questions from the audience. First I don't know if there's anything through the app as well as a first pass. Any questions from the audience? Please Dr. DeLaw. As for Dr. Martin, what's your burr size and what do you use when you do your anterior impingement? So Jen and I'm using a 4-0 burr. You have a whole lot of options when you do that. Some burrs have a little more of a hood to them. Some of them have a retractable hood. I have not found those to be useful personally, the ones where you can retract the hood. There are situations, the advantage of the retractable hood is there are situations where you almost you need to use the tip of the burr and not the side of the burr and that's an advantage. So I've experimented with that. I think the key though is adequate joint distension so you're not under traction in that situation and visualization. I mean you need to see your burr the whole time as you're moving, you know, especially as you're getting up to the top of the osteophyte just because we know what's on the other side of that capsule right there. The capsule really goes up higher than you think and you can actually get above the osteophyte. There's room on the capsule and work down. Same thing on the tailor neck. You can go further down on that tailor neck than you think but I generally use a 4-0 burr. Just a second thing on that. So when you're looking at arthroscopic cannulas, there's a lot of small joint 2-7 cannulas. If you're doing a lot of bony work, you need some flow and I've just found that the 4-0 cannula is a lot more helpful maintaining visualization, especially using a 4-0 burr with suction. The 2-7 cannula just doesn't give you enough flow in my opinion for a lot of bony work. Great. Yeah, I mean the other thing I would add to that as well, not in the back but anteriorly, you know, there are some, depending upon who your industry provider is, there are some that are instead of spinning burrs, there are rasps that you can use where at least anteriorly to not spin up that anterior capsule, the ability to really kind of contour that without having to worry about what your flow is, turning suction on, sucking the capsule back down. I think that can be incredibly helpful anteriorly. Posteriorly, much different beast. Are you doing these with a C-arm in the room too? No. I actually am not now. In that case that I showed you with the anterior bony impingement, I actually did because I wanted to make sure, you know, obviously the athlete I'm dealing with and I wanted to make sure I got adequate resection. On the posterior ones, I don't. You can usually see all the way across and you just go from anterior medial to anterior lateral and make sure you've got it completely, you know, medial to lateral completely debrided and then you put it up in the dorsiflexion and you make sure that you've got that full range of motion. So generally no C-arm. In that case, I actually did take a intraoperative C-arm pick just to make sure I was good. Yeah, with these, I use a combination of some of the rasps that are available commercially and I have no industry relationships with anyone and some of the shavers. Some of these aggressive shaver bone cutter conversions allows you to actually utilize those as well and it avoids you also opening up four or five different devices and your rep is always high-fiving you when you leave the case because you just basically bought a small Mercedes-Benz for them. So be mindful of that. I have another question for Dr. Martin. Your approach with the combined anterior and posterior impingement patient, of which I have on my operative schedule on Thursday in a dancer. So what's your approach with that? I actually have a soccer girl on Thursday for both. I start prone. I'm gonna do posterior first in her and then I'll flip her over and do anterior. She's actually an interesting gal because she's ten months out from a pure ankle dislocation with no fracture. Went in and did repair of everything with internal bracing and she's still getting a lot of impingement symptoms, especially posterior. And so that's my primary. But prone first and then I'll flip them over and do supine second. Thank you. And then one last question for Dr. Dushman. Are you approaching any of your Jones fractures, those fifth metatarsal base fractures, with plating initially, like in the primary setting? Yeah, the primary setting I use plating pretty sparingly. I still prefer an intramedullary screw. The one situation that occasionally comes up in these very large athletes with big feet, depending on your implant, because if you're using the historical Jones screw, your thread length is one-third of the screw. If you're using some different screws, it'll just be like they'll have two or three threads. So if you're getting that fracture that's around 30 to 35 millimeters down and you're using an intramedullary screw, you may come up a little bit short on getting across the fracture and you never want to be in that situation. So that is a situation, and again it's kind of the big-footed athlete, where if you don't think you can get your threads across, I will do primary plantar plating. So I think there is a role. I agree the intramedullary screw is still my go-to on most primary Jones fractures, but I think you need to look at your athlete. I think there's a subset that has a higher refracture rate than others, and that subset, if you look at the results out of the NBA, and what is it so special about the NBA, it's that very huge foot with a little bit of metatarsus adductus, maybe a little bit of tilt to the foot, and you're asking a lot for the intramedullary screw because of the torsional strain on that plantar lateral side that Torg showed way back. And so I think there is a role for primary plating, and you're gonna see a little more primary plating being done in the literature. You're gonna see a couple of things coming out. The problem with primary plating right now in that same individual is we don't have a plate that fits that individual. The plates that we have are way too small, not long enough, and so I'm pushing some of the industry folks to come out with a better plate because you'll get in there and nothing is big enough for those individuals. The other situation I've had a couple times is where you really just don't have any intramedullary canal with that, you know, direct osteoblastic formation on that plantar lateral cortex. It totally burr beaks the intramedullary canal, and they have a little bit of various tilt to the metatarsal, and I think a plate is a better device there too. So I have primary plated a few. The other thing I want to bring up for the benefit of the audience with with the folks that are here, so obviously all the mechanical issues, the technical issues about these stress fractures, particularly fifth metatarsal, but what about your all's indications as to when you will jump to things like Forteo? Is that only in a bad revision? Are there any times will you do that primarily? You know, who are you involving? Because I have certainly had some of late that have required that from folks that have completely healed at three months on a CT scan, their fifth metatarsal, and then they refracture at six and seven months because they've fallen off the orthotic wagon. So talk about that. So I will very, very sparingly use Forteo, so teriparatide, and I'm at a university setting. I will always involve my endocrine colleagues. There's a pretty nasty black box warning with that. Fortunately, the post-market surveillance has been pretty low for osteosarcoma, not enough to take it off the market, but anytime you're talking about using a medication that can cause cancer, I think it's helpful to get someone involved that knows a lot about that medication. So again, at a university setting, it's easy for me. I involve my endocrine colleagues. Yeah, that's my approach. So we've had a few. All of them were elite athletes. One was a tibia. Well, was there a few? I've been involved in two. One was a tibia, and one was a Jones. And in both scenarios, we were fortunate to involve our metabolic bone division, and we allow them to drive the dosing. They drive the co-management. I mean, we're partners in it, but it's also one of those moments where it's like, hey, you know, I'm the humble foot and ankle surgeon. We use it a good bit, and we don't involve our endocrine colleagues. The black box warning, when you look at the post-surveillance, we've had over 20 years now, and there really hasn't been any direct osteosarcoma formation. And so I think the risk is very low. Obviously, you discuss it with the folks, but when you, you know, obviously our medical legal climate, as you guys know, in the sports world is changing, and so maybe we need to rethink that. But I think we're also in a climate where everybody is pushing. You know, we're just like everybody else. And so we use it probably in two, three, four times in a fall season on fracture work. I think the other consideration for the benefit of the audience is what is everyone's thoughts here as far as use of orthotics, how you're getting them, when you're providing them, because certainly, Steve, I'll have the folks that come in that have, you know, gotten two, three, four injections for impingement, and what they actually have is subfibular impingement because they have severe pes plano valgus. And so that's not a primary impingement as much as it is a secondary impingement just from the hind foot going into extreme valgus. So kind of help me understand what your thoughts are in working through that. So, you know, we're lucky, so I don't know that we can compare. But we have an orthodist that comes every Wednesday to our football team. Every foot gets 3D scanned. Every cleat is custom-sized to the individual, which we have found that is actually a good left-to-right size difference in a lot of the players. So it's position-sized. It's 3D scanned for foot and cleat measurement. We have an orthodist that comes every Wednesday, and so I can get an orthotic anytime I want on anybody. And so we're kind of the exception. So I have a very low threshold for, you know, footwear. I mean, that's what they live on. I mean, my soccer guys and gals, they live with their feet, and so anything you can do. And so this orthodist is good also with the orthotics in a soccer boot where they always wear a half-size small, so that's very difficult to do, and he's good at it. And so we use it a lot. I think that's an important perspective, so just remember that. I'm getting the sign from the back that we have now officially gone over our time, but hopefully this was of benefit to everyone in the audience. Certainly appreciate you hanging with us here at the end of the meeting, and wish everyone safe travels home. We can stick around for some questions after. Thank you very much. Thanks, everyone.

surgical techniques

4-0 burr

joint distension

arthroscopic cannulas

bony work