse. Is in a competitive Spanish dancing group. Great insurance. CC: Hates her large bunions. They irritate and rub on everything. What do you see when you look at this? I get a different opinion from everyone I show this to.

 

[heybrother]

Metatarsus adductus week.

CC: My bunion is big/hurts but I think my foot is unstable and its causing back and knee pain.

CC: Lateral column pain.

CC: Also lateral column foot pain.
Does this image belong here?

 

[GreenHousePub]

I love how they are all in - or headed fast into - hallux varus, esp the one on the right.

I've seen a number of these on Linkedin that had me concerned

 

[ExperiencedDPM]

So, what do you do on this one, and why?
...no significant equinus, moderate-to-low flexibility/hypermobility. 65F in good health, MPJ1 moves ok but highly track-bound. Opposite foot is 90% similar.

I know what I will do (did the boarding slip just now), but definitely not exactly the 15degree IM that we usually have. This one is not minor leagues... I'd probably rather do a rheumatoid forefoot. Seems rare to get to adulthood with that level of adductus not being casted or UCBLs or surgery.

View attachment 358785View attachment 358786

I love the title of your post. Specifically the infamous “spot weld” arthrodesis.

It’s either an arthrodesis or it’s not. If you don’t prep the joint it’s not an arthrodesis.

Spot weld arthrodesis……that’s analogous to being half pregnant.

 

[Feli]

I was going to do this plan (in order):
-osteotomy prox 3rd met then 2nd met with Lepird-type cut (pretty much metaphyseal oblique shortening Weil... dorsal dist to plantar prox, but cut at prox metaphysis), shorten... 2 screw fix each
-Lapidus with large wedge from cunieform, correct as much IM as able based on 2nd... steel lag + plate
-MPJ1 fusion... steel lag + plate

I do the MPJ fusions a lot on revis or severe HAV since these huge hallux valgus angle bunions will slingshot back into valgus - or varus (like the industry "example results" above"). It probably seems like overkill until you see a ton of recurrent bunions done by other docs - recurring even after just a year or two sometimes. This person is 65 and doesn't need recurrence or more surgery for the same issue (eventually wants to do other foot though).

I didn't want to mess with the hindfoot or proximal midfoot as that's not the main complaint ("I just want to fit in shoes" ...she wears sandals even in winter). She uses arch supports and will post-op. I suppose I could've put that in orig post 🙃



Always easier planned than executed, we shall see in a few months. The three medial rays should all end up shorter than I drew them. I think her surg is Nov. Everything looks good on paper
I played around with the idea of some super duper medial cunieform osteotomy and MPJ1 fusion, but then I realized I don't have superpowers... and 1MC has no real motion or importance anyways.

My vote is 1st MTPJ fusion +/- lesser met weils depending on callous formation and pain. Not sure if you have enough room for a plate so maybe crossing screws?

Curious what procedure you selected.

I do that a lot for OA/revision bunions sometimes. MPJ fusion is a good bunion procedure - esp for revision, but I can only usually get 5-10deg of IM correct out of MPJ fusion... sometimes add Lapidus something to it. For the met adductus, the lesser mets have to move out of the way of the first, and I don't think the atavistic cunieform will allow decent IM correct on this one with just MPJ1 desis or any met osteotomy. We shall see.

 

[CutsWithFury]

View attachment 358824View attachment 358825
39. Female. Nurse. Is in a competitive Spanish dancing group. Great insurance. CC: Hates her large bunions. They irritate and rub on everything. What do you see when you look at this? I get a different opinion from everyone I show this to.

I see traditional Austin/akin or MIS bunion correction +\- akin

 

[CutsWithFury]

So, what do you do on this one, and why?
...no significant equinus, moderate-to-low flexibility/hypermobility. 65F in good health, MPJ1 moves ok but highly track-bound. Opposite foot is 90% similar.

I know what I will do (did the boarding slip just now), but definitely not exactly the 15degree IM that we usually have. This one is not minor leagues... I'd probably rather do a rheumatoid forefoot. Seems rare to get to adulthood with that level of adductus not being casted or UCBLs or surgery.

View attachment 358785View attachment 358786

You really didn’t give a great history. Where is the pain?

 

[Feli]

You really didn’t give a great history. Where is the pain?

She just has medial forefoot pain, can't fit into shoes, no major midfoot or hindfoot or lesser met/digit complaints. "I just want to fit in shoes" ...she wears sandals (even in winter) due to width of forefoot.

 

[Shiyuan]

You really didn’t give a great history. Where is the pain?

”Toenails are painful on palpation.” 😜

 

[Feli]

View attachment 358824View attachment 358825
39. Female. Nurse. Is in a competitive Spanish dancing group. Great insurance. CC: Hates her large bunions. They irritate and rub on everything. What do you see when you look at this? I get a different opinion from everyone I show this to.

That is usually Lapidus +/- Weil 2nd in my hands if hypermobile, super-shift Austin if not hypermobile.

 

[deleted1138023]

View attachment 358824View attachment 358825
39. Female. Nurse. Is in a competitive Spanish dancing group. Great insurance. CC: Hates her large bunions. They irritate and rub on everything. What do you see when you look at this? I get a different opinion from everyone I show this to.

Austin/akin.

 

[Feli]

Here is another beauty from this morning that makes you proud to be a DPM... this is the joy I get on at least a weekly basis lately.
New pt who had bilat cheilectomy in her mid 30s "in the office; that was weird" and then silicone implants bilat when she was 39 and 40yo... wise.
Now 63F, current complaint is mainly 2nd hammertoes, central met pains, trouble walking. She does have planus, but no complaints or exam pain hind/midfoot.



I will probably do MPJ plate fusion with DBM for all the gaps with major shortening of 2 and 3, hammertoe PIPJ pin 2 and 3, Weil 4th...
Other option is a bone block graft MPJ fusion with allo or ASIS with only minor shortening of centrals and HT repair 2 and 3. I always find better luck shortening than lengthening stuff.

Fun stuff, good forefoot recons. The adductus one is just crazy genetics; this surgical cripple one is genius procedures done prior.

 

[Pronation]

That’s a lot of cystic changes in the bone there. I think I would set my dremel speed to low while I am manicuring their toenails because I wouldn’t want the heat to exacerbate their condition.

 

[Weirdy]

I see traditional Austin/akin or MIS bunion correction +\- akin

Was also thinking this.

I see metadductus but if her goal is to fit in shoes and get her back dancing- distal 1st met procedure and leave the rest alone is reasonable.

 

[Feli]

I ended up doing this orig post case plus 2 other similars last week...

I told my scheduler to be careful putting 3 burnout cases all on the same day (fairly long surgery day, no residents):

1 met adductus bunion...


2 severe OA + neglected bunion...


3 CPalsy bunion hammertoes (gastroc, IPJ tendontomy, lesser tendonotomies 3-5th


...and here is the failed silastic one from above also (she is about a month out now)

 

[Shiyuan]

I ended up doing this orig post case plus 2 other similars last week...
I told my scheduler to be careful putting 3 burnout cases all on the same day (fairly long surgery day, no residents):

met adductus bunion...
View attachment 365333

severe OA + neglected bunion...
View attachment 365334

CPalsy bunion hammertoes (gastroc, IPJ tendontomy, lesser tendonotomies 3-5th
View attachment 365335

...here is the failed silastic one above also (she is about a month out now)
View attachment 365336

Ahhh... the return of Feli 😋😋😋

 

[Feli]

Ahhh... the return of Feli 😋😋😋

Yeah, posting while banned is ... ... banned.

 

[Twin2012]

I ended up doing this orig post case plus 2 other similars last week...

I told my scheduler to be careful putting 3 burnout cases all on the same day (fairly long surgery day, no residents):

1 met adductus bunion...
View attachment 365333

2 severe OA + neglected bunion...
View attachment 365334

3 CPalsy bunion hammertoes (gastroc, IPJ tendontomy, lesser tendonotomies 3-5th
View attachment 365335

...and here is the failed silastic one from above also (she is about a month out now)
View attachment 365336

in any of these cases did you consider lapifuse or was it not warranted? I don't see these types of cases in residency

 

[Feli]

in any of these cases did you consider lapifuse or was it not warranted? I don't see these types of cases in residency

All reasonable implants and "systems" for a Lapidus can work... that one you ask will put twice as many holes in the bones, higher cost, weaker softer plates, more risk stripping screw or cold weld (since it's softer).

It's just personal pref... I tend to do what's strong and cost effective (nearly always basic AO steel), esp for small forefoot/midfoot plates. It's the technique and procedure selection that corrects the deformities, not the implant flavor-of-the-day

 

[heybrother]

Feli loves to go on about steel plates but what he's not telling you is that if your foot is placed over an induction cooktop it will heat the fusion. That's not going to happen with a well countoured copper plate or a gas stove.

 

[Sweatshirt]

I ended up doing this orig post case plus 2 other similars last week...

I told my scheduler to be careful putting 3 burnout cases all on the same day (fairly long surgery day, no residents):

1 met adductus bunion...
View attachment 365333

2 severe OA + neglected bunion...
View attachment 365334

3 CPalsy bunion hammertoes (gastroc, IPJ tendontomy, lesser tendonotomies 3-5th
View attachment 365335

...and here is the failed silastic one from above also (she is about a month out now)
View attachment 365336

That met adductus one is really cool. What exactly did you do to the bases of 2 and 3? I haven't seen any of those in residency either. Wedge cuts?

Also was the order of operations lapidus, 1st MPJ, 2nd base, 3rd base?

 

[PTPuser]

Feli, is that the Lepird procedure for 2nd and 3rd met for that adductus case?

 

[Feli]

...Also was the order of operations lapidus, 1st MPJ, 2nd base, 3rd base?

Normally first ray first...
On this, you have to set 3rd and 2nd mets first... otherwise no room to close IM. It was Lepird (basically proximal met Weil), then wedge Lapidus to reduce IM, then eval foot and still huge valgus at Mpj... so fusion there (McBride would fail to correct and/or fail premature).

 

[NatCh]

I'm having dinner with Paul Dayton this Friday. Do you guys have any questions you'd like me to ask him?

 

[billBOB213]

[mention]Feli [/mention] how is your Lepird met adductus patient doing?
I haven’t done many lapidus + 1st MPJ fusion cases locking up that first ray like that. I get why it was done, just interested to see how she is doing. Thanks!

 

[Pronation]

I'm having dinner with Paul Dayton this Friday. Do you guys have any questions you'd like me to ask him?

Yes I have a question about metatarsal rotation. Let’s say I’m doing a lapidus in China but then I go do a lapidus in Australia, does that affect how much I have to rotate the metatarsal based on the rotation of the earth in that area?

 

[Feli]

[mention]Feli [/mention] how is your Lepird met adductus patient doing?
I haven’t done many lapidus + 1st MPJ fusion cases locking up that first ray like that. I get why it was done, just interested to see how she is doing. Thanks!

She is doing well... maybe 6wks post op now, saw her last week. Incisions are healed. Still fairly edematous... that was a LOT of work done.

My usual protocol for forefoot stuff (or Lapidus) is 1mo boot NWB, 1mo boot WB, then tennis shoes or post op shoe if they can't fit into running shoes due to edema.

 

[Feli]

I'm having dinner with Paul Dayton this Friday. Do you guys have any questions you'd like me to ask him?

Is quad plating in the works?
(dissect and de-attach the whole first ray, plate all four sides, reinsert the ray, bill for 6 single TMT fusions)

 

[heybrother]

I'm having dinner with Paul Dayton this Friday. Do you guys have any questions you'd like me to ask him?

I would love to talk to him about MIS vs lapiplasty and concerns raised by Shibuya about frontal plane rotation and overcorrection. However, you'll probably get more enjoyment talking to him about things he likes (a) watches (b) wine (c) building stuff / metal cutting (d) shooting.

 

[Utvolsdpm]

I would love to talk to him about MIS vs lapiplasty and concerns raised by Shibuya about frontal plane rotation and overcorrection. However, you'll probably get more enjoyment talking to him about things he likes (a) watches (b) wine (c) building stuff / metal cutting (d) shooting.

More like Dayton the residents

(Rimshot)

 

[msuDPM]

More like Dayton the residents

(Rimshot)

Spicy.

 

[Pronation]

I would love to talk to him about MIS vs lapiplasty and concerns raised by Shibuya about frontal plane rotation and overcorrection. However, you'll probably get more enjoyment talking to him about things he likes (a) watches (b) wine (c) building stuff / metal cutting (d) shooting.

Oh definitely. Please ask him to comment on why the MIS bunionectomy is so much more superior to a Lapidus bunionectomy.

 

[heybrother]

Oh definitely. Please ask him to comment on why the MIS bunionectomy is so much more superior to a Lapidus bunionectomy.

15 days till my MIS lab. Excited!

 

[ExperiencedDPM]

Why are you having dinner with Paul Dayton? Business, pleasure or romance?

 

[NatCh]

Why are you having dinner with Paul Dayton? Business, pleasure or romance?

Must I choose?

Actually, he said he wants to ask me about SDN -- hopes he might learn something.