Good evening, everyone. My name is Angad Halim. I'm the chair of the Young Physician Committee of the ALCS. I thank you all for joining us today on this session. People are going to be trickling in as we start. I would like to remind everybody that this is a one and a half hour session for 1.5 CME credits. So feel free to claim your credits for the end of the session. I have my wingman and co-pilot and co-chair of the committee, Dr. Cesar Neto, co-moderating with Samuel Attar, assistant professor of the University of Toledo, Ohio, and Matt Conti out of North Carolina. We have a very special guest today that we are honored and very grateful to have him on board and accept our invitation. We look forward to learning a lot from him today. Without further ado, I'll hand it over to Cesar, who's going to go through the housekeeping items, and then Samuel Attar, who's going to present our guest of the day, Dr. Keith Wagner. Cesar. Good evening, everyone. I think Angad started super well, so don't want to take a lot of time. So what we usually ask people, and I see a lot of well-known names here that are frequent flyers in the Ask the Expert sessions. But what we ask you guys is if you're not speaking, please keep your microphone turned off. And that we behave the same way that we would behave in a grand round situation, sharing cases with colleagues, respectful of patient identity and all the hyper-compliance stuff. And we don't allow for people that haven't joined us before, we do not allow people to share cases without being posted in the website. So if you want to share cases in the future or today, post it in the website, the AOFAS Connect, and then we can run for the case using the AOFAS Connect website. Thanks for being here. And I'll give to Sam Attar to introduce the guest of the night. Hello, everyone. Hope everybody had a good Thanksgiving. And Dr. Wagner, Happy Hanukkah. I was lucky to be one of Dr. Wagner's fellows back in 2018. And as you guys all know, he's one of the pioneers in the field of foot and ankle surgery. Dr. Wagner is an emeritus professor of orthopedic surgery at the University of Pennsylvania, where he also serves as the past chief of division of foot and ankle surgery and past director of the foot and ankle fellowship program. He was also an adjunct professor of orthopedic surgery at Drexel College of Medicine in Pennsylvania as well. Dr. Wagner obtained his undergrad degree from the University of Pennsylvania. Then he completed medical school at Temple University School of Medicine. After doing a one year of surgical internship at the University of Pennsylvania, he went to do his residency at the Hospital of University of Pennsylvania. Sorry, Dr. Wagner for putting the numbers. I know it makes you look old, but I know it's just numbers, you know. After finishing his residency, he went to complete two fellowships. One of them was an adult reconstruction fellowship at the Ohio State University. And sorry for any Buckeye fans for the loss after 10 years. Yeah. And then he went to do his foot and ankle fellowship with Dr. Roserman in California in 1986. After completing his foot and ankle fellowship training, he went back to his home in Philly and he started the foot and ankle service at Thomas Jefferson University, where he stayed there for about 12 years. Then he moved to Penn and really started the entire foot and ankle service and became the chief and took over the fellowship also, where he stayed the fellowship director for about 20 years until he stepped down in 2017. Dr. Wagner, again, as you guys all know, he served as the president of the OFS back in 2010, 2011. He also was on the board of the OFS for five years from 2008 to 2013. He also served in the managing board of the AFI, shared courses for the AOS and AFS, and also was a board examiner for the AOBS. He also reviewed for top-notch journals like the FAI, the Core, the AJSM, JBJS and JAOS. He published over 100 peer-reviewed manuscripts and authored about 41 book chapters. He has given over 300 scientific presentations, not only inside the USA, but also around the world. He is also, again, a pioneer who participated in developing novel surgical techniques and also development and designs of multiple orthopedic devices in the field of foot and ankle surgery. My fellowship year with Dr. Wagner was amazing. We really had great time every single day in the clinic and OR. Everything was going fantastic until the day the New England Patriots made it to the Super Bowl against his Philadelphia Eagles, which was a disaster for me because it went downhill from there. It got so tense that Dr. Wagner really told me if I don't stop wearing my Patriots gear to the office, he will not sign my graduation certificate. I really had to stop wearing my New England Patriots gear for like a month before I finished. And, of course, he keeps, actually till now, he keeps texting me after bad losses and making fun of me and of the New England Patriots. But I always tell him it was just a year and he has to always remember that we have six rings. And guess what, Dr. Wagner, the New England Patriots are back and they might make it to the Super Bowl and your Eagles are bad this year. Right? They are bad, but Sam, what you have to realize is the reason I didn't want you wearing the New England Patriots jersey around the hospitals, I didn't want somebody else to kill you. I actually sent my two kids the week of the Super Bowl to their school and they came back crying. They went in Patriots hoodies and jerseys and both of them came back crying because they got destroyed. So anyway, I just showed you that I was I was doing better parenting than you were. Anyways, we are really lucky to have you today and we I'm sure it will be a great session. So. Yeah, we would like to welcome you. Thanks, Sam, for the for the introduction. Dr. Wagner, we're going to start with first, I just want to know, is Dr. Metikala with us? We usually allow the person to present the post of the case to present it. Do we have Dr. I don't see Shelley, do we have him with us? Here you go. There he is. Good evening. So just so you know, is there is there one preferred case that you would like to start? Because we're going to do one of yours. You're supposed to treat cases and we really appreciate your support posting the cases for us to discuss. Is there one case specifically that you prefer? Can I start with this first one or is there any other one that you would like to start? The first one is good. OK, good. So feel free. I'm going to I'm going to run the the window here. I'm going to just let me know when you want me to go down. Things like that. Just say keep going, keep going. I'll keep going here. OK, thanks for being with us. Thanks for the cases. Thank you, Cesar. Dr. Wagner, this guy is a young man. Twenty three years has bilateral bunions for several years. But his main complaint is on the right side with pain along the medial eminence and difficulty in using the shoewear for the past five, six years. He also has plantar callus at the level of the third metatarsal head. Can we move up a little bit, Cesar? Could I show the pictures or do you want me to stay in the history here? I'll briefly summarize the examination findings and then we'll go to the pictures. Here we go. Yeah. Examination wise, he's quite tender at the medial eminence. Again, right side being worse than the left instability of second metatarsophalangeal joint with positive Lachman's test has got hammock to in the second two, which is flexible. He's also tender along to three metatarsal heads. And but the painful calluses at third metatarsal head. And he has got hypermobility of first TMT joint, Dr. Wapner and bilateral flexible flat feet. And he has got tightness of a heel cord with positive silver skeleal test. We can now go to the x-rays if that is OK. The clinical pictures on the right, the plantar aspect of the foot with callus along the third metatarsal head, the dorsal aspect of the foot. Then can we move to the x-rays, please? This is on the left side, which is less symptomatic. And the next x-ray, please. The next one, please. The one with the bilateral standing weight bearing AP. Yeah, the next one shows the deformity parameters. Just go back to the lateral for a second. Yeah. If we see the deformity parameters x-ray. What is interesting is he has got the Haleck's valgus angle of about 35. IMEA is normal, but DMEA is about 24 degrees on the right versus 17 on the left. He also has Haleck's valgus interphalanges more pronounced on the left and the right. With the IMEA being normal with massive DMEA of 24 degrees. Now that the patient is interested in surgical options, I have raised a few questions for you, Dr. Wapner. And I formulated my treatment plan, if you can kindly go through and then start from there. So let me ask you, you say that he has hypermobility? At the first DMT. First DMT joint, okay. Yeah. All right. My plan is to... A couple of things. Yes, sir. Go ahead. Go ahead, Srin. No, go ahead, tell me your plan. Yeah, I wanted, I'm planning for bifocal first metatarsal osteotomy. I feel he's too young for first DMT fusion. I would like to plan for a proximal medial open wedge osteotomy and then distal biplanar chevron osteotomy to be able to remove a dorsal-based pisa-shaped wedge along the dorsal slice. Add Akin with no lateral soft tissue release, realizing that the joint is congruous. So I think in a patient like this, a couple of things, you know, one is the flexible flat foot and the heel cord contraction, I think are things you have to take into consideration. And as the guys, a couple of my fellows are on the phone here know on the call, I'm not a real big fan of doing gastroc releases and TALs and patients with bunions, but I do think it's important that you address the gastroc contracture. And I think the proper way to do that actually is through teaching him how to do stretching properly. And it becomes important because of his age. So even if you were to say, OK, he's got a flat foot and he's got a tight gastroc, so I have to do a stretcher when I do my bunion. Otherwise, he's going to continue to pronate. The reality is if he doesn't start stretching and make that part of his everyday routine, the high likelihood is over time it's going to get tight again. And we found this out actually when we started doing Achilles tendon lengthenings and Strayer's in diabetics for the treatment of their ulcers. And Jeff Johnson actually did a series of really good articles that showed over a period of, you know, two to three years, anything you release, unless the patient stretched, just came back. And I think to a certain extent that extends into patients, especially at this age, if you don't teach him how to do stretching properly. The biggest key in addressing the tightness of the heel core, if you're going to do stretching, is you've got to realize that unless your forefoot is completely adducted, if you have a patient like this that's trying to do gastroc stretching, almost all their motions are going to occur at the tail intervicular joint rather than at the ankle joint. And so when you're going to teach a patient like this to stretch, what we always have them do is stand up against the wall and have their feet in tow. So really almost toe to toe and have them stretch both sides at the same time. And so what you're doing is when you get their foot in that position, you're locking the transverse tarsal joint. And that allows you to get all the motion occurring at the ankle joint. And then you're truly able to stretch out the gastroc. So I think I would, I would not do a TAL on a patient like this, but I would, or a Strayer, but I would teach him how to stretch. And I would explain to them that this is an important part of your treatment, an important part of your going forward to make sure you don't get recurrence. The second thing, if he's truly hypermobile, and again, that's, it's sort of like the Supreme Court when they define pornography, you know, I can't really tell you what it is, but I know it when I see it. And it's a very subjective thing. So when you look at his, it's interesting when you look at his left foot there, a little bit of a gapping between the base of the first metatarsal and the second metatarsal. And if you look at the very base of that lateral base of that first metatarsal, it's, it's subluxed a little bit medially. If you look at the right side, let's go to the right foot x-ray, you see in that projection, it's everything looks completely different. So it's really difficult sometimes to tell when there's true hypermobility. And so one of the things you can do is, is if you have a fluoro machine, you know, just look at it under fluoro. If you can't really tell from your exam, but I really, if this was hypermobile, I would not be reluctant to do an MTC fusion because basically if he's truly hypermobile and he's already got a flexible flat foot, he's going to continue to pronate. And if he continues to pronate over time, any proximal osteotomy you do has the potential to get more of a recurrence because of progressive instability at that MTC joint. That joint's not going to get more stable as he gets older, it's going to get less stable. So I think you need to do something proximal. You know, on this view, it does look like he's got a little bit of metatarsus abductus, and that's why the IM angle is so low, but I don't think it's to the point where you need to do something to that second metatarsal to shift the position over. But I probably, if this, if this is truly hypermobile, I probably would do a Lapidus at the first MTC. And then I agree with you doing additional chevron, biplanar chevron, because you do need to get that DMMA corrected. If you don't get that corrected, you're not going to have a correction of your bunion. So I would probably, if I was doing this, the sequence in which I would do it is actually, I would probably do the first MTC joint first, and then I would reassess it. So once I have that alignment where I want it, then I would do my biplanar chevron, and I would get that DMMA where I want it, and then I would look and see, do I really need the acan? And I think probably on this side, once you get everything corrected, you probably wouldn't need to do the acan. Would be my guess. But I would do it in that sequence because you want to correct the deformity from proximal to distal and address each component of it. The other thing is, if you look at the lateral x-ray, he's got a little bit of metatarsus adducta, metatarsus elevatus. And so when you're doing your Lapidus, one of the things you could do is bring that metatarsal down a little bit into its position and maybe, you know, diminish his flat foot deformity a little bit to that as well. So that's the approach that I would take as far as the hallux. Any other comments or suggestions from anybody? Yeah, Dr. Webner, with your Lapidus, this would be like a Lapidus in situ. You wouldn't do any wedge or any cuts because he doesn't have a big IM angle because of the adductus, I know, but would just be cleaning the joint and fusing in situ. Yeah, if you go back to the AP, I would try to plantar flex him a little bit more just to try to bring up his arch. But yeah, if you look at that, I would probably close that down a little bit because you look at that, you look at that IM angle and you say, okay, it's only seven. But if you, if he didn't have the metatarsus adductus and that second metatarsal was straight, right, that IM angle would probably be more like 14, 15, right? So you have to take that into consideration. So here you want to close down that IM angle, right? And you're going to end up with maybe an IM angle of zero or one or two. But if you don't correct that, even after you do your bi-pointer chevron, you're still going to have some residual, some residual deformity. So when you have metatarsal adductus, what I look at the IM angle is I will, I will basically do it as if the second metatarsal was straight. If it's the metatarsal adductus is enough where that, when I have to pull the first metatarsal over, I'm going to get impingement. That's a situation where I may consider shifting the second metatarsal over as well. But yeah, I think in this situation, that IM angle measurement is deceptive because although it's only seven, it is that, that IM angle is still contributing to the deformity and that the adduction of the first metatarsal is contributing to the deformity. So I wouldn't do it in sight. Naomi, Naomi, if he has some inputs, Naomi, do you want to, you want to speak? Can you turn your camera and talk or should we read your messages here? I'm trying. Here we go. We can see you just, you're muted. Can you unmute yourself? Okay. Here we go. Yes. Okay. So Keith, this is a varus hindfoot with forefoot pronation. Look at how the tailor head is covered by the navicular, the hindfoots in varus. I really think you need to look at that. Yeah, but when you look at the clinical pictures, that's not what it looked like. If you go back to the clinical pictures of the foot. But when you go to the lateral x-ray, that heals in varus. That heals neutral in varus. This is forefoot pronation due to hind foot varus. I think, I don't see, to me that looks like it heals in neutral. And I think he's collapsing more through the mid, through show parts joint. Okay, so I think that's why that arch is so flat. I think that, that it, so I would not do anything on the hind foot in this patient. I'm not saying do anything on the hind foot. I'm just saying that hind foot is not in valgus. This is not a plain old valgus foot. No, but he's still got a flat foot deformity. And I think if you, I don't want to shift the hind foot. You know, if he's, if he's truly got a gastroc contracture here, which is what Sri says, I think you stretch that out. All right. I absolutely think he does. Yeah. All right. So I would do that with stretching rather than anything surgically. But if you look at this picture and you're looking at, I mean, I don't see me that I, we, what we really need is a picture from behind to tell, which we don't have, unfortunately. So Sri, when you, when you saw this, you're the one that saw the patient. So you, you're the arbitrator. I mean, when you look at this patient from behind, was his heel in varus, was it neutral or was it valgus? And how much subtalar motion does he have? It is neutral in alignment. I have the picture from behind. I don't know if I can upload it right now. Because you see the entire fifth metatarsal and most of the fourth, you see the entire subtalar joints. He's either inverting his foot to avoid weight loading on the first or he's in varus. Right. Why? But I don't think you can make that judgment based on one x-ray. I think you've got to look at the patient clinically to make that. We all know. Yeah. We know from x-ray to x-ray, there's so much variation. And so I would base this on the physical exam. So if this patient, you know, when, when Sri was seeing this patient, if he's examining the patient, heels in neutral or valgus or whatever, I think that's the determination you have to make. Because I think it's just, you can't make it. And even if, to prove the point, if you look at the AP, when we're looking at both feet together, as opposed to the AP individually, the alignment looks completely different. But I, I wouldn't make that call based on the x-ray itself. I would make that call based on your physical exam. And if the subtalar motion was good and normal, and his heel was in neutral and he still had overpronation in the midfoot, I don't think you'd do anything dressed up other than correcting the bunions, you know, which, which legs of the tripod are you going to address? Well, I agree, Keith, I'm just playing devil's advocate here because that lateral is a varus hindfoot and midfoot, and then you get forefoot pronation. I totally agree with the biplanar Chevron, and I would probably do a proximal first opening wedge metatarsal osteotomy and address what's painful. But to me, that's, even Mary's angle is now, I don't know, negative or positive. That's a cavus foot. Right. But that doesn't look like, but if you look at his, if you look at his clinical picture, it doesn't correlate. And that's what I'm saying. I wouldn't trust this x-ray, that one x-ray. Because that doesn't fit with what you're seeing here. That's not a cavus foot. I mean, he's, he's advocate. Yeah, yeah, yeah. And Tri, I don't, I don't know if you were trying to share something, but unfortunately, we cannot allow participants to share their screen just because of the sake of protecting information. But we, but we, but we trust you. Whatever you're saying, we're going to trust you. I have uploaded the clinical picture of looking from behind. If it is possible to see. Just a minute. Not the same foot. Give me one second. I'm just refreshing here just to see if it's there. Yeah. Also, Dr. Waffner, any role for Weil? Because he has got instability on. Yeah. Yeah. And one of the things you can do with the Weil when you have metatarsal seductus, is you can actually shift the head a little bit laterally, which gives you more room to bring that first metatarsal in and get better correction of your IM angle. Okay. And no soft tissue release, correct? Because the joint is congruous. Well, I think if you're doing a biplanar chevron, I wouldn't do a lateral release. I don't think you need to, number one, because you're going to, you're going to shorten it a little bit. So you're going to take the tension off. But I also not want to do it because I don't want to end up with AVM. How the heck? Sorry, Trey. He's not working for Semington. Yeah. Yeah. So I think the big, I mean, to me, it's, if there's truly instability at the first MTC, then I'm doing Lapidus. If it's not, then I would, you know, you can pick and choose whatever proximal osteotomy you want. I mean, I'm still doing Christianic osteotomies because they've worked for me for 30 years, but you know, you can do opening wedge, you can do whatever. If, you know, if you go back to the AP x-rays, if we can, we can get back to the AP. Yep. So, you know, in a situation like this, where you're, you know, you're going to do a while to shorten that second metatarsal to address the second MTP instability, um, I think you could get away with doing any kind of, you know, a Christianic osteotomy. If you had a situation where the second metatarsal was shorter, um, or a long second metatarsal was long, but he had no symptoms at the second MTP joint, um, probably there, I would do an opening wedge osteotomy proximally if he wasn't hypermobile and do the biplanar Chevron. And that way you kind of make up the lens proximally for what you're taking away distally when you do the biplanar Chevron and you're losing some lens there. I think those are all the things you have to think about. Great, great case. I think we have to move to the next one. Just before we move, Dr. Wapner, just because you mentioned, what is, how do you decide when, uh, what is your cut or your limit, uh, for thinking about changing the position of the second metatarsal or the lesser metatarsals for metatarsal adventists? How do you exactly, what is your threshold? So, you know, the order in which I usually will do things, I usually try to correct the first, um, first metatarsal, first rate, you know, to begin with. And if I'm having trouble getting that metatarsal ahead, you know, the first metatarsal reduced where I get that end up closing that IM angle, getting it where I want it to be. Then when I do my while I'll shift that over and then I'll come back and finish my fixation. Approximately one of the advantages of the crescent economy is, you know, I put a K wire in before I make my cut. I do the crescent economy. I reduce it to where I think I want it to be. I drive the K wire across and you can look at it under x-ray. If you're happy with what you got, then you put your screw in. If you're not happy with what you have, you can pull the K wire out, readjust it. Or if you feel in a situation where you have significant metatarsal reductus, you know, you basically can leave that pin in, keep it reduced, go back and do your second metatarsal, get that where you want it. And then again, pull the pin, shift the first metatarsal over, and you can kind of dial in the correction to exactly where you want it before you commit to your fixation. A little bit harder to do with, you know, opening wedge because you have to put the plate on to fix it. And once you commit, it's a little bit more difficult to do it. Same thing with lapidus, it's a little bit more difficult. But I mean, you know, if I was going to do this in a situation where I'm doing a lapidus, I would do the same thing. I would pin it first, make sure my reduction is where I want it. If I thought I had to move the second metatarsal, I would then do that. Then I would come back, pull my pins, check my position for my lapidus. If I had to trim the cut, trim the cut, and then do my fixation. Excellent. Well, thanks. Thanks for the for the input. So let's go to the next case. I'm going to come back to your cases later. Okay, so we're going to run. Thank you. Thank you, Dr. Wagner. We're going to skip Amgad. So do we have Dr. Randy with us? Here we go. All right. Can you hear me? How are you doing? Thanks for being with us. Anytime. How are you? Good. So he was one of my residents way back when I had black hair. My hair used to look like his. So anyway, so this is really for anybody, you know, if you have any experience with this. So this is a 39 year old lady. She's a visiting nurse. She has a refractory left foot, forefoot pain. She underwent an isolated fourth metatarsal head resection. As you can see there about seven years ago, it was kind of unclear as to why she had it done. And what she described sound like she's had an isolated keratosis there, but unfortunately underwent this. And then, you know, not surprisingly, she didn't do very well after surgery. So she's been kind of dealing with this for a while. She's kind of been through several different providers. Nobody really wanted to touch her as well. And so I talked to her, I tried kind of managing her with a couple of different things. And, you know, so she really just wants to get this fixed. And ideally she just wants to have her anatomy restored if possible. And so, you know, as you can see is a good portion of the fourth metatarsal it's missing. She's got a floating toe deformity there. She's got IPKs underneath the third and fifth metatarsals. I talked to her about doing just a metatarsal resection in a lesser ray. She really wasn't interested in that. So I kind of explored the option of doing a 3D implant, you know, for the fourth metatarsal head. So I just want to see what your thoughts were, or if anybody else has any ideas about what they would do. Yeah, go back to the AP if you could. So a couple of things on the exam with her, again, this is somebody where you always want to check to see if they have gastroc contracture. It's not surprising. The only thing that's surprising about what you said is that she doesn't have an IPK under the second metatarsal head also. But gastroc tightness can contribute to, you know, forefoot calluses. And so when you see this, the things that come to your mind, one is the length discrepancy between her first and the second and third, which actually I think kind of works to your advantage in trying to solve this problem. So when I would examine her, I want to make sure she's not tight with the gastrocs because routinely anybody we see with metatarsalgia, you know, part of that treatment plan is the gastroc stretching. I would be worried about doing an implant on her since she's seven years out, because for any type of implant that you're going to put in there, you would need to have some type of capsule or stability of that fourth MTP joint. And you wonder like how much damage they do initially. And it's seven years out from that surgery. Is there anything that resembles normal anatomy? Probably not. It's probably all just, you know, a bunch of scar ball. Yeah, I agree. The worst case scenario is put in an implant and there's no stability and the toad dislocates dorsally. And now she's even more unhappy because now she's got an IPC under a third, fourth and fifth metatarsals. I don't think at this point at seven years that I would go that route. What I would talk to her about is if you think about the length discrepancies that she has, you know, I would consider doing while osteotomy with two and three to try to bring them back to the length of the first. And then depending on how mobile her fit is, you might get by with simply doing a debris condylectomy on the fifth. Because if you bring two and three back to about the same length as the first, you're going to get a little bit better pressure distribution. And rather than shortening the fifth metatarsal, I think if you just did a plantar condylectomy, you would then end up with a foot that you probably could treat with, you know, a good insert and just even something as simple as a metatarsal hay pad to help offload that area. And, you know, a plasticine PPT install or something like that. You're doing a little bit less damage there. And I think that's how I would, that's what I would recommend on this patient. If anybody else has any suggestions. This is, this is a bad problem. Yeah, no, it's, yeah, it's tough. I, I've, I've done, I was actually, I've seen it not that uncommonly, unfortunately. I've done Wiles on some of the adjacent rays and I kind of had very variable levels of success with it. But no, I agree. I think that's probably a reasonable approach. Yeah. And you can, I mean, some people would do mid-shaft osteotomy. That's another way of approaching it. I think it's, you choose your, which way you feel most comfortable. But I think the goal here for me would be, I want to change that cascade so that two and three are about at the level of the first, because the fifth is already a little bit shorter than the first. And so if you could re-establish some type of cascade, then I think using a metatarsal pad, you know, placed in the proper position is going to give you enough offloading. And you combine that with gastroc stretching, that there's a reasonable chance that this would be manageable without going in and taking out all her metatarsal heads. You know, to convert her to a Hoffman, you know, I don't think she would be happy. And I think over time, you'd probably end up increasing your hallux valgus deformity, because there's no, there'll be less stability of the first NP and long-term, I think you'd end up with an unhappy patient. Yeah. And she even said that she really did not want that at all. And I think that would really be a great option for her anyway. She's fairly active. And like I said, she's a visiting nurse, so she's really on her feet quite a bit. Yeah. And to answer Naomi's question, I'm not, you know, my goal in shortening, I would really want to get that second metatarsal, you know, at about the length of the first. So it's, you know, and just recreate a cascade. So first as long as second slightly less, third slightly less, fifth is already in a good position. And then, you know, compensate for the absence of the fourth by getting a metatarsal pad in there and it's helped offload everything. And you kind of wonder what the hell were they thinking? Yeah. Yeah. I don't know that I, you know, Naomi's also putting on the chat would consider a fourth-rate resection. I have a feeling that that's not something this patient would want to consider. No, no, she wouldn't. Yeah. Yeah. And she does have, you know, a gastric aquinas. So you're absolutely right, Keith. So I was actually even going to do a, I didn't put that in here, but yeah, I would do a Strayer on her as well. Yeah. I'm not a big fan of Strayer. I think that this is one of my pet peeves and Sam knows I have some pet peeves. So, you know, gastric contracture exists and it's really more a function of our lifestyle and how we operate, you know, sitting most of our lives. And if anybody who's done yoga or anybody who's gone through physical therapy for back problems or neck problems, you know, you can stretch muscles out and there's nothing unique to the gastroc that makes it different than any other muscle in the human body that says it's refractory to stretching. But one of the things that I've done throughout my career, when people come in and they say, oh yeah, I stretch my Achilles all the time. The first question I say is show me how you do it. And 99.999% of them end up with their foot externally rotated or in neutral, doing one leg at a time. And with their knee bent, all the things that are wrong in terms of gastroc stretching. And one of the best talks I ever heard on this was by Dr. Moskowitz, you may not know he's a pediatric orthopedic surgeon. And he talks about this also, the proper stretching techniques, you know, with adduction of the forefoot goes back to the Verne Inman studies of how do you stop the motion of the transverse tarsal joint. When your foot's abducted, it locks the axis of the tail of the truncated cuboid joint, makes your foot a rigid lever. And if your foot's a rigid lever and you're doing your stretching that way, all the motion goes through the ankle. And if you keep your knees straight, they're going to stretch out the gastroc. And like all the patients that I see with plantar fasciitis, all the things, I mean, those patients, if you measure them over time and you get them do the stretching properly, they stretch out. And the key is having them continue to do it. And, you know, I think in a situation like this, I would have her do stretching, you know, start that before surgery, continue it after surgery and stay away from strayers. And I'm a little bit prejudiced just because one of my partners, you know, when he came and joined, you know, he was a big component of strayers and our nurses and our PAs used to always say the most complaints they got from patients were after strayers. I just, so I'm a little bit prejudiced against it, but that's my own pet peeve. This is a tough one. And this is also where you need to really understand how to get an orthotic. You know, I'm sure she went to multiple podiatrists who made her rigid orthotics, you know, nice bit hard orthotics to put in there and they didn't work. And I wonder why, you know, this is something where if you're going to make an insert for her, that insert has to be soft. It has to be something like Plastazo PPT or something component like that. So she's getting, adding under the metatarsal heads, not something hard, and that she's getting lift in the arch. And that's a critical part of the treatment for these patients. Great case. Any other comments from anyone else? I think Mark Sanders put a a comment here, Dan, Gus, any comments? Can you go into the details of how you tell patients, how you explain to patients to stretch the gastroc? Because that's probably a pearl that we're all missing. And so I'm a patient, pretend I'm a patient, teach me how to stretch my gastrocs. Yeah, so it's really simple. So what I do is I get them to stand up against the wall, and I do this with them at the same time. I said, stand up against the wall like you're doing a pushup. So they're standing arms distance from the wall, palms on the wall, right? And their feet are shoulder width apart. And stand up straight like that. And then what I tell them to do is get your toes pigeon-toed. So your toes are pointing towards one another. Most patients understand what pigeon-toed is. And so you get them to stretch those, basically get their feet so they're adducted, right? And then what you have them do is you say, you're gonna do like a pushup where you're gonna bend your elbows to let your body fall towards the wall, but what you're doing is you're not trying to bring your chest to the wall. You're really trying to bring your hips to the wall. So you wanna keep your back arched a little bit. Because if you don't tell them to do that, what they'll do is they'll bend forward at the waist to get their chest to the wall because everybody wants to cheat and get their chest to the wall because they think that's the most important part. And as soon as they bend at the waist, you're actually stretching your hamstrings. You're not stretching your gastro. So the key to this is you want their body to be perfectly straight. And I tell them sometimes, just make pretend you're strapped to a two by four from your heel all the way down to the top of your head. So you keep your body straight. And once your feet are in that adductive position and you lean forward, your goal is to get your hips more towards the wall. And if you do it that way, you'll feel they'll go, wow, yeah, I'm really tight. And most of them, you know, I'm 68 years old. I can get my hips all the way to the wall when I'm three feet out from them. So I make them feel really bad. Look how tight you are. And they get it. And so we have a diagram. You know, I have a little video clip that I have. And I also have a diagram that we hand the patients all the time. But that's really the key. Think about what you're trying to do. You want all of the motion to occur at the ankle. None of the motion to occur, none of the dorsal tension to occur at the transverse dorsal joint, the show parts joint. Well, if you go back to your anatomy, you know, those great biologics, those great diagrams that Vern Inman published, you know, for the clinical pictures in Roger's textbook, where it shows when the forefoot's adducted, the axis of the tail and vicular joint, and the CC joint are now divergent. So the foot is rigid. So that's what the adduction does. When we have some people that are hypermobile, one of the things you have to do sometimes is put a lift under their first metatarsal, just to get them into a little bit more adduction and inversion, because people that are hypermobile, even if they're in the correct position, a lot of times we'll still get some breakthrough stretch at the tail and vicular joint. But that's really the key. And we have them do it. You say, let's do this 10 times in a row, 10 seconds each time. So it takes literally two minutes a day. So it's not like you're giving them this exercise program that's gonna take 20 minutes. And we start them out, we tell them, look, do this four times a day, breakfast, lunch, dinner, before you go to bed. You tell a patient to do that, you know, they'll probably do it twice a day. If I tell them to do it twice a day, I'm lucky if they'll do it once a day. So a little bit of psychology involved. And invariably, these patients will come back four or six weeks later with really seeing a significant difference. Now, I mean, Sam was my fellow. He can tell you, you know, Sree, you know, they've seen this in the clinic. Dr. Robner, I teach every single patient, same way. Yeah, I mean, half the time when Sree was with me, I'd walk in the room, the first thing they said is, yeah, Sree showed me I was doing my stretching the wrong way. Yep. It sounds like your clinic is a giant yoga studio. No wonder you stay so young and limber. You're doing that stretch about two dozen times every single time you're in clinic. It's exactly right. We used to see 80 patients, eight zero patients in clinic. I also tell them to roll up a towel or a washcloth and put it under the inside of their foot so they get that abduction and inversion. Yeah, especially in places that are hypermobile. Yeah. But it's amazing. You talk to physical therapists. Yeah. Yeah, you can finish, Dr. Robner, go for it. No, I said it's amazing. You talk to physical therapists and even physical therapists don't really know how to stretch the gastroc. I mean, they're not taught properly. So my thing to you is anytime you see a patient, plantar fasciitis, Achilles tendon, whatever it is, and they tell you, I've gone to physical therapist to do Achilles stretching, or runners in particular, you know, show me what to do. Invariably, they're doing it wrong. So for everybody on this call, shows 10 patients a day how to do it. By next, ask the expert. We'll all have stretched out gastrocs. I love it. Exactly. So you're saying we should all do that. Excellent days. Let's move to the next one. Daniel, Gus, this is yours. You can take the lead. Perfect. This is one that I love your thoughts on. This is a challenging case. This is a 36-year-old female who about six years ago tweaked her ankle somehow in a ski boot, enough that she had to stop skiing, but wasn't anything horrible. And then over the next three years, her pain worsened. She was eventually seen at a local hospital, had these radiographs. The pain did localize, you know, around the anterior medial and deep medial ankle. She had other cross-sectional imaging. These, you know, were again in 2018. We can move on, Cesar. And you can see this right here. This is the CT scan and the MRI. These are representative slices. And why don't we start- These are 2018 studies, right? Yeah, yeah, this is 2018. There'll be a- And so before we move on, I'm curious, what would you do, and anybody on this call, what would you do for her now? 2018, she's tried all the rest. Again, this is three years before I've seen her, but I think it's a good pause moment. I would start praying, because this is probably not going to end well. You know, I think at this point, when you have a cyst this large, especially close to the shoulder, it's really difficult. So you want to try, if at all possible, to somehow address that, get that healing from the bottom up before the whole cave collapses in. And it's difficult, because it's difficult to access that, because the talus is so covered with cartilage. So you probably have to do something retrograde to try to come up under fluoro, get into that cyst, and try to clean that out, and try to bone graft that, either with allograft or some type of bone graft substitute. But that, to me, is a very worrisome lesion. And I would tell the patient at this point that not necessarily a great prognosis, and I would also be a little bit worried about the activity that she was doing. But this, to me, is one of those things where you think this is not going to be a happy outcome. I don't know if anybody else has any other suggestions. I would scope her ankle. I would retrograde from the sinus tarsi. I would bone graft or use a bone graft substitute, such as Tectaset, which sets up and incorporates. And I'd fill that thing in as long as her cartilage was still good. And I think she'd do okay. And then let me ask you this just out of curiosity. Let's say she came in from an entirely different problem, and then you saw this, and they weren't symptomatic. Does that change how you manage it, presumptively, or not? Well, so what I worry a little bit, if you go through the MRI, there's a lot of surrounding edema on that far right, on the T2. And that's what worries me. That's the part that sort of is the red flag to me, because to me, that means that all that surrounding bone is now, even though the cyst hasn't expanded to that, the likelihood is all that surrounding bone is not healthy. Now, you know, Wen Chow, who's my partner, has, she's never published this, which drives me crazy, because she should, but she's had a series of athletes, and particularly a lot of dancers. She does all the ballet dancers and the high-performance athletes around Philly, who have had OCD lesions with a lot of bone marrow edema. And what she's done with them is she's used bone stimulators with a boot immobilizing them. And it's gotten, actually, very surprisingly good results in terms of resolving that bone marrow edema and getting these lesions under control. She needs to publish it. And that's another thing that you can consider here. But if you had this, so if you had this lesion here in a patient that was completely asymptomatic, I don't think you'd have an MRI that has that bone marrow edema surrounding that cyst. And so that's a different scenario, because that's basically a stable lesion. And that lesion, you know, maybe it's been there 15 years, 20 years, who knows? But with the amount of bone marrow edema on the T2 here, that's what makes me very worrisome about this. And so even if you are successful, like Naomi says, go in scoper, the cartilage is good, go retrograde, put a subtype of void, you know, some type of filler in there, the question is, is the rest of the blood supply surrounding that already compromised? And if it is, it's not gonna heal. And that's where this thing continues to go downhill. If the blood supply is good, and if the surrounding bone is not compromised, then maybe you get lucky and this heals and she does well. But to me, this is very worrisome and I would not make any guarantees to this patient that I can fix her. I'd say, look, this is a tough problem. This is what we can try. Hopefully it works. But if not, then we have to consider other options. And to that point, truth be told, I find that with these large cystic lesions, I'm often getting both the CT scan and the MRI. The CT scan better defines the bony void. The MRI shows the other soft tissue, but also the reactive bone helps confirm exactly what you said. And Naomi, to your point, I've actually had some decent success with the retrograde drilling, similarly from the lateral process or the sinus Darcy. I have. What's a little worrisome about this one is the sclerosis around the entire lesion. This has been here for a long time and something has failed that this person is now having pain and having the bone edema. But when you look at the AP, the cartilage and subchondral bones still looks intact. So I think you need to scaffold this. You need to support it. And I think if you do that, you're giving her a chance. I mean, what are your other options? You go in with an allograft and replace it? That's not a good hit in my mind. Certainly not to start with. No, no. And to your point, I've had actually some decent, and obviously there's not a ton of these, but as long as the underlying cartilage is intact and done CT, especially the subchondral bone, the retrograde drilling and fill in, but we can go to the next, has had success, knock on wood. So she told me that in 2018, she underwent an ankle arthroscopy and these were her words, calcium phosphate drilling and injection. And I remember as she's telling me this story, before I even, before you see the images, I'm looking at the scar and noticing that there's no incision along the sinus tarsi or anything like that. Not a little. And so this is, for whatever reason, she got an MRI again, three months after surgery. It's still tibia. Yeah, and then if you go now to 2021, these are her current films and then we can go to the CT scan. Because now she's progressed to ankle arthritis. Yeah. Makes you wonder. I mean, it looks like what they did is rather than go retrograde, they went through the medial wall, which is really kind of stupid, excuse me, but that just takes away any chance that you have of containing this and maintaining the scaffolding. And then looking at that damage of the tibial profile, you just wonder if that wasn't pathogenic at the time of the procedure. But now you went from difficult to really bad at this point. And I mean, at this point, you could talk to her about the possibility of an allograft to try to replace that. But the problem is you've already got the damage to the tibial profond. Exactly. And with that much damage now, you're just in a whole nother ballpark. So if the tibia was okay and normal, this is a situation where I would maybe consider doing an allograft. And I've done some, and it makes success. I mean, it's not one of those things where you hit a home run. When you have this much damage, when you think about, well, how am I gonna treat her for her ankle arthritis? Not a good candidate for total ankle because her tail is gonna subside. And you do a total ankle on her and you're gonna come back and do it again. You do a total ankle on her and you're gonna come back in a year later and the tail's gonna be sitting on top of the calcaneus. So really your option is, unfortunately, ankle fusion. So I think to do an allograft, especially if the tibia wasn't as bad, is a reasonable thing to try. I've not had good success in getting ankle replacements on patients that have had significantly large lesions either medially or laterally on the tails of this size. Because I think the tail just collapses. So I think right now, options are non-operative management with an Arizona brace to try to control it. Explaining to her that we don't really have a great solution for her. And sometimes the problems, you can't make better, but you sure can make worse. At age 36, it's tough because she's not gonna want to hear that. If you do an ankle fusion on her at this point, odds are, when she's in her 50s, she's gonna have subtalar and talon or vicular arthritis, and that's not a panacea. And so my discussion with these patients has always been, I recommend, look, you wanna get in an Arizona brace. Not perfect, use it the majority of the time. It'll get your pain under control. It'll slow down the progression of your arthritis. If you're getting dressed up to go out for dinner, you can cheat, go without it. I would get a little bit sore, but your goal is to not do anything definitive until you're 56 rather than 36, because otherwise, when you're 56, you're gonna have a lot worse problems than you have now that we potentially don't have solutions to. And I try to use a little bit of orthopedic psychotherapy here, because I don't know a way to hit a home run on this patient right now. This is a really difficult problem, especially in a 36 year old. And so Danielle Thomas asked in the chat, could you share a brief summary of your retrograde technique for filling a bone cyst? What type of cannula device are you using to pass the graph? Dr. Wapner or Naomi, go for it. Yeah, for me, it's easy. I have women do all these because she's a much, she does all the arthroscopies. I don't like arthroscopy. I don't do it because I don't like it and the wind's really good. So my technique, and Sam will tell you, yeah, this patient needs to see Dr. Chalamar. A question, if you don't mind, has any of you used the O-arm instead of the C-arm and localizing this interoperatively when retrograde drilling? What's an O-arm? The O-arm is the sophisticated C-arm or machine that they use now in spine surgery. And it gives you a much detailed image. I guess since I'm asking, the answer is no. I'm good. We are actually just purchasing one right now at our hospital. So very soon we'll have it. So Sam will tell us how it works. So I'm gonna answer a little bit the retrograde technique. I think you have to be able to have a system that you can cannulate a guide wire up to where the cyst is and a way to push bone graft or bone substitute up there. I actually did a woman about four months ago who had a large OCD with extensive Taylor edema. And I used Tactoset and I don't even know which company makes that. And I pushed it up into there through their guide wire and she came back to see me. She's thrilled. She'd been two years with pain and she's incorporating this Tactoset into her bone. But the thing is to be able, if you can see your defect on radiographs, you can put a guide wire up, you can then drill up to there. And I scoped her first to make sure her cartilage was okay. Cause I told her if your cartilage is not okay, this isn't a contained lesion and I'm not gonna stuff anything up there. But I think you need to look at what your options are to put into a defect of this size. How do you access it? I've done some of these by coming in medially and breaking in through that medial cyst wall, bone grafting it, doing other, I don't know, DBMs, whatever. But that's a sclerotic lesion. It's not gonna heal. And now it's a disaster. So I think you need to look at it, see where it is, figure out how you get to it and then just put something in there that fills that space and gives it support because that's gonna break down whether you put something in or not. So I just think you need to fill it in. Yeah, that's how I- I agree with this point. I mean, I think the reason you have all the edema on that tissue image is because it's in the process of breaking down. It's failing. Even though that lesion is sporadic, it's starting to fail and that's why her pain's getting worse. This is a tough one, Dan. So Danielle, to your point, yeah, I've done it similar. I've just taken like a Synthes 4-5 screw set and used the guide wire. You know, you can triangulate with the C-arm and then just overdrill with the cannulated drill. And then usually if you're gonna do bone grafts, you have to enlarge it to, you know, usually about maybe like a 4-5 type drill, and then you can, you know, push it in gradually. Either autograft from the calc versus the injectable ones are easier. I always scope them first as well. I'd be nervous about anything that involves breaching kind of the wall of the cyst from the side that's intra-articular rather than from below. Because then I worry about being able to contain it. But the point about scoping at first, I think, is critical because you never truly know just by looking at the cross-sectional imaging. So I have just a very small point to your point, Daniel. Well, you can freehand it, which is gonna actually work to your advantage because you're gonna be drilling more holes through the tails from decompressing it. What I find really helpful is an ACL guide, not with a tip. So as I go in with the scope, I put in my ACL guide through the anterolateral corner and rest it on the anteromedial corner. And it's not one of those ACL guides with a tip, but with a rounded, actually with a rounded guide. And you can actually drill the wire because I can localize, even if it's not showing on the x-rays, I can localize it inter-articularly and then aim that wire towards it. And that limits the number of freehand trials you're gonna go with it. But you don't want that wire, just Daniel's point, just his point, you don't want it to perforate the articular surface, but to get it just beneath the articular margin. And that actually limits the number of free trials I'm trying to get there without a guide. It's a good one. Thanks for sharing. That's why these sessions are wonderful. You mean tibial guide for ACL, I'm good? Yeah, the tibial guide, but not the one with the hook. The one with the rounded tip that can press on the surface, not the one with the, yeah, the tibial guide. Are you partying? Is that why you don't have a mask? I'm actually in the OR. Daniel, what is your plan? It was analogous to what Dr. Wapner had said. We had a long conversation about the fact that I similarly, you know, we spoke about the tough, you know, the difficulty of the problem, but it doesn't have an inherent, you know, easy solution. I worried about the allograft because of the plafond component. And so it's just supportive care. The idea that's intriguing is the role of bracing and preventing progression. I thought that was an interesting point that you raised, Dr. Wapner, not just for symptoms. I think we often think of it mostly for symptoms. It's something that I can talk with her about. And so that's where already this was helpful for her. And then the other thing I would be curious about is something non-medical. I think it's always benefit to learn from those that have more experience. One of the questions she asked is, was something done wrongly before? Should something have been done differently? And I'd love to hear, I think it's always benefits to learn from wiser people than yourself, how you handled those kinds of questions, not just the medical part. So I think you have to be honest with patients and I think the first question you'd have to say is in this, unless you have the opportunity of reading the operative report, you can't answer that question because you don't know. I mean, to me, it looks like they breached the medial wall when they did the surgery and that's the wrong thing to do at this time, right? If you see something that's been done incorrectly and a patient asks you that, you can say, in my opinion, that's not the way I would have done it. I'm not sure what that person was thinking, but it doesn't go along the way I would treat you. And you don't wanna be, we all live in glass houses, so I'm not a real big fan of throwing stones, but I think that part of our responsibility is to be honest with patients and it can come back and haunt you if you don't because if this goes into litigation, you can very well be called as a treating physician and then you can be asked questions. So you have something that you saw that was done that is obviously wrong. I mean, I have a case right now that I just got asked to review, it's unrelated to this. It was a high volume pressure washer, like 6,000 PSI pressure washer, right? Guy lost control of it, went through the top of his boot, lacerated the top of his foot, right through the shoe, goes to the ER, they had a consult and unfortunately the consult was with podiatry and the podiatrist came down, rinsed it out with a bulb syringe, closed it, sent the patient home, right? Guy was working in a fracking field, right? Three days later, he's in the ER, high fevers, gets taken to the OR, surprise, surprise, they open it up, there's shoe, there's sock, there's silicone, there's debris inside the boot, right? Well, if the patient says, was this done properly? You have to say no. And although you don't wanna be somebody that's going on, because we have people who always, there's those people in our, not just in our society, but in any medicine, well, anybody who, anybody that I didn't do was done wrong, you don't wanna do that. But I think you also have to be honest because you get called to testify and then you're under oath and then they say, well, Dr. Gus, do you agree with the way this was done? Is this done properly? Then you don't wanna lie under oath. So it's more of a problem. So you can tell the patient what your opinion is and you can say, in my opinion, I don't think this was done properly, this is not the way I was trained and this is not the way I would have treated it. That doesn't commit you if you don't wanna get involved from a medical legal standpoint. You don't have to become involved. You don't have to, depending on the state, you don't have to write the letter of, they call it, I forget the name of it, there's a letter that you write so they can start the litigation. And you can just say to the patient, look, at this point, I think that's a discussion, if you wanna pursue this, you need to get an attorney and pursue that with the attorney. And then it becomes the attorney's job to find an expert to say, yeah, you're next. But I think you're better off being honest than not being honest. That's my opinion. I agree wholeheartedly, Keith. I also think that I will tell the patients, I have 20, 20 hindsight now. You're a year, two years, three years out from what the initial treatment or thinking was and I wasn't there. So I can tell you what you have now, I can tell you what I would recommend now, but I can't tell you what should have been recommended back then. And I think you have to be careful because you don't wanna throw stones. And we don't know what the patient told them, presented, blah, blah, blah, blah, back at that time. So just be careful. Great case, guys. Do we have Dr. Passmore with us? Yes, can you hear me? Yes. Okay. So thanks for posting the case. You can take the lead and let's discuss this one. Thanks so much, guys. Okay, we'll go over the clinicals first. First of all, let me tell Dr. Wapner, I was a Brodsky fellow years ago and he taught us the correct way to stretch your gastrocnemius. So he's very good at that as well. Yeah, Jim wouldn't know. So anyway, this is a case, this is a 68 year old female that was referred to me with an obvious, I guess the terminology we're using now is a progressive collapsing foot deformity from posterior tibial insufficiency. I would call it late stage two in that she was flexible, but the deformity was pretty pronounced. And she was having not only medial and lateral hindfoot pain but also lateral ankle pain. And there are some images, I don't know what order, when I loaded these, they didn't all, yeah, I don't know. So I don't know, I think that's the later, that's the later MRI. And so there's her, that was an original X-ray, but that's how she presented. And she had a previous malunited first MTP arthrodesis. There's another, there's an AP X-ray as well, preoperative. There, and so, go back. Yeah, so that was her. And I don't know, these X-rays were done out by someone else, and so I'm not sure these are weight bearing, so you can't really appreciate the lateral talonevicular subluxation. There's also two MRI. MRI, she had an MRI. Do you have any ankle X-rays? No. Do you have any ankle X-rays? Yeah, there's one, that's later. This is pre-op, that's post-op, yeah. This is pre-op. There is an AT ankle. Like I said, I don't know how to get, that's later, yeah. Yeah, post-op. No, that one's later. Anyway. Yeah, just with the timing of this, to me, I really think there was probably something going on with the ankle preoperatively. Yeah, well, I mean, so the MRI scan, the preoperative MRIs that she already had done when she came to see me showed just pretty diffuse edema throughout the entire talus. But there was not a well, sir. Yeah, that's later. That's not the original. I don't know where the original MRI scans are, but they were loaded in here. That's one right there. So you can see the edema that's in the talus, but no specific cartilage lesion or osteochondral lesion, anything like that. And so- It's there. Yeah, I would, I'd wanna see, yeah. So I mean, if that's pre-op, she got it there. That's later. Later, yeah. Yeah, but I mean, to me- And that's later too. Yeah, so. Anyway, so the point of this really is, so she underwent a, that's an earlier AP, MRI and coronal MRI before. So, I know- Yeah, so she's- Go ahead. No, I mean, she's got all this, you kind of got trapped. I mean, all this stuff was going on ahead of time. You do your surgery, she gets, her foot hurts less and she starts walking more than this thing kicks in. I mean, I think it's the pre-existing part. I don't know what you can do, what you would have done differently pre-operatively necessarily. So this is an X-ray that, so I did a medial slide, a lateral column lengthening, medial cuneiform osteotomy, FDL transfer, spring ligament reconstruction, and strayer. And the foot position, and we do have some post-op X-rays, the foot position is dramatically improved. There's kind of a post-op X-ray. Her foot position was dramatically better and she was doing great until we take her out of her boot and let her start transitioning back into a regular shoe. And that's when she starts getting deceased ankle pain and swelling anteriorly and laterally. And the other, that other ankle X-ray that shows the lesion. And there's also, I've got a CT scan and an MRI scan all that I've done. And they basically have this large lateral talus, what the radiologist described as an insufficiency fracture. It's basically just a large, loose cartilaginous fragment sitting there with some eroded bone. And there's actually, you can see right there how it's kind of collapsing laterally. And her deltoid is actually confident clinically and the MRI scan didn't really show any pathology with her deltoids. I think she's just kind of subsiding into this lateral talus. And so the question, and there are MRI scans and CTs that show the lesion. There's one of the CTs. You can see how there's some, almost like some cystic change or some washout of joint fluid underneath that cartilage fragment there. So I guess the question is now, she's really limited with the ankle pain and the ankle pain and swelling. She really, I saw her actually this morning and the foot is fine. She's not really complaining of the foot at all. It's this ankle. And so I guess the question basically is, I don't know of any way to address this other than maybe considering an ankle replacement on her. I mean, I don't think you're, I don't think people would be interested in doing a hemi-talus on a 68 year old who does have some arthritic change in her ankle already. So I don't know of any other option except for an ankle replacement on her. Is there anything that I'm missing or is there any other option you can think of that I have not thought of? Yes. Yeah, so a couple of things. I always worry, and I got this, I guess, from Hake and Kofoid. Kofoid always said that if you had any degree of avascular change or any kind of cystic lesions in the talus, that he would never do an ankle replacement. And I think early on we kind of said, oh, he's just being a little bit overreactive. And we started the STAR study that actually became one of the exclusion criteria. But when you talk to people and who have done ankle replacements in patients that have talar lesions like this, there's a much higher percentage of failure. So I've gotten to the point where I guess the older I got, the less I wanted aggravation. So I just said, I'm not doing them. So I won't do ankle replacements in patients like that. I don't have good scientific data to back that up. And it was really just protecting myself from the aggravation that I didn't want to have. I don't know of any good studies and maybe somebody else does because the older you get, the less rigorous you get on following a lurcher. But I don't know of any good studies that really define how much AVN or how much change in the talus you can have and still do an ankle replacement. One of the components, let's say, go ahead. I was just gonna add, I talked to the radiologist today. We were looking at her studies and the edemas are out there. Go back to that previous, go back to the previous one you just had right before this one. That lateral. Yeah, this one. So if you look at that, to me, there's already a significant amount of collapse of that talus and you have the edema down below it. So then the question is, all right, well, how much of that are you gonna resect when you do your total ankle? All right, so depending upon the system that you use, it could be minimal, which means you're then trying to have that get in growth on bone that's really unhealthy already. Or are you gonna do something like a flat top talus where you just chop all that off and hope that the bone underneath it is okay and put a flat top on? But again, you don't know. So one of the options for you is, and this goes back to why I do so much bracing, is what I would do with this patient right now is I would put her in an Arizona brace. And I would say, look, we're gonna follow this along and we're gonna see what it does. And if I can get a bone stimulator on her, I would do that as well. And I would, the brace will control her pain. You know, it's not the optimal solution. And then I would wanna follow this talus along for six months to a year and see if that edema improves, see if the collapse continues or stabilizes. And then I think you have a much better idea of how healthy is this talus. I wouldn't be in a hurry to do something right now. And, you know, you just say to the patient, look, you know, this is the reason we're doing it. We're getting one data point here and we don't know whether that curve's going up or that curve's going down. And if you go in and you do a total ankle on her now and that curve's going down, well, that talus is gonna go down too, right into the calcaneus. And then you got a bigger problem. So you don't lose anything by biding your time and you will get her pain under control. You know, if she's religious and using her brace, the edema will improve. And, you know, about a year out, you're gonna have a much better feel for what you're dealing with. And I think then you can go back and reassess this. But I think in this patient, I think that's a critical way in looking at this is that you don't have enough data. I mean, if you think about it, she's in the boot. If she was developing an insufficiency fracture, it should have healed. You don't develop an insufficiency fracture when you're in a boot. That's how you treat an insufficiency fracture. So that's a red flag to me. Something's going on with her talus. And I think she probably had some pre-existing problems there, but it's worsening. And to be a mechanical problem that created an insufficiency fracture when you had her, you know, non-weight-bearing for a part, yeah, maybe that increases her osteopenia a little bit. But then you had her in a boot, you know, weight-bearing and progressing her weight-bearing, and then you can take her out of the boot and this whole thing collapses. Well, you know, if she had a stress fracture or an insufficiency fracture, she should have gotten better in that, you know, six, eight weeks that she was in the boot, not worse. And that's why I go, all right, something's going on with what's why the talus here. And that's why I would want to wait it out and see which way this goes. You know, you could come out a year from now if she's in Arizona brace, all the edema is gone. The talus looks normal now. And then you go back and, you know, do your total ankle, correct your lateral impingement that you're getting in the subfibular, all of that. And you're great. But you're going now and you're wrong. And that talus is undergoing ABM for whatever reason. No, you got a disaster on your hands. Yeah. And I appreciate, I agree with what you're saying. One question I would have is, do you think, the saying in Tennessee, do you think the horse was out of the barn with how this is going to look? When I did her surgery six to eight months ago, I mean, do you think it was inevitable that this was going to end up looking like this no matter what was done? Yeah, I mean, I think you had to address that problem. You know, her flat foot wasn't helping her at all. So I think that that's good. But, you know, again, I think this started, that's why I'm saying, I think this was preexisting to your surgery and it's just progressing. And, you know, we don't know why, but that's why I think using the Arizona brace and buying time and let's see what's going on with the biology of the talus. I do think, and again, I wish the hell when it publishes because I've seen her results. It doesn't work all the time, but sometimes it's very dramatic. And I've had patients that I've sent to her that have just done really well. It's hard to get a bone stimulator approved because it's, you know, the insurance company, Wiley-Hasselhoff, was approved for, but I've seen that work. You know, Sam and Sri, they're our fellows. I mean, they can attest to that. But I wouldn't do anything invasive for at least a year. I would try to control this with a brace and then see where the talus is progressing just to protect you and the patient. Is there any metabolic workup you would do for her right now? I mean, just, you know, normal vitamin D, calcium, but I don't think there's anything because, and this could be, you know, was she on steroids? Who knows? I don't know where it hit her. And this is the kind of thing sometimes you see it as, is it steroids, is it idiopathic? I mean, there's lots of questions you could ask to try to figure out why it happened. But I don't know of any good metabolic workup that's going to give you why she has unilateral, what looks like, you know, AVM developing in that part of the talus. Thank you. Thank you for looking at the case. Teaches, if you have a moment about bone stimulators, you've brought it up a couple of times. I know the data is mixed. How do you think about it? Is it, you know, the whole distinction between electrical versus ultrasound? What are the situations? Okay. So I trained at Penn, which is the home of electrical bone stimulation. Carl Brighton was the one who really pushed this. The clinical data between the two, I think is pretty similar. It comes down to, you know, that you got to convince that patient to wear that electrical simulator for eight to 10 hours a day, as opposed to the ultrasound, which is an hour a day. So I think you certainly get much better compliance with ultrasound ones. I think that skews all the data and all the studies is, you know, what's the compliance of these, of these patients? You know, I stopped doing trauma a long time ago, so I don't, you know, so the only non-unions I was getting, unfortunately, not a lot was ankle fusions and hind foot fusions, that sort of thing. And we, we use the bone stimulators in that situation and it seemed to help, but we never, never really followed it, you know, clinically where I could say, okay, I did a study such and such. When has the data on her AVN, on her tailor lesions, because she did follow it, she just hasn't published it. And I've seen that data. And that's why I, you know, I've, I've brought it up because it's, it's impressive. I mean, she presented this, she presented the data at the IFAS meeting in Brazil, which probably was 12 years ago, but never followed up by, by publishing it. And that's good data. Excellent case, tough case, very difficult case, Roger. Thanks for sharing. Keep us posted what, what you did. I do want to move to the, at least do one more case. We have to be respectful of the time. So we, 9.30 central time, we usually would like to be finalizing, but I would like to do Danielle Thomas, because I see that she's here. Danielle, let's, can we do a short version of your case? And I'll probably have to, so why don't you tell the story? I can sum it up. I can make it real quick. This is a young surfer and volleyball player. She was seen by a podiatrist in 2019, underwent first TMT fusion, second hammer toe correction, and an aroma excision. Everything did well with the exception of the second toe, which continued to have pain. MRI showed some edema around a little implant that had been used. So in June of 2021, she had that implant excised. And while he was there, he also repaired her plantar plate. She comes to me with persistent, severe second toe pain, really focal to the second toe. This is not the second MTT joint. It's in the toe itself to the point where she can barely walk. And the worst of her pain is with push-off when she's loading the toe. Unfortunately, that's what she needs for her sports, volleyball and surfing. She has tried all the conservative measures I can think of, non-weight bearing period, immobilization, shoe wear modifications, carbon fiber inserts. She's refrained from doing her sports. And we even did get a bone stimulator approved and put that on the second toe. On exam, her second toe is quite shortened. Her cascade is disrupted. It is very tender over the proximal and middle phalanges. And otherwise her drawer test is negative. There's no instability. It's really focal to the toe. Her latest MRI shows significant edema around where that implant had been. There's no clinical signs of infection. The radiologist is reading it and I'm interpreting it as it's almost like a just persistent stress reaction. There's just edema in the bone all around where that implant was. I would love, I'm just out of suggestions for her. And she's in so much pain. Her quality of life as a young active woman is really diminished. So if anyone's seen anything like this, or would you consider amputation? Would you, I don't really have a great revision surgery option for her. I'd love any thoughts that you have. I just want to say, I'm trying to open here. I could see it before, but for some reason, I already refreshed and I'm not being able to download or to open them. So if you can send me the images while we discuss here, but I'll, I'm trying to zoom in the more I can here. So Dr. Wapner can take a look here, but it's not, it's not good. So let me ask you a couple of questions about her exam. So when she does range of motion, she's not in weight-bearing sitting on the table. She does range of motion of her MTP joints, no pain whatsoever at the MTP. The pain's more like at the level and the pain's more at the IP level or is it IP and VIP? More at the IP and the phalanx itself. All right. I mean, a couple of things that I wonder about is, one is if any of that's related to where her neuroma was excised and if it's nerve related pain. So one thing that I would look at is just doing an injection in that second web space with some anesthetic and see if that changes her symptoms. Cause I have seen, it's almost like phantom pain. I've also seen patients that had incompletely resected nerve and basically had continued toe pain related to that. So that's, that's one thing to consider. Can I interrupt you there one second, Dr. Wapner? If that was, if that is positive, so if you do conclude it's some type of phantom nerve pain, what's your next step for treating that? Well, so one is you want to see, and we do these under ultrasound guidance. And we look at the ultrasound just to see, you know, is there a bold neuroma at the end of that second nerve? Was it properly resected, proximal enough? And again, this is, I have a patient that I'm thinking about specifically that was very similar to this. And I don't know if this is the answer here, but basically when she had her neuroma excised, it was excised right at the level of the transverse myocardial ligament. She got a bold neuroma. She was walking on it all the time, but where she had majority of the pain was that she just talked about the burning pain in her toe, not so much in the web space. And so we, we did an ultrasound and you could see the bold neuroma. They injected her with Marcane and basically for six hours, she had absolutely no pain. And her, we went back and resected the nerve back to about the mid shaft of the metatarsal. And I think that anytime you do neuroma surgery, that's kind of where I'm trying to get that because anytime you cut a nerve, you're going to form a bold neuroma. And the last thing you want is that bold neuroma to be on the waistband surface of the foot. And she got better whether that's gone on here or not. I don't know, but it's certainly something to think about. The other thing to think about is if there is some type of low grade infection that's staying in that bone itself, or if there's somehow some local nerve entrapment around the toe itself. So if you inject the web space and she goes, well, some of my pain went away, but it's just the lateral side of the toe. Well, then that's not from the neuroma. That means there's something in the toe itself because the medial side of the toe is the first web space nerve, not the second web space nerve. So it does help you distinguish that a little bit. If she has no pain at all with MTP motion, that you can almost, it is a little radical, but you could consider doing an amputation. But again, you then run the risk of having phantom pain. So it's just without being able to really see the images, it's a little bit difficult. But I would be, you know, when you think about chronic pain like that, I always think about some type of a low grade indolent infection as being the source of it. So I think the other thing to do is, is just open it and get some cultures and get some pathology and see, you know, is it dead bone? Is it infected bone? And see if that gives you an answer. So I would do cultures and I would also look at the path to see what the health of the bone is. Those are the only things that I can think of. Thank you very much. I'm sorry about that. I don't know what happened with the imaging there. I'm sorry, not being able to open it. I don't know. I think I saw it earlier. Yeah, I think it loaded earlier and then refresh. We'll just blame it on Susan. I'm sorry. Yeah, it's fine. Blame it on me. So Amgad wants to run a quick question through Dr. Wapner here. Because he's the boss, I have to do it. You don't have to do it. I always post my cases first. I never get to present them. So it's just a punchline question. I've got about that much bourbon left, so you can ask. All right. So it's what I learned early in Brazil. Amgad, the boss asks, you just go for it. No questions asked. Anyways, I'm going to make it super, super quick. Without going through the history, a 51-year-old diabetic with sarcophagic changes came to me. He had underwent a TTC fusion. Cesar, you can jump to the images. I know the history. He underwent a TTC fusion outside by another podiatrist for cavovirus deformity. And then the TTC nail failed once. That podiatrist switched him to another nail and put an Elizabeth frame over the nail and compressed it. And then four months later, took out the Elizabeth frame and let the nail in. And he came to me with these x-rays just last week. So a fused ankle, a broken nail, nonunion of the subcalar joint with residual forefoot pronation. And I don't know what these two places across the TTC joints are doing. In my hands, I know what I'm going to do. So I'm just running the infectious workup. I'm going to remove it. But I want your tips and tricks. I've taken out broken locking screws and nails before, but I have not taken out a broken TTC nail. So here, I'm going to make your life a little bit easier. So basically, they never fixed this hindfoot deformity. You still got cavovirus. And the reason the nail keeps failing at the subcalar joint is that's where the inversion and eversion is going to go. So that's where the pressure across the nail is. We do have nice hindfoot Saltzman's views, Cesar. If you can get them, that shows the varus. Yeah, there it is. Right. Yeah. So they never fixed that. So really what you have to do at this point is, I would leave that proximal part of the nail in. Because you basically need to do a triple arthrodesis on this guy and probably a closing wedge osteotomy through show parts to get his heel back in a normal position and his forefoot back in a normal position. And if you take out all the existing hardware laterally, because that's a non-union, and you loosen everything up, you're going to be able to rotate that hindfoot significantly back into its normal position. And basically leave that proximal part of the nail in, because it's not going to interfere with your fixation. You can fuse your subcalar joint by putting screws around that nail. And the nail broke proximal to the subcalar joint. So once you finish your workup, rule out infection, all the rest of the stuff, when you go back to actually fixing it, unless you go in, I would take out the distal part of the nail, take out the plates at the CC joint, get some cultures. See, as long as everything comes back negative, then I would come back in this situation, fix my hind foot, get it in the right position, do whatever osteotomy you need to do as part of that fusion, you know, fix that, assess your forefoot position once your hind foot's corrected, because you may need to readjust your forefoot once your hind foot's in the right position. All right. But I wouldn't even, if there's no evidence of infection, I'd leave that proximal nail in place. And if there is evidence of infection, sir? If there's evidence of infection, then what you're going to do is, the easiest way to get that out is take out your screws, all right, take a guide wire from like a, one of the nailing systems, but a smaller guide wire than the size of this nail. All right. And basically what you want to do is put a little bend, like a little hook at the end of that guide wire, almost like about 180 degrees, but you want a smaller guide wire because you want to slide that guide wire all the way up proximately to either the top of the nail to where that longitudinal slot is. Touch that hook on that slot, and then that allows you to pull the nail out. And that way you don't have to try to make a bone window approximately and try to work it from the top down. If there's infection, this nail is going to be loose, right? So once you get the proximal screws out and that, you know, the tailor screw out, if you can just slide that little wire up with a little hook, grab it on the distal part of the nail, or the proximal part of the nail, you'll be able to slide that out. That's a very nice tip. Thanks a lot, sir. Okay, we'll let Cesar do the closing remarks, but Sam, since you were moderating and started the session, any final words? Well, I would like to really thank Dr. Wapner for taking the time to be with us today. We really enjoyed having you, and go New England, forever. You know, you try to train them, you teach them every day. So, all of you guys, before, nobody leaves here because we need the picture. Remember, if we don't take a picture, it didn't happen. So, we turn all the cameras on. Before we take the picture, I would like to thank everyone for being here. We have very frequent flyers here. Dr. Wapner, thank you so much for the great case discussion. You're sharing your expertise with us, and we really appreciate it. Thank you so much for being here. Case discussion, you're sharing your expertise. I do want to announce that inside the Young Physicians Committee, I first would like to thank AOFAS and the Young Physicians for the opportunity of leading this task force that started with the SE Expert Session. It was a great pleasure for me to lead it, guided by the prior chairs, and now with EMIGAD being the chair. So, thanks so much for the opportunity. We decided in our last meeting that we would change things a little bit because we want all the members to participate. So, I'm stepping down as the chair of this task force, and I'm very glad to announce that Matt Conte, that is a very active member of the Young Physicians Committee and has been doing a great job with the podcast, will be leading this task force now. So, Matt, I'm sure you're gonna keep up the great work that the committee has been doing, and we're very excited to have you. Thanks for being here with us. I can see that we have other new members from the Young Physicians Committee here, like Shamrock, so it's great to see that. I'm still young, don't get me wrong. I'm not going anywhere. I'll still be here bothering you guys, but I'm not just gonna be taking the lead anymore. So, Matt, good luck. Keep up the good work, and again, thank you all guys for being here, and thanks so much. Let's do the pictures. So, one, two, three. Picture, picture, picture. Now you can go crazy. Go crazy. Go crazy. Excellent. That was good. Before you go, I just want to say I see several of my former fellows and residents and even a former partner on the line, and I just want to say thank you all for joining. It's great to see your faces, even if we didn't get to talk one-on-one, but it's good to see everybody, and everybody looks healthy and happy. It's good. Thanks. Everybody have a great holiday. Thank you so much. We will be out for the end of the year, of course, but we're back in January with Lise Cody, and before you guys go, otherwise Dan Guest is going to be mad at me, so please register for the winter meeting. The registration is open. It's going to be very fun because it's going to be a light scientific agenda, so we can have fun in the swimming pools and get to spend time with each other. It won't be light. It'll be efficient. That's what it will be. It'll still be a very nutritious meal, so please everyone attend, and actually this session inspired an actual session within, which will be an Ask the Experts session in a smaller group setting to sort of cross generational divides and make friendships that you otherwise may not have made. Optimized. That was the problem with the Portuguese-English translation. That's what I thought. I just couldn't say that, okay? You guys have a great night.

video

cases

management approaches

ankle pain

cyst

retrograde procedure

bone grafting

prognosis

second toe pain

nerve-related pain

infection

TTC nail

evaluation