All right. Good morning, everyone. And welcome back to day three of the advanced course. Things are going well. I'd like to thank you for participating and taking this course. I'd also like to thank you for your patience as we adjust to a virtual platform and figure out our technical difficulties. But things are moving smoothly and we think we've fixed some glitches and we look forward to today's sessions. Again, a huge thanks to our faculty. It is now the weekend. And despite being at home, this is still time spent away from their friends and family on a Saturday. So thank you. Thank you, faculty. To the audience, please keep those questions coming. We'd like to make this to maximize audience participation today. And you don't need to get up and go to a microphone. You can just type in a question. We'd like you to interact with the case presentations if possible. We have room at the end of the session. So keep those questions coming up. This is going to be as interactive as possible. I'm going to hand it off to my co-chair. Thank you, Chris. Yes. Thank you, everybody. I want to remind everybody before we start this next session. Number one, we have the back room Zoom kind of faculty consultation room that is available. There's a link that you can tag on to and drop in. I will be in that room at some point this afternoon. And there were some questions last night from the last session that never really got addressed. So if anybody has those questions that they have and want to ask those in the room, we're more than happy to field those questions at that time. And then, of course, if you have any cases you want to share to ask the faculty about, you can go through that mechanism and that platform. Number two, I do want to thank and encourage everybody to visit the exhibitors. We do have six exhibitors that were kind enough to help with this course. I know it's always difficult in a virtual platform in terms of how to manage that. But there is an ability to visit those exhibitors through the platform. So please take time during this day's session to visit the exhibitors. They include one of our gold mission partners, Striker, one of our bronze mission partners, Paragon 28. And then Acumed, Curve Beam, DJO, and Mobius MD. So if you could please take the time. Without their support, we can't do this either. Industry plays a big role in how we take care of our patients and advancing our patients' care adequately. So please thank them for their sponsorship and visit their exhibitor booth. At this point in time, I'll turn over the mission or the platform to Becky Serato, Dr. Serato out of Baltimore. She can start this next session for us. Thanks, Pete. And thank you, Chris, for the invitation to both speak as well as moderate at today's session. So welcome, everybody, to day three. So our first symposium today, either afternoon or morning for some of you guys, is going to be on hindfoot and midfoot trauma. The fix is on. And so as you guys know, this is a really important topic, often covered in many of our meetings that we have, because particularly with hindfoot and midfoot, they can be really challenging. You do not have to be at a level one center to be tackling these. Most of us foot and ankle orthopedic surgeons will get referred many of these difficult injuries just to our clinics. So I am always looking for pearls, techniques, ways to avoid problems. And we've got two great faculty to give us some pearls and wisdom on some really challenging trauma cases. Our first one, which I will introduce, is Dr. John Kwan, who is coming from Boston. And he's going to be speaking right now on calcaneus fractures, sinus Tarsi and minimally invasive approaches on. Thanks, Becky. Thanks, Christian. And Pete, for inviting me to speak. Let me go ahead and share my screen here. OK, so I'm going to be talking about sinus Tarsi and less invasive ways to fix calcaneus fractures. These are my disclosures. I do have a specific disclosure where I was involved in designing a calcaneal fracture plating system. But this talk is free of any bias. It's actually not about plates and screws at all. So we know calcaneus fractures are high energy injuries that really have a high impact on the life of our patients. And we certainly know that when we treat these surgically, there's high complication rates, whether it's infection or dehiscence or the development of post-traumatic arthritis. Now, throughout the history of calcaneus fractures, there's really multiple debates. And we still are debating these today, whether we should even be performing surgery, timing of surgery and what may be the most optimal approach. And I'll touch on some of these things during this talk. So we do know that the sinus Tarsi approach and more percutaneous approaches have lower complication rates. And if we're able to achieve anatomic reductions, which literature states that we are much better at, we do get equivalent functional outcomes. And now, obviously, smaller incisions are safer, but they definitely are more technically demanding, given the fact that we see less of the fracture and many of our reductions are indirect as opposed to directly being able to move the fragments. And, you know, philosophically, I think we really should think about whether these smaller, safer incisions should be treating, should be changing our traditional contraindications for surgery. And so, you know, in the past, if patients had bad diabetes or peripheral vascular disease or tobacco, we may have not treated them surgically where maybe we should be thinking about doing so with safer incisions. So the extensile lateral approach is really been in the workforce for a very long time. It's an excellent approach for getting exposure and for direct fracture reduction. But we know that it has a high wound complication rate, over 30 percent in the literature. And now certainly this is multifactorial. But, you know, one of my thoughts is that it may be related to our surgical technique and mainly incision placement. So there have been multiple studies and Dr. Daniels yesterday taught us a lot about angiosomes, but there are many studies looking at the lateral hind foot angiosome. And we know that the lateral calcaneal artery is mainly responsible for perfusion of that area. And, you know, unfortunately, I think that the traditional teaching is still being propagated. If you're using an extensile approach, placing that vertical limb halfway between the Achilles and the fibula. And Joe Borelli and other people have done very elegant dye injection studies that have shown that that incision placement will likely violate the lateral calcaneal artery and may be contributing to some of the wound problems that we've historically seen. This is interesting. So this is from Roy Sanders' current concepts review in 2000. So 21 years ago. And he had shown a picture of a Selecson's approach, which, as you can see, the vertical limb was far more posterior than the traditional distance between the fibula and the Achilles. Now, Selecson and Gould's approach predated most of those vascular studies. But I think early on, people recognized that it may be safer to bring that vertical limb more posterior. And we did a cadaveric study. You can see that the dotted blue line is the Selecson approach, where the dotted red line is the more traditional incision. And even moving that vertical limb about one centimeter posterior really protected you from getting into the lateral calcaneal artery, much less as well as the sore nerve. Now, so what if you have a patient that presents two weeks late, three weeks late, maybe even a month late? How do you know which incision to use? And I think one of the things that can be daunting, especially when first starting to learn the sinus tarsy approaches, is what happens if the fracture doesn't move and you can't get your reduction. And so this is a very simple technique that you can do where you make a small keyhole and you can place a freer or a right angle clamp or anything under the poster facet to see if you can reduce the fracture. So the patient on the top row was about three weeks out and you can see that that poster facet is not moving. So I had concerns whether I could treat this through a sinus tarsy approach. So they get an extensile lateral approach. The patient on the bottom row also three weeks out. But you can see that I can get some movement of that posterior facet. And if I see that, I know I can correct that deformity as well, as well as the associated deformities through a sinus tarsy approach. Now, what about timing of surgery? So this is a patient I took care of earlier in my practice. And you can see my reduction. I was pretty happy with how this came out. But we were both certainly unhappy when the patient came back and he required multiple surgeries thereafter, unfortunately. And if you look at the literature, you know, timing of surgery, there's some conflicting data. So a BD and others had said if you operate too early, you get complications. Tenet and Kosky said if you operate too late, you get complications. And Folk and others did not find any correlation with time to surgery with wound complications. Although some of these other studies were underpowered. And so, you know, with all due respect to Roy Sanders, who's been a pioneer in this area, the wrinkle sign hasn't scientifically been correlated with decreased wound outcomes. So we did a multi center study in Boston with Mark Meyerson's group with the Ortho Carolina guys. And we did look at about 500 calcaneus fractures. And this is probably the money slide. So if you look at the X axis, the X axis is time to surgery. The Y axis is wound complications. And the dark blue is the extensile lateral approach. And what we found in, you know, very experienced surgeons, good surgeons, that there was probably no real safe time to do the extensile lateral approach. And I do think the complications are inherent to that approach. But interestingly, if you did the sinus Tarsi approach early, the complications were far lower than if you waited. Another thing that was interesting was, and this was contradictory to the literature, was that our senior surgeons had more wound complications than the junior surgeons. And we did a multivariate look at this. And the only difference was their predilection for the extensile lateral approach. And so our senior surgeons, which were very experienced trauma and foot and ankle surgeons at these institutions, had higher wound complications because of this fact. So in the OR, this is how I like to set up the patient, the patient's lateral decubitus. And I actually use two C arms. So I bring the large C arm in from one side and I angulate it so I have a perfect lateral and have my tech lock the coordinates there. And then I have a mini C arm turned sideways. And that allows me to go back and forth between my lateral, my Harris heel view and a Broden's view as well, very quickly without changing the position of the C arm. Another thing that's actually helpful is if you very slightly over rotate the patient. So you can see this is Max Michalski, our fellow who's now a staff at Cedars-Sinai. And if the patient is slightly over rotated, you can see that the C arm is not in your face. So you're able to perform fluoroscopy while you're instrumenting the foot without risk of contaminating the C arm. The mini C arm, I think, is helpful because it allows you to get that Harris heel view easily. I like to operate on a regular table and it can be difficult with the C arm hitting the bottom of the table and then having to take it off that lateral view to get a Harris heel view. So this allows us to move between our views pretty quickly. I do like to get contralateral views. And so, as we all know, looking at a lot of foot x-rays, there's a lot of different morphology of the calcaneus, in particular, the posterior facet. But fortunately, many population studies have shown that there are side to side equivalents in regards to Bowler's angle and whatnot. So I do think that this is helpful. And what Kent Ellington and I were able to show was that the operative time was less if you had a contralateral template. Now, we'll talk a little bit about heel varus. I think that heel varus is one of the toughest deformities to correct. It's tough to correct. Technically, it's tough to look at in the OR. And I think it's also tough to understand what you're looking at. And so keep in mind that the Harris heel view was really a view developed to assess talocalcaneal coalitions before the advent of CT and MRI. And it's really not a true axial view because it's taken at a tangent. And so because it's tangential, it can actually make your deformity look worse than it actually is. And so we developed this view that we put in the literature recently, which is basically more of a axial perpendicular axial view of the calcaneus. It's an AP view of the foot, but essentially an AP of the calcaneus. And I found this to be helpful, just like any other radiographic view. You have to kind of use it and get used to looking at it both both before you deformity correction and afterwards. But I think it may be helpful to try this out and helpful to assess various deformity. This is a 47 year old, and I apologize. I don't have her preoperative X-ray and CT scan, but she looks to have really a minimally displaced calcaneus fracture. You can see we're marking out our sinus Tarsier approach. And when the perineal tendons are dislocated, I like to ride that incision up posteriorly to allow me to repair the superior perineal retinaculum. Now, one of the things that that I could appreciate is I had the preoperative CT, but you can't is that this patient has had significant sustentacular displacement. So even though the bowler's angle doesn't look so bad, if you look at some of those cortical lines, they just don't match up. So there's there's irregularities and that sustentacular displacement. So we perform our sinus tarsier approach and what you can see is with my freer I'm elevating up the sustentaculum and then you can see that dramatic improvement in the contour of the calcaneus but on the image on the right you can also see that one of those cortical lines now matches up. Now our posterior facet is still depressed and on the top right this is classically what we see where that primary fracture line goes just posterior to the angle of gasoline and what we see in the OR is in the bottom right. You see the angle of gasoline and you see that the press posterior facet and then once we elevate that fragment up now the lines that were broken on our initial fluoroscopy now make sense and the calcaneus is anatomic. Now a point about heel varus again you know the primary fracture line separates the calcaneus from into two pieces essentially the front and the back so we really need to be comparing the tuber to the anterior portion of the calcaneus and that's why the Harris heel view can be difficult because it's hard to see the front of the calcaneus. Keep in mind that there are anatomic features such as a lateral process a prominent perineal tubercle which can even more so make the heel look like in varus when it may not be. So there's various techniques described for this of course you can always place a chance pin as as we're doing here into the tuber and you can see I'm using my right hand thumb as a fulcrum and I'm taking it out of varus while my resident places some pins in here. Now I've tried various things you can you can use an osteotome now an osteotome doesn't allow you to translate the tuber posteriorly if you need to but it does give you a broad surface to really lever the calcaneus over. Another thing that you can do is obviously use your plate and I've gone certainly more towards correcting all the deformities before I place any fixation whereas the way I was brought up was to really rely on the plate at the end of the case to pull it out of varus and the ability of the plate to do that really depends on the order of your screws and so you can see here that if I've placed some screws more in the central portion of the plate before working posteriorly I probably would not be able to correct some of this varus and of course you always see can look at it make sure that you're in some valgus. Now one thing that that took me years to figure out and and I'm sure other people have figured it out before me but it is how can my calcaneus look short and in varus on my heel view but look out to length on my lateral and so this is something that's always confused me a bit and I think the explanation is this so that's a calcaneus on top uh that's varus and short and the the bottom bars are one that's anatomic and it's based on your fluoroscopy and your fluoroscopy hits that cortex and so it can give the appearance of being out to length on the lateral but you really have to look at your Harris heel view to assess your axial alignment and or the captain's view. In terms of a lot of these sinus torsi plates slide under that soft tissue envelope and one technique is to make sure that you're feeling your elevator underneath your thumb so I want to make sure I'm feeling my elevator if you're not sure you can even get a view to demonstrate that you're not intramedullary. I think for those of us who've done enough of these we've all slid that plate inside the bone and that can be really frustrating when you're you know finishing up the case and maybe putting some final screws in and you and you don't see your plate so this is you know I learned the hard way this is a case I was doing we have some pretty good reduction and I've gotten my screws in and when I went to percutaneously place the final screws I was looking at bone so because I like my reduction and my alignment I decided to just take a ranger and nibble off some bone and put a screw in and this is what that post-op CT scan looks like but but obviously I should have checked it beforehand. Now what about elevate before fixing again you know correcting all deformities before you start placing fixation but but elevating the tissues off that lateral wall is not atraumatic especially if the patient is a couple weeks out it can take a lot of effort and you can lose your reduction a bit if you've already started to fixate your reduction and then do that so you can see at the end of this case this is all one case that I've lost a little bit of reduction here but I think acceptable. Another thing the sinus tarsy plates sometimes it can be tough to get your screws in especially more central or posterior so so stop fighting your perineals and make a retro perineal interval you do not have to detach the superior perineal retinaculum to do this you can just simply dissect posterior to the perineals and you can really get up all the way around the the top of the calcaneus if you need to by doing this you can see the images on the right you can really get to the top of the posterior facet. Laminar spreaders I think laminar spreaders are really helpful you can see the image on the top that tuber is not only short but it's elevated and in most cases especially if you're operating acutely simply reducing the height of the posterior facet should drive your tuber back and down but once the patient has started to consolidate it may not so you can place a laminar spreader in you can k-wire it in place and that gives you room to elevate up your posterior facet and do the rest of your surgery. This is my technique for for open calcaneus fractures which we know tend to be open medially and so what I'll do is make a small sinus tarsie approach and place a laminar spreader in from the lateral side of course and then that will help me get the tuber down you can rotate your hand to get it get it out of varus and that's extra capsular I know it looks like I'm creating some iatros on the on the cartilage but that's outside the joint and then you go ahead and then you go ahead and put a pin in we perform our IND and this allows them to sit for about a week or two before you can perform their definitive fixation. K-wires this is one we did recently he was a one pack per day smoker so we decided to use the Essex Lopresti technique and do it all percutaneously and sometimes this can be hard to hold in place and if I don't have to I don't like to put a pin through the posterior facet into the underside of the talus so I think I showed this before but this is a neat way to put a K-wire in to hold your reduction. So a couple cases this is a 40-year-old triathlete with really a minimally displaced calcaneus fracture and you know I think this is this illustrates that we need to have more than an extensile approach in our armamentarium. So this patient had an arthroscopically assisted RAF that's Bonnie who's finishing her uh fellowship with Becky in Mercy and and Phil Kaiser at MGH and basically you put the scope right at the angle of gasoline and that allows you and you can do this with a dry scope that allows you to look up the posterior facet and you can see of course looking through the arthroscope that that displacement is much more than uh what's visualized on the CAT scan. Once we get it reduced you can see I'm having trouble even looking across the posterior facet now and you can do this all through a pretty small incision if you're aided by the arthroscope. Now same case so something that I was doing during this case that triggered a thought you can see that K-wire and even though it looks like it's in the bone we know that that's probably not and then I started to really appreciate this medial cortex and this is something that I I didn't see for years but was certainly seeing me and I think that we have to understand that our axial views may not really fully illustrate where the medial cortex is because the sustentaculum juts out and so this is important to know so this is a cadaver and I think we've all had screws for osteotomies or whatever we've done that that are in this position but once you appreciate that medial cortex you can appreciate that that screw may not be in a in a good position anatomically. So this is an interesting case this was sent from Florida and you can see that that axial alignment looks really pretty good but once you're looking at that medial cortex you can get an appreciation that things maybe aren't so good here and so I tried to take those screws out and they were all stripped and cold welded and so this patient was having mainly medial pain and so unfortunately I had to do a big medial approach and to burn the head to those screws off to give her some pain relief. A 48 year old had bilateral calps this case is just illustrating that medial cortex but also the captain's view so now that we're starting to look at that medial cortex we get an appreciation that that screw may not be as good as we think the screw on the medial side you can confirm it through a Harris heel view and we reposition that and things look pretty good. This is a 24 year old she was high smoking marijuana in a tree and high in a tree and taking selfies right before she fell and she has this fracture dislocation with lateral ligament disruption and this was sent to me six weeks after her injury like this and so you will look at this and I think many people will say this this has to have an extensile approach you can't do this through a sinus tarsy approach but one thing to consider is that this is this fracture is essentially in two main pieces and so once you get comfortable doing the sinus tarsy approach I think you can get comfortable doing it supine and so supine allows you to approach the medial side of the ankle safely and then to get a reduction clamp to get your reduction. Now she had a extensile approach on the lateral side because of the need for the lateral ligament repair but what you can see is being able to approach it both medial and laterally allows us to get a not perfect but reasonable reduction and we repaired her lateral ligaments. This is a similar case this is a 48 year old had a fall in Greece and presented me six weeks after his injury and it was a little bit unclear exactly what was done but it looks like they thought he had a ligament injury and repaired a ligament but realized he had a calcaneus fracture intraoperatively because this CT scan was performed on the afternoon of his surgery and he was sent to me six weeks after but again you can appreciate two pieces so put them supine do a combined medial and lateral approach get this clamped and you will need a periarticular reduction clamp but then you can avoid a extensile approach. The final case you know Sanders two A's and B's because you're dealing with two pieces is are the ones to learn to do the sinus tarsy approach but what about threes and fours and so you can see we're in the lateral decubitus position laminar spreader helps me get that tuber down and back and then it's a matter of simply elevating each fragment up to the sustentaculum and this is where Roy Sanders and others advocate these uh bioabsorbable pins that you can cut off and which we don't have approved at our institution so I happen to have a very good resident that day that was able to to nail each of these pieces once we got them elevated up and so we have the lateral posterior facet elevated but you still see some gaposis there and that gaposis is varus right so that heals in varus but once we correct that you can see that closes down and then we go ahead and plate it and we have a not perfect but pretty good reduction so I think in summary you know consider sinus tarsy approaches for all calcaneus fractures operate early if you're going to do minimally invasive approaches it's safer and easier um I think if we can avoid complications all patients benefit from realignment of their calcaneus and um and keep in mind that you know if that patient ends up with a real bad malunion or early post-traumatic arthrosis that's a complication of non-operative management which you have chosen potentially for that patient so it behooves all of us to learn minimally invasive approaches thank you thank you john fantastic talk um we got one um actually two let me see so the first question you kind of answered in some of those cases that you um had um illustrated at the end but the first question is is um what what are the role for medial approaches to the calcaneus so you noted that there were two large fragments are there any other times where you will um pre-operatively know that you're going to need to make that medial incision as well yeah so I look at the sustentaculum carefully you know um it's it's not as constant as we think it is and sometimes it's really widely displaced and when it's widely displaced um I worry about my reduction of the poster facet I've even had patients who have necrosed their skin on the medial side because it was not addressed so I do look carefully at that and if I do see something that I think needs direct reduction I'll play some supine and do a medial and lateral approach it's a curvilinear incision on the back of the heel and you can elevate everything away from you and then you can see that that area of deformity so yeah a follow-up question to that is where do you um where do you make your medial approach to the calcaneum and in in those details which you sort of illustrated right there yeah so it's it's a curvilinear incision on the poster medial heel um what that allows you to do is stay back from the neurovascular bundle but then as you elevate up that medial cortex to bring everything away from you so you know Bordeaux originally described this in the 1980s and what he had talked about which is true is you can't see the articular surface and so really what you're seeing on the medial side is you're seeing that big spike which you can address and indirectly reduce that part of the of the joint perfect and we'll do one more question before we move on what's the role in your practice for a primary subtalar fusion yeah that's that's a great question so um you know um so so Buckley um uh did a level one study and it was it was smaller numbers about 15 in each group but he surprisingly showed that for the Sanders threes and fours that that there wasn't necessarily a benefit to primary subtalar fusion um so I was doing more and I trended away from that um I think it's really a case by case basis in terms of how bad the joint is what the patient does what their expectations are self-efficacy all all these things but but I certainly think about it when I see a a bad fracture great thank you John all right so now we're going to move on to another not so easy problem our Liz Frank injury and we're going to have Dr. Christopher Kiyoto also from Boston to help us with this and he's going to speak on Sir Liz Frank still haunts us. Chris? Hi Chris, sorry your microphone is on mute. Sorry to interrupt you. Great, okay. Thank you for that. John, thank you. I want to commend you on not calling it the Kwan view, but the Captain's view. And I also want to tell the audience that probably at least in the last six months, twice now, we've, we'll say to the fellow, find out what Kwan would do with this one for calc fractures. I'm going to move a little bit distally into the foot and talk about Lisfranc injuries. I have no pertinent disclosures. Lisfranc was in the 18th century, 1790 to 1847, he was a French surgeon. Napoleon's army was the first to use stirrups. And so when they were thrown from their horses, their foot remained in the stirrup and he actually did a lot of amputations through the Lisfranc articulation. Interestingly, he trained under Dupuytren. As we all know, and Becky made a great point when she said that, you know, these cases will find us, you know, the high energy pylons are coming through the trauma centers. A lot of these injuries get packaged at urgent care centers or ERs and they come find you. And often it's, it's two weeks out. And I think that a great point there is to make sure that your, your schedulers know that midfoot injuries need to come in soon and any trauma needs to come in soon. But they're really a heterogeneous group ranging from injuries that are possibly missed, as you see on the left, to these higher energy injuries. And your goal, as John pointed out, was it's one is a safe anatomic reduction, minimizing post-traumatic arthritis. So I know this is the advanced course, but some basics and we'll, we'll fly over these, but you have direct and indirect injuries. Again, Lisfranc injuries, especially the lower energy injuries are often missed. The more direct injuries entail a crushing force with comminution, soft tissue damage, and compartment syndrome. Your indirect is more common with twisting or an axial load or a combination of the two. Your soft tissue injuries are less severe and they're often missed. So you have to watch out for it. Now, the Lisfranc articulation is, is really quite stable due to both bony anatomy and ligamentous constraints. And so really when we say it's a low energy injury, it's actually more of a higher higher energy injury than you think, because the foot is serving as a lever and a moment arm. And so you can see that Lisfranc ligament, which is intraosseous, uh, between the second metatarsal and cuneiform. But also you can see that keystone, that trapezoidal keystone shape of the second metatarsal base and cuneiform, which really makes it, uh, quite stable. So these quote-unquote lower energy injuries may be, um, higher, more higher energy than we think. In terms of the diagnosis, any midfoot tenderness on physical exam is really important to me. This person, if they don't have any displacement on their x-rays, they're coming back to see me probably more than once in the first, uh, four to six weeks. And they may very well be getting advanced damaging, either an MRI or now with weight-bearing CT. So any midfoot tenderness, is a red herring. And if you have plantar ecchymosis, um, then you certainly have, uh, bleeding and Lisfranc injury, and you want to watch carefully and make sure that you don't have anything that's displacing. Um, in terms of imaging, uh, weight-bearing imaging is essential. As you can see in this subtle, uh, Lisfranc injury that we see here, um, you want to make sure you don't miss this. And your toolbox for questionable cases, serial exams, uh, both, um, clinical exams and radiographic exams. It's so easy to say, come back and see me next week or come back in five days. Um, one, one, uh, very useful tool are comparison films. And I'm going to say, John made that point. I've learned that from him, uh, in terms of ankle fractures, calcaneus fractures, we're always getting comparison films, uh, both to detect injury, but also for intraoperative guidance. Um, CT scan, I find that more helpful than MRI. Um, and now that we have weight-bearing CT scans, uh, I think that we should be getting, uh, weight-bearing CT scans on any questionable Lisfranc injury, especially if you can get both feet, uh, involved in the imaging. So if you don't have a weight-bearing CT scanner, I would, I would think about getting one, but I'm sure there's one in your city. So if you have any concern, tend to patient for a weight-bearing CT, ideally, uh, with both feet in the gantry. And then, uh, finally stress views under anesthesia are not unreasonable. I, um, had a patient just a few weeks ago that I'll show you that we took to the OR because I even thought the weight-bearing CT scan was questionable. Uh, this is a patient, you can see displacement here. Um, and this actually, this is a patient actually came in and was seen at our hospital, uh, x-rays were fine. And they came back and saw me a few weeks later and they had displaced with walking. Uh, here's another patient. You can see how subtle it is. And you can see the step off on the CT scan. And this patient goes to the OR in my hands. I'm sorry, this is that patient was seen, uh, in my institution. Um, they had x-rays that were non-weight-bearing, told they were fine. And then they came back a few weeks later with persistent pain and he had displaced. Uh, Jim Nunley did a nice study, uh, showing that 50% of patients with diastasis had non-weight-bearing x-rays, which were normal. So you have to get weight-bearing x-rays in this group, suggested doing it under an ankle block, which are superior to stress for you. I think now with weight-bearing CT scans, uh, that's different. And here's another case of some perhaps subtle widening that you see, including perhaps between the cuneiforms. And here you can see a step off at the CT. This is, this is a case actually, um, this is a patient I mentioned, uh, just a few moments ago. This is someone who I thought was, was more wide on the right side, uh, sent them for a CT scan and the weight-bearing CT scan, I still thought this patient is unstable. Um, but I still wasn't sure. So even despite a CT scan, we took him to the OR for stress fluoroscopy. The patient is consented for RAF versus stress fluoroscopy. And no matter what we did, we couldn't open him up. And so he did not get, uh, surgery and just saw him last week and he's feeling much better. But the point there is, even if you have a question on weight-bearing CTs, don't hesitate to go to the OR and just do a quick, um, exam under anesthesia. Okay. Looking at, uh, PERL surgical strategy, strategies, and some controversy. So, um, as my mentors said, good outcomes are associated with good reduction and nerves. Uh, Mark did a study, uh, when he was younger with Gonzora and other colleagues, I think Burgess was on that study and said, you know, no surprise, the better your reduction is the better your outcome. And then Lou would say, yeah, that that's absolutely true, but don't forget the nerves because as you approach these injuries, especially in our younger patients, um, the chance of a symptomatic neuroma is higher. And I think that we cut nerves on in older patients and often they're not symptomatic. I think there's some degree of neuropathy that a lot of older patients have, but in these younger patients, a, uh, a neuroma, an SPN or DPN neuroma is, has a higher chance of being more symptomatic. And so, um, you really want to watch the nerves. And here's my standard. Um, I do like an open approach that is an extensile approach. Um, I do like to use a reduction clamps and I do put a, I will often put a screw across the first TMT joint. We'll talk about that in a bit. Um, but I, I do like to open this up. I'll show you a slide a little bit later on about percutaneous, uh, reduction, but I, I like to see that, um, base of the second metatarsal reduced into its mortise. And I think that just clamping it down, I think often there's a rotational component to these injuries. You can feel a little bump, uh, or prominence on the top of the foot and just squeezing that down without rotating it back down into its mortise is not sufficient. So this is my go-to and there you can just open that if you need to do more, that's an extensile approach and you can just, uh, do more to whatever bones need it. So that's my standard. And these are some x-rays, uh, with a nice solid fully threaded screw. Uh, and this will be done in my hands for the most part through an open reduction. Okay. Let's talk about the, the medial column, and this is more directed at not missing subtle injuries like we saw in some of the earlier x-rays. So at the first TMT joint, slight varus is normal. Metatarsus premus abductus. You want to have some slight varus and beware the straight medial column. So if you have a straight medial column, as you're seeing right here, um, this is usually associated with the, or is associated with the, uh, diastasis here. And what's happening is because of the transverse metatarsal ligament, the first is traveling in a kind of homogenous type, um, pattern over with the second. So if someone comes in with midfoot tenderness, um, I'll be looking at that medial column and be aware of that straight medial column, get some comparison views. Uh, as you can see here, and this is the injured side and left, this is not quite as much varus, metatarsus premus varus as we see here. So be aware of that straight medial column. Uh, and usually that'll tell you that you've got a Lisfranc here, and this is not so subtle, uh, but you can see that first metatarsal traveling laterally. And this is just a typical weight bearing C or typical CT scan that you can see the fact that, Hey, you know what? The base of the first of the second is still lining up with the cuneiform. The first is traveling with the more distal, um, fracture fragment. And this is telling here. So you have some incongruency at the first TMT joint. So you want to watch out for that. These are just some other cases. Again, looking now at the medial column, look at the incongruence more subtle here, but more obvious on CT scan, looking at the incongruence of the first TMT joint. And here you can reduce it. You can determine your incision just with a needle under thoracoscopy and I'll put that screw. And here we are making sure we bring that second over and reduce it into its mortise. Think about the second TMT joint sitting into a mortise in the axial plane. Just like we talk about a mortise with the ankle, we'll have a mortise in the second TMT joint as it sits in that recessed cuneiform. Okay. Let's move to the lateral column. Um, you want to get it out to length and these are for higher energy injuries where you can have either dislocation or compression of the lateral column. And so this was not appreciated in this case. Um, that, uh, was probably treated nonoperatively, but that cuneiform, that cuboid is, is impacted and crushed. And so the lateral column is not out to length and it makes for a very challenging correction down the road. So we'll often start medially with our reduction, but you can start lateral if need be. And your medial reduction may be inhibited by cuboid impaction or lateral dislocations as we see in that x-ray. And in that case, you want to reconstruct the lateral column first, either by either by reducing it, um, or by using bone graft and that you need to make an open incision over there. And I'll make a second incision for that in addition to that more medial extensile incision that's centered over the first TMT joint. And here's a case where we, we had to pry up the articular surface of cuboid and pack graft. And we had an external fixer on this. Uh, and you can see our other more dorsal incision. So, um, don't forget the lateral column, uh, and channeling Lou Schon on this, this, uh, photograph. Where's the nerve, right? Where's the sural nerve? And if you don't see it, um, hopefully it's crossing approximately, but in a case like this, Lou would want to see the nerve dissected out a little bit more proximally. And, um, it's really a critical point. Mind the nerves, especially in younger patients, the symptomatic neuromas can be just as painful, um, and as much of a problem as an improper, improper reduction. So here you go. Uh, here's a case that, you know, you just can't even see the most lateral aspect of the cuboid. Um, and here now we've bone grafted that and we've propped it up. This was the case I showed you before. Um, here's another case, and this was more just a dislocation on the cuboid. And so we did our standard medial reduction, um, with screws. You can certainly use plates, we'll come to that, but we put some wires and we reduced that lateral column. And this is a more substantial injury, um, that required a plate on the lateral side. Okay. So let's talk about plates. I've shown you screws and I, I still will use screws, uh, primarily. Um, but the indications for plates are, uh, comminution, uh, impaction. It's fine to use it for everyone because you're not putting a screw across the joint. Um, and I, I think that maybe I should be using plates more commonly, but, um, maybe everyone, you have spanning fixation, you don't violate that joint and you avoid articular compression. So if you do use screws, uh, you know, the cartilage doesn't want to be compressed. So you can use a screw, um, but don't compress the joint. And in that vein, you can use a fully threaded screw, as you see in the case where I used both plates and screws. Um, here's a study, uh, showing that screws and plates showed similar ability to reduce the first and second TMT joints after TMT. And let's frankly admit transsection. So biomechanically, uh, they're fine. Um, here's a very common injury, uh, that I used a plate for the second, and that's not a primary fusion. I still thought that that joint had a chance, um, putting a screw across the first and a right or across the third. Um, here's a plate that I used to reduce the second. In this case, I found some instability between the cuneiforms. So I'll put a screw off and, uh, we'll put two screws there, but I think one screw's enough. Um, finally, here's just another case, uh, using plates for the second and third. And I, I'd say not a great reduction, uh, there. And I think that you still have some, uh, space between the, uh, cuneiform. So I wouldn't give that one an A. Um, this is Mike Wilson, uh, one of my mentors, um, one of John's mentors, uh, from the, the Brigham. And he loved what he called a ladder plate. And as you put plates along that medial column, you can really reduce, uh, the second and sometimes even the third metatarsals over. You just have to be careful. You still have a bit of a straight medial column, so you may want to incorporate a bend for it. You have to watch, uh, for the anterior tibial tendon, but it's a very powerful construct. Uh, he wrote this up, um, and here you can see a very long medial plate, but a very nice reduction. Again, a very powerful tool. You have to watch the anterior tibial tendons and its insertion. And here's some other cases with what we would call the ladder plate, uh, technique. Now, what about transarticular screws? You've probably seen me use this screw. It's on the, the head of it's on the medial side. Um, I'm sorry, on the lateral side of the first metatarsal. And I'm using that to kind of push the first metatarsal over back into varus. So often I'll, I'll put one of these screws in using the head of that screw laterally to push that first metatarsal over immediately. I think it's a useful technique. Uh, my, if, uh, to my colleagues who like plates, you'd say, well, you've got a screw across the joint. Uh, but some studies have looked at that. Um, a study by, uh, Vinod's group, um, looked, and this is a screw in the Lisfranc articulation. Um, and it only compromised 2% of the Lisfranc ligament. And then other studies have shown that in terms of transarticular screws, it's four to 5% of the surface area of the joint. I don't think that's necessarily a problem. Um, but that would be an argument against the screws and instead of an argument for plates. But if you say what's the surface area, what percentage of the joint is being compromised by that screw? It's, it's four to 5%. So it's, it's not much, we don't know if it's significant. What about primary fusion? Um, what are the indications? Well, for advanced, uh, comminution, and, uh, there've been studies showing that for purely ligamentous injury as well. Um, this is a case of a neuropathic, uh, Lisfranc, uh, Lisfranc fixed with, uh, plates. Um, here's, uh, another patient that we, uh, fixed with, um, the old compression staples and screws. Um, certainly in more, uh, complex, higher energy injuries, uh, you're going to opt towards primary fusion. Again, if there's any, uh, advanced comminution, this is, uh, Chris's, Dr. Kotsia's study, uh, a very, uh, high level RCT published in JBGS. And they said that the folks who had a primary fusion did much better in return, uh, of function. Uh, my one caveat is that the screws in the screw group in terms of screws versus plate, the screws weren't routinely removed unless they caused symptoms. And I think that perhaps we had a bit of a handicapping the control with that group because those screws are across the joint. They were left in place. And I think that that could have handicapped the control group in this study. Um, and then a subsequent study out of Michigan said, uh, there's no difference in terms of outcomes except for planned returns to the OR to remove the hardware. Uh, now another study has come out that I don't have it, uh, in here, but there was a study out of the military that did show back to, uh, Chris Kotsia's, um, argument that primary fusions do better. Um, they did a study in the military and the, uh, uh, folks who had primary fusions, uh, got back to duty earlier and more reliably than the patients who had RAF. So I don't think this debate, uh, is over about primary fusion versus RAF. I think that there's sound evidence on both sides. I'm going to just in the interest of time, um, with this talk was supposed to cover a bit about midfoot fusions. Uh, so I'm just going to talk to you a bit about a midfoot fusion and not necessarily in the setting of trauma, but in the setting of midfoot arthritis. Um, your goal is to, to create a fracture environment. Uh, just remember that capsule release is essential. Yesterday, I tried to, um, highlight the difference between approach and exposure, and they're not the same thing. So once you see the joint, don't start working on it. You want to get the far capsule, the far periosteum and make sure you release that. Then you can distract the joint. Then you can start to do your work. So once you see the joint, don't start working, keep up with your exposure, releasing those structures, low speed burr under irrigation versus flexible chisels. I think both are fine. Just remember, you're a biologist, and if you're using a burr, you really want to irrigate. And then, as I said, yeah, uh, two days ago, I love a small drill, not a K wire. K wire is going to impact the bone as it goes in. A drill will have flutes and it actually serves as bone graft. It's not going to impact the bone in the tunnel. And we do that to, again, create a fracture environment. And we want bleeding, you know, fusions love clot. As one of my basic science colleagues said, fusions love clots. And so if you're doing a fusion, you know, you may have done your joint prep either with chisels or burrs or fish scaling, but take out your drill and drill it because you want to have some intraosteous bleeding, um, and you'll love clot. So here are your chisels. These are not osteotomes. A chisel has a, a single bevel. Um, there's no thermal injury, but you take away a bit more bone, uh, especially with curved and, and, uh, saddle-shaped joints. So advantages, disadvantages. Well, a burr is a great, and you can golf ball it. That's sorry, this is not a midfoot. It's an ankle, obviously, but you can see the golf ball that we're doing this rather extensile fusion, better preservation of your contour and your joint congruency. You less likely to have that gap. Um, but there could be thermal injury and are you creating a fracture environment? So if I use a burr, I'll then come back and fish scale with the chisel and drill. So I just really want to get that environment. And here you go. There's the capsule point made makes you look at the difference between the left here and now here. And we've really got that distracted and where you're doing midfoot fusion, don't forget to appreciate the depth of the joint. You really wanna get in here like you see in the top right with the lamb spread. And this is my case. You can see that I prepared the dorsal two thirds, but I didn't prepare the bottom third. So don't disregard the depth of the joint. Wedges, Chris in his JBJ's article talked about wedge resection. You can read about that. I don't find that I need it as much, but it allows you to have correction in more than one plane. And then, when I did a fair amount of work with Dr. Jupiter as a resident, and he always talked about bone graft for fractures, and he was actually doing some calc fractures back at the time. So I have a low impact, a low threshold for bone graft. Allograft is certainly fine, but iliac crest graft is much better than tibial graft. Okay, back to Lisfranc injuries. Anything else? CT scan for preoperative planning and getting to know the nature and the personality of your fracture? Yes, yes, yes. I think that John has made that clear in some of his research, but I'll often get, or just about always get CT scans on my patients who are undergoing Lisfranc injuries. Here you can see this is a patient who came in an unfortunate, I think she was 18 and she was hit by a car. It was a hit and run. They left, she was jogging. And the CT scan, I thought maybe we would do an ORIF, by x-rays we do an ORIF. She needed an ankle fracture as well. But on CT scan and you can't see it as well, but it was very common and she needed a primary fusion of the first and second TMT joints. And the CT scan gave us clues of that. So she was certainly consented for a primary fusion. So yes, CT scan on just about everyone. Place your incision strategically and make them extensile. Again, I think it's fascinating on the calcaneus talk. I think that the sinus Tarsy incision to me should be called the extensile incision because it really is extensile. You can take it up the lateral zipper, as we call it, and you can go up to the fibula and get to the peroneals and go distantly if you need to. So for me, my home run incision or my workhorse incision is over the first and second TMT joints. You can extend this if need be, and you can add lateral incisions as you need to, to perhaps get to the third and get to the lateral column if that's dislocated. So extensile incisions. What about percutaneous fixation? I think that these fractures are rotatory. And I think that they're really, they occur in more than one plane than just the axial plane. I think it's more than just squeezing it down. Have I done it? Yes, there's excessive soft tissue swelling. Perhaps if you're concerned about non-compliance, I might compress it. While I'm doing that, I'll put my thumb on the top of the second metatarsal base and try and push that down as we rotate it down into its mortise. Then we'll put the K wire in, the kind of home run Lisfranc screw. And then Steve Rakin had a study where he looked at this 38 patients with three-year follow-up. The patients did well. But in those cases, it wasn't, in 20% of cases, it wasn't really percutaneous. He made a small incision, used a freer elevator, and just kind of coaxed that second metatarsal down into its mortise. Again, thinking of it as a rotatory injury, and these patients did okay. Intercuneiform fixation, yes. If you ask me how often do I do it, when I'm there, I'll look for any instability between the cuneiforms. If I see it and it's just loose and there's hematoma there, I think if you see hematoma, that's a helpful sign, and I will put one or two screws across the intercuneiform joint. I give credit to Dr. Anderson, Bob Anderson, for helping us understand this. Suture button fixation, I just, it hasn't panned out. Vinod did a biomechanical study. I just, I think that I'd rather have more rigid fixation. So in summary, don't neglect the medial column, especially when you're trying to pick up subtle injuries. Get the lateral column out to length. Plate fixation for comminuted injuries, or perhaps for everyone if you're concerned about transarticular screws. Primary fusion, yes, certainly for comminution. And if you have ligamentous injuries, there's data now to support that, and bone graft. And Becky, I may just take a few more slides on midfoot arthrodesis. Just a few thoughts here. And we touched on this a bit yesterday, but an in situ fusion, which is really a more straightforward case, is different than a realignment procedure. And here you can see the lateral deviation of the forefoot. And these are challenging cases. You can get in there and you think you're gonna reduce your first metatarsal, but it's gonna be tethered by the intermetatarsal ligaments and the congruency of the joint. And so this is no good. This is better, right? We're putting plates now on the tension, distraction side here. And you can see this is even better with the ladder plate. So you wanna be aggressive with realignment procedures. And if your lateral column is painful, which is rare and uncommon, these were those spherical implants that Bob Anderson designed. I had someone the other year, last year, that had pain over a lateral column. And I went, I said, okay, this person needs something. This was a case of mine. This patient did well, but they're not making them anyway. We talked about joint preparation. In terms of your fixation for fusions, be versatile and be rigid. And with regard to bone graft, even with my fusions, I never hesitate. So thank you very much, Becky. Thank you, Chris. Great talk. I'm gonna try to do just a couple of quick questions just so that we have enough time for Dr. Kwon to get his ever so easy lecture on talus fractures in. Real quick, this was the first question that came out. And both of you guys can chime in if you want to. What is your opinion on foot compartment syndrome, which then you may have to turn a closed fracture into an open? My opinion is to open it. I think that sometimes you'll hear people say, oh, you can get clawed toes that you can always correct later, but you can also get neuropathic pain, which is harder. So I would lean towards opening it. And then you can do provisional fixation with K wires if you want to let the soft tissue settle down and then come back and do something more definitive later on. John? Yeah, I think this is really tough, right? We all know it's tough to diagnose. The compartments may not be separate compartments. Releasing actually all the compartments is pretty technically difficult to do, but maybe you don't actually even have to release all of them, right? So there's all these issues that we think about. I think if you're there and you're worried, then you should go ahead and do your fasciotomies. If it's a Lisfranc or midfoot, ideally you're putting your fasciotomies, I'm sorry, yeah, your fasciotomies in the areas that you're gonna place your incisions. But I think if you're there, you should do it. Another good technique is just pie crusting, because it seems that if you pie crust it and you get a lot of that hematoma out, it really decompresses the foot, so. Yeah, I agree. I think it's crazy to think that it's insignificant to get compartment syndrome of the foot and all we need to do is fix some claw toes later on. Some of these patients can have debilitating neuropathic, basically a non-functioning foot if foot compartment syndrome is just left alone. So I agree with you guys. All right, here's a question. Any difference that you guys have noticed when you're talking about that plantar ecchymosis of a Lisfranc versus let's say a calcaneus fracture? Do you see something different and does it matter? I think it's important in either injury. Certainly, I'm not surprised to see it with a calc, but with a Lisfranc injury, I'm gonna say this is more likely going to the OR. John? Yeah, I think the traditional teaching is correct that if you see that plantar ecchymosis, you have to rule out a, it's a Lisfranc in my mind unless you, until you rule it out. Yeah, I mean, I always teach the fellows, you know, if you see plantar ecchymosis, something bled. Okay, and could it be the Lisfranc injury, particularly if you have fairly normal looking x-rays, but you can get plantar ecchymosis in anything that caused bleeding, you know, a cuboid fracture or any of those things. So it's not only related to a Lisfranc injury, but certainly it should put the hairs on the back of your neck up if somebody's tender there and you can see a subtle, you know, ecchymosis, a little bruising on the bottom of the foot. All right, so one last question. In a patient with normal bilateral weight-bearing x-rays, edema in the Lisfranc ligament, but not a frank tear on the MRI, is a stress view in the clinic acceptable if the patient can tolerate it to rule out an unstable Lisfranc? Yeah, absolutely. You know, you cannot be faulted for looking for instability there. It may not be necessary because, well, I'll just bring the patient back the next week and see if they can do weight-bearing x-rays. And for me, weight-bearing x-rays, you have to make sure that they're actually weight-bearing. But if they can't, then absolutely. I applaud someone who's gonna be doing stress views and being that vigilant. Yeah, I agree. I use stress views in my clinic, but just like you had mentioned, Chris, I mean, you're not really burning any bridges. If you're not 100% sure this person may or may not have an unstable injury, just have them come back and see you in one week. And oftentimes, as the inflammation and some of that pain goes away, you get a better weight-bearing x-ray, you can get a better potentially stress x-ray. And in some situations, because of the patient's inability to tolerate any of that stuff, in rare situations, you're gonna take them to the OR and under sedation, get a really good stress exam and make sure that you can answer that question. All right, so in appreciation of our time, we're gonna finish up with our third talk. And again, Dr. Kwan's gonna take over and he's gonna speak to us on talus fractures and humble pie. Thank you. Okay, so same disclosures. So talus fractures, these are really tough. You know, there's a high rate of concomitant trauma. When we operate on these, just like calcaneus fractures, we worry about a high rate of post-surgical complications. And sometimes I'll ask my residents, if you had to have one of these injuries, which one would you not wanna have? And I certainly wouldn't wanna have a tailored neck or body fracture. Not only because of the high rates of avascular necrosis, but we know that both the ankle and the sub-tailored joint tend to get affected by post-traumatic arthrosis. And having two joints that are arthritic certainly makes any reconstructive efforts more difficult. So we owe a lot to Leland Hawkins. And so he was a resident in Iowa and he went on to Colorado where he was chair of the department. And at the end of his residency, he published his seminal work on the classification system that he came up with, which was interestingly looking at 24 years of retrospective data before the days of the electronic medical record. So this definitely is a seminal work and really influenced how we thought about these injuries. And so we know that the problem with the talus is the lack of blood supply. And given the fact that it's mainly covered by articular cartilage, there's few areas for vascular inflow. Additionally, it's responsible for a lot of the motion of the ankle and the foot. And this is the problem when you have a neck or body fracture. Now we're all familiar with these numbers when you look at the Hawkins classification and the increasing rate of AVN and arthritis and malunion. But if you look at the primary literature, there really is a question. And even the literature that's coming out today, whether these are a little bit overestimations. So Canale's original work, some of these type twos and threes, which really the standard of care is operative treatment, were treated non-operatively. So maybe this affected some of these high numbers that we were traditionally taught. Now, in terms of when we have to fix these, a lot of the literature has come out of Seattle. And this is one of those seminal papers that I think most of us are familiar with, where they found that time to fixation did not influence the rate of avascular necrosis. And instead, AVN was probably more related to the extent of the initial injury in regards to comminution and whether it was open and things like that. And so although they concluded that there was no correlation between timing of fixation and AVN, they did question in their discussion about what about timing to reduction. And just like any other large trauma series, they had some patients lost a follow-up. Now, Heather Vallier had looked at this more recently and proposed a Hawkins 2A and 2B designation. And 2As were when they were just subluxed or the posterior facet was subluxed, and 2Bs where the subtalar joint was dislocated. And she found that this was prognostic. And so the dislocated ones tend to develop AVN a lot higher, at a higher rate. She did find that Hawkins 3s developed AVN at a rate lower than was reported in the literature. And interestingly, those patients that initially showed osteonecrosis, a large number of them revascularized without collapse. The extruded talus, again, a literature coming out of Seattle. And despite having a small cohort at the end of their collection period, amazingly, there was an exceedingly low infection rate. But given the disruption of the blood supply, the rate of AVN was high and outcome scores were not good. But the authors concluded that salvaging the talus, if you can, does allow for more flexibility in regards to reconstructive efforts. And so this is a case my partner, Chris and I took care of. And so this was a 17-year-old who was involved in an MVC and was taken care of at a outside hospital. And they placed her in an X-Fix. I assume her talus was not salvageable or it was left on the road and they placed this nice cement spacer. But a 17-year-old with this, there are really very few options. And so we had obviously multiple discussions with this patient. But this patient ended up getting a total talus replacement and on last follow-up was doing okay. This is a 28-year-old police officer. She was doing a tough mudder race and jumped over a obstacle and landed into this water pit and ended up with a closed Hawkins III. And so she had a interlateral and intermedial approach with this P to A screw fixation, which we'll talk a little bit, and plating on the lateral neck, which we'll also talk about. And she did pretty well. You can see that she has sclerosis of her interlateral dome, but no collapse. Now I ran into her at the Run to Remember, which is a half marathon in Boston about two years afterwards. And she beat me by about 15 minutes. And then she sent me this picture a year later and she was able to finish Boston, the marathon in four and a half hours. So not all these patients do poorly. Now about P to A screw fixation, there's some biomechanical studies going back to the early 90s, demonstrating the benefits of screws from the back to the front. And this is likely secondary to how those screws cross the fracture line and some of the difficulties given the navicular with placing screws retrograde. These authors said, well, these fractures tend to have medial comminution. So what if we create a model of medial comminution? And again, they found that P to A screws were the most rigid construct. And more recently, some authors have used finite element analysis to also compare this and found that if you can, putting P to A the screws is the way to go. Now, I'm not aware of any study that has correlated this with outcomes, but whenever I can, I do try to put screws in the back. Now, if we have an answer medial and answer lateral approach, it can be somewhat technically challenging. And I'll show you a picture of how I do this. Another thing to understand is that at the level of the ankle, the fibula and the lateral gutter is slightly posterior. The talus tends to declinate medially about 24 degrees. And so the medial gutter and the medial cartilage is a little bit more anterior. And so you really do have more of a cartilage free space on the lateral tailor neck than on the medial neck. And you can see the kind of the bare areas on each side. So it is very hard to get any plate fixation on the medial side. This is a case that was done in Rhode Island and sent to me. And you can see that medial plating, which went up into the gutter. And this patient developed a pretty rapid medial gutter arthrosis secondary to this plate placement. This is a technique I don't think we ever wrote up, but you can plate on the medial side and this plate starts outside the bone. You can tamp it intramedullary. So this is a way of getting enhanced fixation on the medial side without having your plate be close to the medial gutter. This is a 28 year old, tough patient, IV drug user was involved in a bad accident. And you can see that she has that Balear 2B type injury. And a lot of comminution at the underside of the talus at the posterior facet. And so this is, there are very few reports in the literature about ORF and primary subtalar fusion. But it can be an option and maybe something to consider. This patient also had dislocated perineal tendons, which we repaired. And you can see that sclerosis and AVN, but no collapse and she did reasonably well. This is a 27 year old grad student and has a rather complex tailored neck and body fracture. And the reason why I want to show this case is that the thing to understand is that when you have an intermedial and interlateral approach, if you extend those incisions up across the front of the ankle, you can get to the anterior half of the tailored body. So I think that looking at this and reflexively thinking that this patient may need a medial osteotomy may not be correct. And I think that the osteotomy is really helpful for more posterior body fracture. So you can see, I don't have a picture of the incisions, but by simply extending those incisions anteriorly, we're able to access the joint and get anatomic reduction. This is a 56 year old involved in a motor vehicle accident. You can see the common concomitant medial malleolus fracture and a really bad injury. And I understand that looking at select chronal and sagittal imaging, you can't understand the totality of this image, but I think the key for me in understanding how to fix this was the fact that the medial contour of the neck and body was probably the only part of this talus that was still aligned. And so, I can understand how when you have these complex articular injuries, it can be quite daunting to figure out how to approach things. And so this is the approach that I take, is I think the first approach is studying the CT scan. So I enjoy taking care of these injuries. So I'll get a cup of coffee and sit there for 20 minutes and enjoy it and just sit and study it. And mainly trying to determine which of the osteoarticular fragments are important and which are not. And then once I define the important pieces, I think, well, what approaches do I need to be able to access those important pieces? And then it's a matter of just kind of technical aspects of surgery. And so this patient had a formal intermedial and lateral approach. You can see that we're cobbling this talus back together and then fixing the medial malleolus fracture. And as I've demonstrated before, if I have a transverse fibular fracture, I like to put an intramedullary screw without making a separate incision. And so this patient had a big trough in her talus, as you can see there, and went on to develop arthritis. But we were able to perform an ankle fusion with somewhat relative ease. This is a 50-year-old female, and you can see that has that 2B dislocation. This CAT scan was performed before it was reduced, and so we went ahead and took the patient to the OR and reduced it and repeated the CAT scan. I've shown this hind foot pin in the calcaneus fracture talk, but a nice way to get some stabilization without necessarily putting a delta frame on. Now it's certainly not for all injuries, but you can see that for certain ankle fractures or open hind foot dislocations, it's a reasonable thing to do. This I showed in my calcaneus fracture talk, but you can see the corresponding CT scan, and you can see where that pin is, and it really is pretty safe as long as you don't travel too medially. So Hertzenberg wrote a technique about putting a large cannulated screw in the same anatomic area, and he would do this to prevent Aquinas deformity when he was doing his limb lengthening, but nevertheless, he did an anatomic study, and you can see that as long as you're not too medial, putting a hind foot pin is pretty safe to do. So you can see here that I'm trying to get my reduction, and you can see it's flexed, and one of the keys is that if your subtalar joint isn't right, then your fracture is probably not anatomically reduced, and with these 2Bs and 3s, one of the technical problems is your talar body is so unstable that it's hard to build your fracture to the talar body because it's unstable. So one technique I like to do is reduce the talar body into the plafond, and I will put a K-wire across the malleoli to stabilize it in place. I get it, I'm violating the cartilage a little bit, but I think this technique is rather well tolerated. I've seen this before, and I don't necessarily love violating those joints in that manner, but what you can see is once I have that talar body stabilized, it's much easier to get things anatomically aligned. In terms of PDA screw fixation, you know, if you're doing intermedial and lateral approaches, you're supine, and so I'll get a radiolucent triangle, and then I'll rotate my C-arm around, and still technically challenging to do, but if you have a good fellow here, Seth O'Donnell, you can get these screws in. This is a 30-year-old, so had a talar neck fracture fixed at an outside institution. It went on to a non-union, so it was bone graft and refixed and a continued non-union. You can see the patient now has a joint that's degenerating, and so this patient, you know, we talked about all sorts of options, including amputation and fusion, but we thought that a talus would be a good option for this patient, so using the contralateral ankle, the talus CT scan, we templated to make three sizes, and you can see we're going ahead and putting our total talus in here. Unfortunately, this patient had a wound dehiscence and ended up infecting his total talus, and so again, we talked about options, and he wanted limb salvage, which I thought was reasonable, so one of the cool things that you can do with 3D technology is this is a negative made off of the original 3D, you know, reconstruction, and so we were able to make an anatomic cement spacer with the help of my plastic colleagues. We got him washed out, and we got him covered, and he's doing well now. He actually just got a job in a floral store. Now, certainly, he's going to need something else done, right? The coefficient of friction isn't great, and he'll need something done, but this gives him something to be able to ambulate on and clear his infection. Fifty-year-old extruded talus, immediately disguised as a sheriff in the police department, and you can see it was reduced and a CAT scan was performed, taken for IND and X-FIX by my trauma colleagues, and then two screws were placed, and we got a post-operative CT scan, and this, I thought this alignment wasn't acceptable, so we went to take him for revision surgery. One of the other things, too, is you can see that the tail navicular joint is oftentimes not aligned if your fracture isn't right, and so you can see we're marking out our osteotomy, keep it more vertical than you think, and then we are templating and pre-drilling our plate, and you can see that we don't see the medial malleolus in the picture, and what I didn't know going in ahead of time was that the deltoid ligament was completely evulsed off, and so that medial malleolus is now on the back table, unfortunately, which made me pretty worried in the OR, but we went ahead and repaired him. We repaired the deltoid back. You can see our tail navicular alignment looks good. Our subtalar alignment looks good, and this is him about four months out, and amazingly, you can see on the CT scan that that medial malleolus healed, and he had a pretty good motion and function, so he's actually not doing too bad right now, although he is certainly going to go on to have a bad joint. So in summary, these are real bad injuries, right? There's a lot of acute and downstream complications, so I think our goals are achieving anatomic reduction, but avoiding bad problems and various malunion, and you know, take a step-by-step thought process when you when you're faced with a really complicated articular injury, and let's set up patients for a successful end-stage surgery. Thanks. Thank you, John. Excellent talk, and we got one question right now on a talus fracture, and it kind of follows up on that total talus that you had shown us, and so the question was, do you have a minimum age, or is there a minimum age for a total talar replacement? I don't have a minimum age. I don't do enough of them where I have maybe such a rigid, strict criteria. I have done a handful of total talus, and they really have been in patients with end-stage problems who really don't have any other good options as opposed to a bulk allograft TTC, an amputation, or anything else. The older the patients do get, the more I think about doing a hindsight fusion. Yeah, I agree. I mean, I just don't think we have the numbers to be able to comment on that. Chris, let's follow up. There was a lot more questions we didn't get to for the Liz Frank, so I just want to go maybe through about two of those, and then maybe we can try to highlight at least one case before we go. So this one said, Dr. Chiodo, why do you consider suture buttons not a very rigid fixation, having in mind the extensive studies and their use in the syndesmosis? Yeah, you know, I saw that question. I haven't seen it pan out clinically, and I don't think it gives you as great rotatory control. It's one-dimensional in my mind, and I think you can get better fixation with a plate or a screw, so it's not just so one-dimensional. I think I might walk that back and say I haven't seen it panned out in terms of it being used for Liz Frank injuries. I'm not aware of any studies with its clinical use. Maybe I'm wrong, but I just haven't seen it. Okay, so both of you guys can comment on this. If the TMT is fixed with plates, if you're doing dorsal plate fixation, does it have to be removed later on, and if it does, when do you guys do that? John? Yeah, I think this is a really a great question, and I think it's a great question because, well, I've certainly gone to bridge plating as opposed to transarticular screws, and we all throw out this term, you know, if you don't take your fixation out, you're a closet fuser, right? It's really easy to, that sounds like, oh, that makes intuitive sense that you need to take it out or you're a closet fuser, but the thing is that if some of these joints move so minimally, you know, does it matter if the plates and screws are there or not? You know, does it matter if that screw loosens just a little bit, which it will likely do, and even for the first TMT joint, and so in my practice where when I would bridge plate, I would routinely take the hardware out. I've gone to not taking them out because those dorsal incisions are not benign to go back through, and so, and I haven't had a problem leaving my hardware in. So, when I do, especially in younger patients, I'll take the plates out. Just the other way, I think that the joint likes some motion. I think it's better for the cartilage, and so I will take the plates out like that. The primary, the patient I showed you who had a primary fusion, one plate was, I think, not a fusion, but I'll take them out, John. Maybe I'm not there yet, but I'll take them out. Yeah, I think I'm still, I guess I should rethink it because I don't want, I didn't want to be that closet fuser. I typically take my plates out, and like you, John, I lean more towards dorsal plate fixation now in my practice than I do the trans-articular screws, although I'll do them on some occasions. One of the reasons I totally agree in the idea that going back to the, through those incisions aren't benign, but I have noticed that when I plate the first TMT, sometimes those patients can really scar down their EHL, and their big toe will oftentimes get stuck, and so I do think I've found that in those patients when I have removed that plate, which I do anyway, and I typically take it out usually around month six if I'm taking it out. I've been able to improve their range of motions or kind of get the scar off the EHL, which I think is a downside to the dorsal plating. You're going to get much more scarring than you do these trans-articular screws. You have to accept that, and I've improved in that scenario, but I think you're right. I think there's going to be patients who, they were going to stiffen up a lot anyway, and you know, particularly if they're diabetic, they're at-risk patients, maybe you don't want to go back in and take that out, and they'll probably do just as well if you don't. Very good. So why don't we, we've got a little less than 10 minutes. Why don't we try to tackle at least one, if not two cases. John, did you want to highlight one of yours first? Yeah, sure. I'll, since we're chatting about Liz Frank, so I'll show a Liz Frank case here. Okay, so this is a 29-year-old with mid-foot pain, and so she's healthy, maybe a little overweight, non-smoker, non-diabetic, and interestingly, she had a slip in her kitchen on a rug and came with this Liz Frank injury, and so you can see that there's lateral displacement of all five TMT joints, and if you look carefully at her hind foot, she has a C-sign, so she's got a talocalcaneal coalition, which was asymptomatic, but probably explained why a seemingly benign mechanism, you know, given the stiffness of her hind foot, led to this, but nevertheless, so we got a CAT scan, and again, her coalition is asymptomatic, it's in a, her hind foot's in a good position, and you can see that the first and second and first are off, the fourth and fifth are near dislocated, maybe a couple of small, small fractures, but this is, this is what we got, and so some of the things that I was thinking about, I want to hear your opinions, of course, is, you know, fix or fuse or a combination of both, and which joints, timing of surgery, so, you know, when I plan on doing fusions, I have a little bit of luxury of time, but when I'm doing a hybrid, I'm always not sure when to go. Open versus PERC, and where are you going to place your incisions, and do you guys think differently with the lateral TMT joints if they're dislocated versus just a little stable at the end of the case? So, Becky, Chris, thoughts? So, I think, first of all, the, you know, when a patient presents with this, if they have a high energy injury, the soft tissues can be very different than this. Slip on a rug, and you sustain this. I mean, so I'm a little less concerned, unless the tissue's terrible, in this healthy 29-year-old to go and try to get in and fix this fairly soon, which is very different than if this was a more higher, you know, level injury. I just think that the, you know, you're going to run the risk of severe soft tissue problems. So, in that sense, I would probably try to approach this pretty quickly. Looking at the CAT scan, I don't think I'd jump to a fusion in a 29-year-old. I tend to reserve those for pretty common-nuded interarticular fractures, potentially older patients, and stuff like that. And we could discuss the ligamentous only reasons for it. But for this one, I'd probably look to, you know, be fairly quick, as long as the soft tissue would let me go in there, fix it. I would look to do at least two, I would, I like two incisions. I don't like to do one extensile incision to get one, two, and three. I like to make a medial incision for one, and then one that kind of hovers around two and three for me. In this situation, you may find, especially if you can get to them pretty early, the dislocated four and five, once you've reduced your other joints, they oftentimes, you're able to kind of almost do a close reduction to those. And unless there's fragments in the joint, I may just provisionally pin them, and you don't have to make a separate incision for that. And so, in this patient, I'd probably do just that, the two incisions, open reduction, and, you know, bridge plate fixation with a Lisfranc screw. Chris? Yeah, I agree. I really think that once you get the, so timing-wise, I think it's fine to wait in a patient like this, and let's one come down. And then I definitely think it will need more than one incision. The third looks common to me, so you have to be ready. If you're going to, if you're going to spare the joint, you're still consenting for an arthrodesis, because often you don't know until you get in there, and it's just too common. And looking at this, John, I think maybe dual incisions, I think you may find plating the third is going to be necessary, even fusing it, and then I think it's dealer's choice, either bridge plates or screws for first and second. Cool. All right. Well, let me show you what I did, and you guys can make fun of me a little bit. So, I did three incisions. So, I did dorsal medial, and then over the middle of the foot, and over the lateral column, and obviously, I fused the second and third TMT joint with staples. You know, I really go back and forth regarding Coetzee's study. You know, I mean, you know, obviously, we could debate this study for an hour, but you know, we don't have that many level one studies in orthopedics, and it's interesting how much we debate the ones that we do. So, I thought that this patient would be best served by a TMT fusion. So, that's what I did. One of the things I do worry about is whether a two-leg staple is rigid enough for a second TMT fusion, in particular, in the trauma setting, when there's more ligamentous disruption. So, you can see I backed it up with that reverse Liz Frank screw. You know, I used to pin the fourth and the fifth, but when they're dislocated, I really worry about my ability to be able to tell if I have them anatomically reduced because, you know, on the initial injury, more times than not, I need a CAT scan to be able to see it. So, I worry about in the OR if I can really tell if they're reduced or not. So, I've gone to open bridge plating that, and I will do an interconeiform screw. Across the first, we wrote this up a couple years ago, but we're going to be publishing our series. What I have found is that after you do everything else—so, Chris, I address the second first, the second TMT, and then I work medial and then lateral, but I find that the first can be quasi-stable. Not enough that makes me want to necessarily put a screw across it or bridge plate it, but I'm worried about leaving it alone. So, I will use a suture fixation for the first, oftentimes. And so, this is what I did. You know, when I do bridge plate the lateral TMT joints, I definitely think a little bit more about whether I need to go and get that out or whether it's going to loosen and not be a problem or whether it's going to loosen and be a problem. So, I probably would go and get that lateral bridge plate out. John, what's the screw in the first metatarsal base? What is that? The—yeah, that—you mean the Lisfranc? No, not the Lisfranc screw, but the screw in the base of the first metatarsal. Yeah. So, that's what this is here. Now, this is actually a picture from a different patient, but those are two posts, and I have suture winding between those posts. So, it gives me a means of providing more flexible fixation, but avoiding a transarticular screw, and also, for the first, avoiding a bridge plate. So, you know, we know the first moves more than the second and the third. So, I think that when you bridge the first, it's always a question of whether you should go and get that plate out or not. And so, this is something that we developed that gives you some stability, but maybe keeps you from having to go get it out later. And those are ethaban sutures? That's ethaban, yeah. You know, I know that I showed that the screws across the first quite a bit, but you make a great point. When you—for just a lower energy standard Lisfranc, when you reduce the second into its mortise, the first goes with it often, and sometimes you don't need to do anything, but this is certainly better than that. Yeah, I've seen that sometimes when you reduce and put the Lisfranc screw, that subtle instability that you saw at the first EMT is no longer present anymore. And so, yeah, you'll see that as well. And I think highlighting on the Lisfranc, it's not just, you know, divergent, homolateral. There are so many patterns to it and understanding where the zone of injury went in. Did it go into the intercuneiform and then out between the medial cuneiform and the navicular versus through the others? And so, my fixation will be very much dictated by, you know, where the instability, where the injury happened at the midfoot. All right, very good. So, we are at the end of the session. I guess we'll, for time's sake, because we have a long day, we'll move on to the next symposium. Again, Chris, John, thank you so much. This was a fantastic—I learned so much already this morning and—or this afternoon, and we just started. Thank you.

Lisfranc injuries

early diagnosis

proper imaging

open reduction

reduction clamps

screws

plates

midfoot bones

nerve preservation

younger patients

ladder plate technique

metatarsals

complications