transcripts/BigToeFusion_transcript.txt

BigToeFusion — Full Surgeon Narration
============================================================

careful, one is going to be for the big toe, which I generally will do first. Remember, this certainly relates to fuse the big toe and then resect the metatarsal heads. I also make a decision, two of them, dorsal also for the space between the second and third metatarsals essentially, and it goes into that web space associated in between the fourth and fifth. These ones can be a problem because they're in close proximity, relatively speaking. The tissue's not great under the... There's not a lot of tissue under the skin, and so these would be ones where I'll have sometimes wound breakdown. In fact, in this patient, there's a little dehiscence that occurred. Eventually, it wasn't a problem, but I just had to do some local wound care. I've had colleagues that actually do the head resection through a plantar approach, just especially when the toes are extremely dorsiflexed or dislocated where they'll come just under the bottom and then resect them from the bottom. So I think that's an option as well. I did draw up the incisions in a reverse order, but I generally start, as I'm showing here, with the incision for the first minotaur. So you generally need to extend it just about to the IP joint because you're going to need to use that for the plate. It's often awkward because in the pages, especially with a significant bunion like this, the incision curve, but ultimately it will be straight as you straighten the toe. The most common indication for this surgery, by the way, is one with rheumatoid arthritis. So you have bad destruction of all the joints with dislocation and synovitis. In this case, the patient just had a severe long-standing bug in which led to dislocation of several of the toes. And I thought given that severity, the most predictable by far would be to do this Clayton Hopman procedure. I did not think that trying to do the surgery to salvage the metatarsal heads or fix the bionic, for example, with the lapidus or other bionic tech procedure would be effective and I thought it would recur. So once I get through the skin, septum, butane tissue, I need to find and protect that EHL tendon, which I do to the lateral side. I have skin hooks there holding the skin to each side, electro-cauterized small vessels because those will bleed at the end of the case, so it's important, I find, just to cauterize them. I do this with a thighternicate anesthetic, is most often a spinal anesthetic with a papatial fossa regio-inocetic blockade. Again working more on that EHL, tending to get it off to the side. One important concept here is I will prepare the first FTP joint but I won't fix or fuse it until I've done the work on the other toes and that is because I want to see where the best place to position the big toe at the end will become with respect to the others once those toes are more straight. And this is a big surgery because it's doing a lot of work through multiple incisions. It's the head resections, the big toe fusion, a lot of PIP resections. So just take your time, stepwise fashion. I'm using electric cotteries simply to make a mark along the tissue where I'm going to draw my eyes so I can do the open capsulotomy. I will definitely take this tissue at the end of the case and repair it to itself. Watch for the brevis tendon as well, but that usually becomes confluent with the capsule distally, so you just treat it almost as if it's one layer. I tell the fellows always to work from the inside of the joint out, so put your knife in and direct out so you get a nice smooth release of the capsule so that you can close it later. This case was not rigid because it was not significantly arthritic. The indication for the fusion was the severity of the big toe hallux valgus. So you can see the head looks pretty normal. It's actually not too hard to open it. I do need, because I'm using cup and cone reamers, to really see that head completely exposed. I need a reamer on that without either running to the adjacent tissue or the proximal phalanx. And I'm releasing some of the tissue on the bottom of the metatarsal just so I can have it completely exposed. I actually take off cartilage with a joint prep kit or a curette because what I find is it then becomes a lot easier to ream against the prepared bone surface as opposed to cartilage. And what happens with the cartilage is you may have to push quite hard and then run the risk of putting so much pressure on the head. I would not recommend cup and cone reaming in somebody who has a really weak bone because you can get into trouble really quickly by fracturing the head. Notice that I'm taking a curette also and taking the cartilage off the other side for the same reason. You could do this without cup and comb reaming, just match the surfaces. I generally like to do the cup and comb reaming because it gets me down to a nice stable surfaces and the two surfaces will match completely. I use electric cotter just to draw my eye to what I feel like is the center of the meditational head. Now Now if there's an eminence, which there is in this case too, you have to take that into account. I'll start center. You generally have to aim dorsal or uphill a little bit as I say down the head to get an x-ray and looks just like that where I'm starting center in the head and going pretty much down the middle. That didn't have to be perfect because the reaming allows for some adjustments. Here's the reamer tip going on. It's, you don't want to lever it one way or the other. I generally will do this on full power. You start with a larger reamer and work your way down. So this set started with a reamer of 22 and generally it'll start at a 22 and go down. Most of the times in men, the final size is a 22 or a 20, and you have to match the proximal failing side. In women, it's usually 18 or 20. Notice I'm taking a ranger and taking off osteophytes off the surrounding surface from the reamings, and that's because the rebar tends to hit up and a butt up against that, and I can't advance it without a lot of pressure, so I just use a Roger to take it up, and then I'll come back and ream again. If you're thinking about what the size is for ream, I think you want the largest reamer that matches the meditational head, but you have to account for the fact that the proximal phalanx is often smaller, and you need to ultimately have the two match. Sometimes if I'm worried that the proximal phalanx looks quite small, I'll bring this down one more size, which it looks like is probably what I'm doing here, just so again I know that I can get up to that size of the proximal phalanx and have a good match. You can see again that collar, if you will, that it leaves, which I'll then clean up later with a good match. You can see again that kind of collar, if you will, that it leaves which I'll then clean up later with a runger. Just go nice and slow and harder bow like this Beijing Ed, it's generally not a problem. A weaker bow you can get yourself into trouble like I said pretty quickly.

Once I'm happy with the reaming, I'll take the wire out. You can see that I'm decompressing the toe to some extent already and then I'll take the wire to the center of the proximal phallus and set it out and also take an x-ray. It is helpful to shorten that toe a little bit because you're ultimately shortening the lesser toes by taking a head resection. So here is a picture of that same 1.4k wire down the proximal phalanx. I'm going to take an x-ray. Oftentimes you have to maneuver this so you can to the side of the tarsal. You can see it's right down the center. The mistake is also to head planter

as you're passing that wire so you gotta be real careful. In this case we're starting with the smallest reamer. You can't quite see the surface there unfortunately. Here you go. Now what I do here is I'll start with the smallest one and start just developing a little crater or hole. I don't like to get up to high speed on this. I'll oscillate it. I'll do two clicks forward and two clicks back so that this reamer doesn't get up to a huge speed. And you can't quite see that on the video, but just slowly but surely reaming. I start with that smaller size, which allows me to deepen the concavity, if you will, and then I'll expand it out as I increase to larger reamers that ultimately then, with the last one matching, the meditators will hit. Looks like I'm increasing the river size there. You could also clean the surrounding surfaces of that arena with a ranger. Sometimes it's more fibrous tissue, so it's important to distinguish between what's real bone or fibrous tissue. But it looks like I'm developing a nice crater there. You have that kind of yellowish bone color is key. That's what's ultimately going to heal. And most of the meditational phalangeal joints will heal. My experience is the non-union rate is pretty low. I'll get into it later, but the non-weight-bearing period in an empty-befusion gel is about four weeks. I'll go a little longer in these Aiden Hoppins, just because there's more to heal. There's wires that I'm passing into the shafts of the metatarsals that you'll see later. So it just needs a little extra time, my experience. There are people that let patients walk right away after an empty perfusion. I just like to avoid wound problems and let the bone heal. I'm drilling a bunch of holes after I've irrigated the bone with a 1.4k wire. I do that on both the proximal phalanx and the metatarsal side until it fell to make that metatarsal head look like a golf ball. I think there's a fear of fracturing or causing flaking off of the metatarsal head, which in my experience doesn't happen, or if it happens a little bit, it's not a problem. You're just creating almost a fractured surface that's going to want to heal to itself as you fix it. You see, I take my time, but a lot of holes in there and then we'll ultimately do the same thing. The other side I take a very small osseotone we call this a hoax osseotone that I then start connecting the dots if you will, just creating little tiny fractures between the holes throughout the whole thing, Sometimes a softer bone, I'll do less of these or just be more careful. The prox will fail excitedly. The same, the center tends to be a little softer than the outer rim. So you can plunge in there a little bit. The outer rim tends to be long enough and extended enough so that I can ultimately get out metatarsal heads with two and three. I look first for extensor tinnitus, which I generally will keep on the lateral side with the brevis and longus. Notice I'm using electrocautery to cauterize small vessels, which I think is important because it'll save you trouble after once a tourniquet comes down. But this is generally done at a tourniquet. Generally takes you about two hours. You really need to dissect, then down onto the neck of the bone and then from that point in similar fashion to what I even did to the first metatarsal, I'll dissect around. This retractor called a Maclomery retractor can be really helpful. Notice I'm using a freer elevator to identify the level of the cut, which is usually just at the metatarsal neck. I've used that McGlomery you saw briefly just to free around, but you've got to be careful because you can crack the head too. I'm taking a 38 saw blade with some Hollmans holding that bone. I angle so that I'm beveling it dorsal distal, so there's not a sharp spike of bone on the bottom of the foot. and then I'll cut the bone. One of the tricks then becomes trying to get that out. The more dislocated that toe is, the harder it is to get out. We're taking retractors and retracting the skin on one side and the extensor tendons on the other side. Here comes the MacLaren retractor, which you could pass around the cartilage surface and deliver yourself. But in weak bone, like I said, you can actually almost just cut into the bone like you would with an osteotomy, so just carry on. We'll take this, wrap it around, really identify it, see if I can deliver the head. Also a cocker, like you're gonna see here, is real helpful to get around. You can fracture that, well it's not the end of the world, but it's nice to take it out as one piece so it's clean. You don't leave any residual fragments. So just pulling gently and usually getting a knife or scissors and just working your way around it so you get that piece out. You'll see here in a little bit what it looks like. Again, this is not a rheumatoid patient. The decision for Clayton Hopper was made by the level of the dislocation and severity of the hammer toes, so the head probably will have cartilage on it, unlike a knife gently taking care to not get the skin just to release whatever those attachments are and then to get here's what the head looks like get a sense for the amount of bone I took you can see how the cut is beveled the cartilage again looks okay just because it's not really a rheumatoid patient do the same thing now for the third I think there was just smoothing off the bone just a little bit looks It's like I did the same approach to the third which you don't want to show in huge detail because the same concept again this is through that middle incision use the glomerates to deliver the head and then take it out use a cocker this case is a sweetheart put the ligaments on stretch or the platter capsule pre-ostume, and then you can roll this out. You want to watch and not injure the flexor tendons on the bottom, although the truth is they're not going to really do much after this procedure, it's really a salvage procedure. You need to tell the patients that, say that they're not going to have a huge function of those toes. They tend to be floppy. They tend to float up a little bit, but the whole goal here is pain relief. Now notice I'm taking an x-ray after just to look at the relative lengths of each of these. It's probably not as important as a metatarsal head length for weight bearing, but I feel like it could be prominent, so I try to match a cascade like I would with my metatarsal head resection. So here, that third was a little bit long, so I'm taking up just another probably three or four millimeters at bottom. Taking an x-ray, then confirm the amount ofrary section that I've done. Time to turn to the other incision now that's between the fourth and fifth metatarsals. It's often more lateral than you would think. I bring the incision right up to the webspace because that's where the heads will be. In this case, it's a little easier to get the fourth and fifth only because they're not dislocated. By the way, what I find is if you're going to resect a metatarsal head in isolation, patients will tolerate you doing the fifth, but the central three, especially the second and third, if you just take out one, they're going to get transfer metat the tarsialgist so it's really an all-or-none. I'm isolating the head now you can tell that was a lot easier already we get the Holmans around I'll check the level of the cut here in a second wanting the fourth to be just a little bit less in a stepwise way compared to the third and I take the saw bevel it up so that a pointed surface is not present on the bottom. Delivering that head, using the homens, here comes a your time Thank you very much, and God bless you all. In this case, I had taken some bone and then took a little bit more residual bone to match that cascade. It's important also, I think, to take enough bone where you don't end up getting impingement between the toe and the tarsal set. I've had that and I've had to go back in a few cases and actually decompress it more because there's some residual impingement. Here I am delivering the fifth metatarsal. So you can see why it's a somewhat tedious process because we just take one out at a time, but you do the same thing. Here you want to bevel it dorsal and if anything have the spike dorsal and medial so it wouldn't rub against the outside of the foot. I've had a patient or two where it let the small spike laterally and it bothers them on the shoe. So you just have to be careful with that. I am delivering the bone, taking out the capsular attachments, and removing completely that last hit. Often, and most often, these are associated with hammer-toed. As far as you could see in this page, especially on that second, there was a very large callus as part of the second hammer-toed. So generally, I'll be doing PIP resections as well. I generally don't need to do extensor length things because you've already decompressed so much that you don't need to lengthen the tenons. So now I'm sorry, the PIP resections, most of the time I do a longitudinal approach to the extensor tendons. In this case, the callus was so severe, I decided to do an elliptical approach also, which allowed me to get rid of that whole severe and hard callus. The callus, and I tell peopleia will go away eventually on its own, so it's not absolutely necessary, but in this case it seemed a reasonable approach. But generally I'll do the extensile approach, longitudinal. Be careful here, just the skin itself, because you want the other redundant skin to help hold and heal. So I'm just going at the base of it, and I'm taking the claddles down on each side, it's important to get the claddles down because What you're going to do to do then is put a frayer underneath and then free each side. I use an elevator just to strip some of the periodosum off the top. I use a bow, if you've seen other places throughout this case, just to make myself a note or mental mark. It's not really that necessary. Generally for the PIP joints, depending on the severity of the hammer toe and the length of the toe, I'll come at the base of the condos. When you use this saw, it's a 39, we call it oscillating blade, smaller than what I used for the metatarsal head resection. You want to stay perpendicular to the shaft and its long axis. You want to get the hand over the top so you're not taking more bone dorsal than planter, because you could dorsal flex this toe. Then I flex down the toe. And with the soft side of it, I just smooth across, just make these passes. And I'm going all the way across the length of that proximal failingsx so that I have a nice smooth surface that will match potentially and hopefully for good bone healing. It's not an absolute requirement to get bone healing of a PIP resection, but I find it's less full if it heals as a bone unit, it heals quicker and the patient just do better quicker. I'll then pass out a double- 1.6k wire down the middle of that proximal phalanx. I try to come center and just under the nail. I'll bring the wire back so there's enough exposure to the wire to put down a pilot hole which I had made in the proximal phalan Felix and then have my assistant drive it across. You can see the toe looks straight. I'll take an x-ray just to make sure it looks like it's going down the center, holding the toe out of the way. Looks like it's doing that. I'm putting a protective yellow cap because I ultimately will drive these across some interracial heads, but not going to do it quite yet. As you can see here, this is an extensile incision, but the concept is otherwise identical. going on each side of the capsule now to release the capsule. I use that knife to take down the collaterals. See how the skinheads are really protecting that tissue to each side. So just be real careful. I put a freer under the proximal phalanx condyles, mark it out, and I'm going to saw just proximal to those condyles again. You can see the fourth and fifth toes really are not as hammered. They don't have a formal contract with the PIP2. So I've taken that tissue out. now I'm going to smooth down the middle phalanx. This one looks like I was just also taking some of the residual plantar aspect down so it's smooth on the middle phalanx so I don't dorsiflex that toe. I use a small rongier to clean out any residual bone dust. Same concept, I would have made a pilot hole at the proximal phalanx. I take this and drill it out the tip of the toe. It was a little planter so I'm just bringing my hand down to adjust it and raise it up a little bit so coming out a little closer to the nail. If somebody has an overgrown nail you probably want to trim the nail first to give you a lot more space.

A little passive back there. Then I'll drive it across. Same way that I did with the second. You want it right down the center of the toe in my experience. It's also important because I'm ultimately going to drive these wires across the shaft of the third metatarsal, or this across the shaft of the third metatarsal. I hold that toe straight steady while my assistant drives it across.

These are double-ended wires because it allows me to pass it out integrated and retrograde. You can see some of the redundant tissue there. Take an x-ray to make sure it's going down the right path. These don't have to be perfect, by the way, because ultimately, when you pull the pins, the toes will float up a little bit no matter what. Looks like I've got the pin coming out a little planar. You want it right out through the middle of that third metatarsal. But in this case now, I've driven them down and across the shaft. It's real easy from that dorsal wound to see where the wire is and put it right in the center of the shaft and you can start driving it down the center. It comes with little resistance, so you just pass it. I usually pass it just about to the level of the TMT joint. I don't want to go through. It's also important for me to note here, I'm not letting the patient put weight on it in part because of the MTP joint, but also because these pins, if you have a patient with pins going across a lateral head resection, it's important not to let them put weight on it early because they could break that pin. I had some concern that the third toe was out of position with respect to the second so I repositioned it there, going back in the proximal wound to look better at the medtarsal shaft so I can then pass the wire, start it right down the appropriate area. Generally, this is pretty easy. I always find that when you do multiple hammer toes, it's hard to make them all look just right with respect to each other. But I'm stabilizing that toe. My assistant's passing it down, just checking to make sure that the wire continues to go down the shaft of the resected minotaur sole. That looks better. The third toe looks a little up compared to the second, but at some point I'm probably just going to keep it because I know when I pull those pins they'll be more even. In fact this patient I remember exactly that as soon as I remove those pins at four weeks they came up nicely. Now the other thing is there's a second wire that I'm putting next to the first wire. This is for rotational control. It does not go across generally the MTP. I put it on one of the other side. I feel like I have more room. In this case, it was medial. I put it literally completely parallel, bumping right up against the other wire and bone. It does not go down the shaft. It generally just catches bone and I found that really helpful for rotational control. As you can see I'm doing with the third here I'll just put it in my hand, poke it up right onto the bone next to the other wire and then I'll take the driver and just slowly collinearly dry that across. So it's coming up and I don't pass it across the MTP joint but rather right up to the in the proximal phalanx, the proximal lid.

Looks like in that case I didn't get a good position or it skied and if that happens I went from trying on a medial side to now trying on a lateral side and you'll notice I put a little irrigation on my fingers that allows me to actually pinch and hold the wires together with no friction and then use that as a guide so that I can pass the second wire just to chase it to the first. There's a little bit of deviation from one to the other but as long as it's in bone on multiple views then you're fine and you can also tell if you just try to turn the toe if it's rotationally stable then you're good. I place pliers on the base of each of these wires. I'll usually cut the longer one which is the 1.25 wire that I used as a second wire before I cut the 1.6 wire. That needle nose plier goes right at the base of the wire. Hold it securely and then I have my assistant with this metal sucker tip. Push it all the way down to meet the wire cutter. And then I cut it. I leave a little hook. You don't want to leave it real long, because it can catch on a piece of clothing or a sheet. And I've had patients pull it out. But you want a little bit of a curb so that also couldn't be impaled down into the toe and I've seen that too. I leave the curved dorsal visible so it's more out of the way and ultimately I'll put these um stairs chips that uh go around the top so it protects the toes Okay, so now I mentioned quite a while ago that I do that work first, because now I know where those toes are gonna sit and how to match them with my big toe fusion. Now the big toe fusion itself, we all know you put in a little bit of algus, a little bit of dorsal flexion, make sure it's neutral in terms of supination or predation, that is the rotation. But you use the second as a little bit of guide too. I like to put in 2k wires one starting medial and one starting lateral. I generally use a little bit of demineralized bar major so they put in the joint and then I hold it right where I want to go and have my assistant full speed gentle pressures I say drive one wire I'll check it on an x-ray and clinically and then drive the other. Your hand needs to be somewhat down because otherwise it goes out the bottom of the joint you don't get enough purchase. Here's a provisional x-ray showing the angle where I've got those wires they're out a little flatter because you see they didn't go a long way before the cop mode came out. I use a burr often that is because the mid dorsal head particularly but also the proximal fillings has a dorsal contour and to fit a plate on even though they're theoretically pre-contoured they don't really work real well so I use this bone and just take my time and put this dorsal plate on. I secure with my hand. There's a variety of different locking plates that work. I will then hold with an olive wire jelly distally and use a locking tower proximity through which I'll put either 1.25 or this looks like a 1.6k wire down to hold it. You want it pretty well opposed because I don't want to put screws down and have it alter the position that I pin that to it. I'll start with the distal screws. I generally am putting 2.7mm locking screws, so drill through these locking guides and then I'll place the 2.7mm screws through each. As you put the first one down, just be careful not to really go for broke in terms of tightening, because it could still rotate the plate as the screw engages. So I'll gently get the third one down and then really tighten them. Depth gauge to major, they're generally between 12 and 16 millimeters distally. Notice I'm not putting a compression screw or crossing screw first. In fact, I don't use one at all because you can compress through the oblong hole and I find these these heal quite readily. I've removed the olive wire now and I'm gonna drill the other to remove that just because it gets in the way and it's no longer necessary once you've got one screw in. Let your drill just feel gently for a bicortical drill. Some systems have this where you can measure the length off the depth gauge itself or the locking tower itself but I prefer to use a depth gauge.

Measure, then I'm to put the screw in. If I do all the three locking screws distantly first, secure that, and then it's when I'm going to go to the proximal oblong hole to then compress it. If you're going to do a compression cross screw, you'd want to do that before you use the plate to compress it. I suppose you could start the compressive screw which is oblong first but without going all the way down then put your cross screw. I've gone to this because I find that I get good compression it heals well and I don't need a cross screw and the cross screw honestly it's hard to avoid the other screws that you have in your plate. So it just me some steps. Here's the third and final screw that goes in the disk last but to the plate and these are They're locking screws. The critical bone down there tends to be pretty good, but I just find that if you lock it, it just gives you even additional strength in the pullout strength that we always talk about. Doing some final tightening of those distal screws. Notice I still have that locking tower proxley set. This is a knob long

drill guide so I'm going to and it's really important to drill in the proxial aspect of that hole because as the head comes in it will compress it. I used a sucker to suck out that bone so I can get a good look at this, but then

I'll use my depth gauge. Generally the screws are between 14 and 16 millimeters and generally they have good purchase because it's cortical on both

There goes the screw coming down. I'll generally get it almost all the way down and then take off the locking tower and that wire that goes through it so that it doesn't bind up my ability to compress. Most of the times I'll keep setting it down a little bit more and then take out one wire. I find that you can still compress even with those provisional wires in there and especially just one. I don't think it matters which wire you take out which one is either more accessible you think is less important and then I'll cinch this down okay now the compression is done what you have are just two final locking holes so I'll place the locking guide on those Here comes the locking screw. And then I'll lock the last screw. You have to sometimes watch because the wire can be in the way of this screw path, but generally not. If you need to, I think it would be very reasonable to take that wire out now, because it's really held in place. And it looks like I was taking that wire out, because it was getting closer, hitting it. You can see the plate itself has a little black line which is supposed to be right at the joint line which it looks like it is in this case. Also various sets will have different amounts of dorsiflexion built into it so you can go five or ten degrees. I tend to use the zero one because my experience is that I don't want to dorsiflex that toe up more than that and often, I would take the zero and I bend it a little bit down. That's because after I've smoothed the surface off the top with that burr, it tends to fit better and does not risk it dorsal flexing. The position that I show this on the bottom usually is if you put a plate on the bottom, you should have just the pulp of the toe sitting down on it without a lot of pressure. It gets a little harder to do it when you've got metatarsal head resections because the toes are pinned in line with the metatarsals and their natural position is not there. It's more dorsal flex. You've got to be a little careful how you to reinterpret it in this case. Final fixation looks good. I'll really take an AP and ladle view just to make sure my screws are not too long. Now I can close the capsule. I do this with a series of choose your vitals. Notice the third toe that I mentioned before is a little more elevated. It just happens to me the way it looks when I pin down that third toe into the metatarsal shaft. That will regulate itself once I match the other toes. Also, I did not do PIP resections of the fourth and fifth, and that's because they were completely straight. It's very common in rheumatoid patients that have to do them all, but in this case, that was my rationale. These are interrupted sutures. It's a really important layer, I find. Dissolidate, or the extensor hallucinobrevices can flow with the capsule, so you're essentially taking some of it and not advancing it over. Oftentimes, as you're seeing here, there's not enough tissue because it's just thin periodontism to close over the plate, and that's been.

..... can flow with the capsule, so you're essentially taking some of it and not advancing it over. Oftentimes, as you're seeing here, just so there's not enough tissue because it's just thin periosteum to close over the plate, and that's been just fine in my experience. Notice that tissue is now redundant because I've taken a bent toe or Alex Valgo's toe and now straightened it. For the extensor hoods, I generally take a Forger Bicrol and we'll re-approximate those as well. You could argue that that layer is not absolutely necessary, but I find it helpful. And now for the dorsal foot incisions, I'm going to take a series of monocryl. Make sure you have good hemostasis. The tourniquet, of course, is coming out. You can see the bleeding. You have to make sure the toes speak up. You can tell even in this case, the second toe has taken a little bit longer for the blood to go to the toe. You can sense it's already okay. When it's not, the move is though to warm the room. I often will bring the foot down just off the side of the bed because if it's dependent, it will help lot. You cannot leave the operating room unless it's pink and I've had cases where I have to take the pin out and if you take it out past the meditational finder joint that generally almost always lets it pink up because that's the feature that brings it down out to length and stretch to cause the problem. I'm doing these running nylon sutures for the dorsal foot incisions. For the PIP resections I do a monocle deep and then a horizontal matches monocle for the top that is nice because it doesn't have to come out. So you can see all the redundancy now the um first metatarsal head that will get better over time. I place these Stereotrips, sorry, not stereotrips, but zero form. I will place some stereo strips around the tip of the toes. A nice padded dressing because it's four foot on foot padding on the top of the bottom and wrapped with a series of cotton wrap in or whatever we call it here in ABDs. Here goes around the top and the bottom. I'm starting to wrap it. This visual will go into a splint for two weeks. In two weeks they'll come out of the splint and go into boot. I will not let them wait until six. As I mentioned before, the long k-wires will come out at four weeks generally and the short ones will come out at two weeks.