That's four minutes past the hour. Good afternoon slash evening, everyone. Thanks for joining us for this session of Ask the Expert. I'm gonna share my screens. And today we have the honor of having our inaugural female expert of the season, Dr. Naomi Shields. This is an accredited session with 1.5 CME credits. So please all claim credit at the end of the session. Dr. Naomi Shields, our expert of the night, was born and raised in Central Western Massachusetts. Graduated from the regional junior high school, played field hockey, basketball, fast pitch, and softball. She then graduated third in her class, attended Rennesselaer Polytechnic Institute and Albany Medical College in their six-year biomedical program. After completing a catechological internship at Albany, she went to Rhein-Main Air Force Base, Germany as a general medical officer. During her time in Germany, she learned how to ski, won a bronze medal in the USAFE cross-country race. In 1985, she was the first woman orthopedic surgery resident at the Wilford Hall USAF Medical Center in Texas. 1991, 92, completed her foot and ankle orthopedic fellowship at the Medical College of Wisconsin, and then proudly served 11 years as active duty in the US Air Force, finishing her career with a lieutenant colonel rank. She's a highly regarded orthopedic surgeon humanitarian, a former AOS and AOFS board member, and the 2020 recipient of the AOFS Career Impact Award. She's had 50-plus humanitarian medical missions to Vietnam, Costa Rica, Haiti, Nicaragua, et cetera. A broad foot and ankle expertise in deformities, reconstruction, total ankle replacements, arthritis, and sports medicine. I first came to know her in a case-based discussion course that was industry-sponsored. I sat with her on the table, and I was really astonished by this very soft-spoken, humble orthopedic female surgeon who had a lot of insights into many difficult cases. I then had the pleasure to join her in the Egyptian Foot and Ankle Society meeting just before COVID in November of 2019. And ever since then, we've become very good friends. She joined us with Dr. Nunley and our good friend from Egypt, Mohamed Mokhtar, whom I believe will be with us on the call tonight. I always describe her as a person with a beautiful small soul and an ever-lightening smile on her face, and an excellent orthopedic surgeon that I hope we all benefit from her insight on today's cases. Without further ado, Dr. Naomi Shields, welcome to today's Ask the Expert session. And I'll grant you a few words as Cesar gets up the screen and introduces our housekeeping items. Wow, Amgad, that was amazing. Thank you. I've totally enjoyed my time with the Egyptian Foot and Ankle Society and getting to meet. And for those of you who are unaware, the Egyptian Foot and Ankle Society is a very up-and-coming society and are making a big difference, I think, in the Middle East, particularly for foot and ankle care. I've been totally impressed by the quality and what they do over there. So Amgad asked me if I would be the expert. I'm like, okay, I'll do that. It's a great honor and pleasure for us to have you, Naomi. Thanks for sharing with us your expertise. I see just familiar names, most of them here. So what we usually ask that this is a case discussion of cases that were posted in our AOFA-Aspen Act website. So we cannot discuss other cases that were not posted in our website in AOFA-Aspen Act. In our website, in AOFA's website, we ask that guys, if you want to ask questions and interact, please turn your cameras or at least your mic on and ask the questions. We're here to interact. I think the interaction is the most important part. And we always ask all of us to behave like we would behave on a grand rounds or something like that. And we try to protect patient information here. We shouldn't give any patient identification information during this session. And I think without any further delays, we can go to the first case. We have Daniel Guz with us. I'm here. How are you doing everyone? And thank you, Naomi. Hey, Daniel. I really appreciate it. You sent some wing dingers today. They were sent to me first. I just passed the baton. Here you go, Daniel. You can take the lead there. You know, I'll run the desktop here. And so this first case is literally a patient I just saw yesterday. He's a 63-year-old male and incredibly kind and to his credit, honest gentleman. He's had multiple admissions over the years for alcohol detoxification, the last in our system in 2020. He states that he went through some difficult times, no longer drinks hard liquor, but does drink six beers per night. He's been on disability since the mid-2010s for a neck injury that he sustained. And he presents to clinic about eight and a half months after having undergone a foot procedure by an outside provider. And while he does have some residual foot pain, his greatest complaint is ankle pain. On exam, he has significant swelling of the ankle and hind foot. He does have, you know, pretty preserved amount of ankle range of motion with about 30 degrees, including five, maybe even slightly more, degrees of dorsiflexion pain along the tibia tail or joint more so, but also along the medial column. And so he comes to me having seen two other outside non-orthopedic providers who had recommended an ankle replacement and showed up in clinic expecting to be signed up for an ankle replacement. And so I only have these x-rays, you know, we don't have any cross-sectional imaging yet, but just as, you know, obviously we're looking at x-rays. I tried to provide broader contracts given that we treat people, not x-rays. And I'd love to hear your thoughts. How would you approach this complex situation? Can you just go through the x-rays so people can see? Because there's a lot to consider here. Caesar is the one with control. I have very limited control over many aspects of my life, including this. Same here. Is that moving? Are you, do you guys see it moving, the x-rays? So you have an AP that shows tailored to first MTT fusion. I don't think all of it's fused for one. It's done, there's also a sub-tailor fusion. And the thing I think is really affecting him is his medial column is elevated. And so he's going into valgus through his ankle joint. And I'm not sure, can you go back one, Caesar? I'm not sure if there's, if you go to the most proximal two screws, I don't know if that's a break in the plate that's impending. Between the two screws and the third most screw. You see what I'm seeing there? It may just be the plate. Yep. Or the overlapping plates. But I'm not sure the navicular cuneiform or the tail navicular is healed. But I think the bigger question is his ankles and valgus. So I'm gonna throw back to you, Daniel. If he didn't come in with the drinking history, and he was Joe Blow without that, what would you do? I would sign up for an ask the expert session, no matter who it was. That's not an option on the table. And so the honest truth is, when I saw him, and I thought this was an incredible kind of starting point for a lot of discussions. And obviously the taking into account social history is key, but the reality is what the understanding of some of the public of what it means to have an ankle replacement. And the fact that just because your ankle is arthritic and painful, doesn't mean an ankle replacement. And so the reality for him is, what I told him is, I'm respectful of other providers, but I am pretty convinced that if you elect by someone, other than me to undergo an ankle replacement, it will fail. Because you can't, an ankle replacement is dependent not only on the ankle, but also the foot. And it's like building a building on a crooked foundation. It's just, it's going to mechanically fail. Right. I think that's especially true of Valga as compared to Varus. And so, even remotely considering something like an ankle replacement, which is what we often do when other joints around the talus are fused, because the pan-taler fusion has marginal outcomes. And are all relative to what your other options are. You have to somehow sort of reconstruct the foot first in order to therefore be structurally even able to accommodate any sort of prosthesis up North. So that's the point. I mean, stay on this Caesar, because if you look at this lateral, your foot is rocker bottom through the midfoot, even though they put a straight plate on it. But they didn't get the bone straight. And I think that's driving him into Valgas. And if you were to do a total ankle, and that's an if, you've got to bring that medial column back down to provide the tripod that Daniel's talking about. Your other option instead of surgery, because your social history is a little sketchy. I mean, I think you need to see him more than once to figure out his support system. And unfortunately, the social history is a big issue. Because if you could plantar flex that first ray and put an ankle in, I think he would do fine. But what's his neuropathy? What's his social status? And so he lives at home with his wife. His niece, for better or worse, is at one of the major medical centers and finally said he should seek care. He himself said he sought care at a medical center before for other things. He just didn't think the foot was that big a deal and that he could do it locally. And so I think for him, to your point, is you have to bring the entire foot out of that severe Valgas. Because the reality is with that ankle tilted in its current state, it is plantar graded. It's just in severe Valgas. My worry for him is that even something like plantar flexion, the first ray, the ability of that to work is very much predicated on the hind foot joints being able to then accommodate. And given that there's been attempted fusion, I think the majority of them are unsuccessful. And the big unknown is the status of the subtalar joint too. Ironically, if that one united, that makes it a lot harder to then bring his foot out of this severe Valgas. And so my next step was gonna be to get him a CT scan. Do you have the ability to get weight-bearing CT? Yeah, we do, we do. The only downside is the, and it'd be interesting. And with Cesar listening, let's collaborate. You know, the idea of the contribution of metal suppression to be able to see better, you know, these algorithms that are not yet available on weight-bearing CT, at least not on ours. And so often I find that when there's a lot of prior implants, we're choosing between the benefits of metal suppression versus the advantage of seeing what the foot looks like plantar grade. The latter usually outweighs, but in this case, I think the big question is what's going on with the subtalar joint and then what sort of revision fusion he would need to successfully undergo before you can remotely consider anything up north. So if you were to try and brace him, how would you write that script? And so that is a script that is already written. And interestingly, he already has an Arizona brace. So we're gonna try something pretty severe, a crow boot. So when you're writing that crow boot prescription, are you having them add medial posting to the forefoot to help take him out of valgus in the hind foot? Again, traditionally you would certainly think about that. The issue you have here is anytime you do posting, it's dependent on at least some degree of the foot to be able to accommodate. You know, what I always tell patients is at the end of the day, we only have two options. You can either change the way the foot hits the ground, which is surgery, or you could change the way the ground hits the foot, which is sort of a realigning orthotic. You know, in his case, I think because of the prior attempted fusions, you're sort of wedded to accept and lock him where he is now, at least to some degree. I mean, I think some degree of medial posting will give him support, especially to the deltoid and prevent further, or at least try and prevent further tilt. But I think this is what makes this so hard, is you almost, you know, and I've asked them to come back to your point, 100% agree. See patients with complex problems multiple times before you sign them up for anything. Develop a relationship, understand what their chief complaint is, make sure they understand what your point of view is. What's his end goal? What is he looking for? He just wants to be pain-free. You know, he bought an RV last year, and they envisioned this retirement of driving around the country in an RV. And so this is more than just pain. It's sort of this retirement dream and life coming crashing down on him. He's a very genuinely nice guy, and to his credit, very honest. But he's got a tough problem. And it's hard because everything is related to expectations. When he literally walked in my clinic thinking, oh, I'm just gonna sign up for an ankle replacement, then I'll be fine. So can I, just so that we can get a home message from this case, I'll ask a series of questions on Naomi and Daniel and Cesar and whoever's on the call, feel free to pitch in. Just a record show that my name is not on the, ask the expert head, you know, title. But you posted. I'm not on the Broadway play, I'm just in the acknowledgement. So what were you saying? I want to hear what Naomi has to say. Let's do a poll. I mean, number one, should you get a weight-bearing CT or a metal suppression non-weight-bearing CT? Number two is, would you do, of course, we all agree to a stage procedure, but would your stage procedure involve removing all the hardware, reassessing, realigning the foot generally, and then going back and doing an ankle replacement, or would it be a single stage horrendous procedure? And depending on this last question, what would you do in the foot before attending to do the ankle? And then finally, would it be a primary prosthesis or revision prosthesis? That's too many questions for my pea brain to remember, but let me start with the first couple. First, I would love to have a CT scan weight-bearing. I have no accessibility to that. So the only option I would have is a non-weight-bearing metal suppression. I suspect it's going to show massive non-bridging, non-unions, but I'm not hearing that he's painful through those joints. He's marginal. I mean, he does have some tenderness there, and so it's not that he's not painful, it's just the ankle supersedes, and that's a great point to truly understand, not to be drawn to the x-ray and assume you know where they hurt. So I think you get the CT scan. If you can get a weight-bearing, great. More power to you, I'm so jealous. But if you can't, then look at it. And if he has a non-union in some respects, that's almost a gift, because then you can correct the non-union and correct, I mean, the talus is plantar flexed, it's driving your foot into valgus. And in correcting his foot position, bringing his ankle back, I mean, he's lost cartilage on the lateral aspect, but you might actually give him a foot that's braceable and in line without taking out his deltoid, and he may not need an ankle. I mean, I think you've got to realign the foot before you do anything with the ankle. And anyone in the audience who wants to chime in, you're welcome to. This is where I would love to benefit from everybody in this group. I know even if you're not in the title, Bill. I can give my input, Daniel, but I'm also not on the list of the experts that I can, I suffer with this kind of case here as well. So, I mean, I think the part that I can tell you with more experience is the weight-bearing CT part. I think that for this type of metal, I think you can get a regular weight-bearing CT, and you're going to be able to see the mid-foot joints for sure, and the subdural joint without having tons of problems. I don't think you need, I think the weight-bearing is very important here, so I would not go non-weight-bearing. I would at least try the weight-bearing CT, and then if you have to fight with the insurance later, if you don't like the quality of the images, I would still go for the weight-bearing because I think it's a game-changer point here. The second thing is, if you want, I think any of the, I know which machine you have, so I'm giving inputs without providing names here, but one thing that most of the people don't know is if you want matter-of-fact reduction, it's on the acquisition time, and I do think that the weight-bearing CT that you have already has a matter-of-fact algorithm there that you have to click before you scan the patient. So you have to, I would call your radiology tech and talk to them and make sure that they are using whatever is the algorithm that they have there, but they for sure should have one, even if it's not the up-to-date person, and if it's not, you should contact the company and get the up-to-date software for your hardware to make sure that you have the best matter-of-fact reduction available. I totally agree with Naomi here. I think that, I disagree a little bit with you with the fact that you mentioned a couple of times that the medial forefoot post would only work if the subcutaneous joint is moving. I think that when you fuse your subcutaneous joint, then it makes even more critic that you, and I learned that with Dr. DeLand, he's always very careful about the first rate for anything that he does. If you fuse your subcutaneous joint and you have a dorsiflex first rate like Naomi's mentioned, the whole stress is gonna go to your ankle. So I would assume, and I would bet that this ankle was not at all bad before the surgery that was done, or at least was minor. And then after the surgery, well, since they dorsiflex the first rate, the whole stress, when now the whole medial column's stable, even though it's not completely healed, and now the whole stress is going to the ankle joint. So I- I completely agree with that. So we actually, I see that Neil is here, so we actually did a cadaver study when I was in Baltimore for my last fellowship, and unfortunately it's not published yet, but what we did was we looked into the ankle pressures after you change the position of the first rate versus the ankle pressures when you change the position of the medial, with a medial displacement calcaneosteotomy. And what we found was marked difference that when you move your first rate, the pressures in the ankle changes, it changed significantly compared to the medial displacement calcaneosteotomy. In other words, if you want to do something to protect your ankle in a valgus situation, move your first rate, because it's going to be much more effective than your, than your calcaneus. And we usually do the opposite. I mean, when you do a total ankle and you think there's still some residual valgus, you usually go with MDCO, and we should do the opposite, in my opinion. And when you fuse a subtalar joint, I think that would be even worse, and that would be the follow-up study that we were planning once we published the one that we already have the data. So that, those would be my inputs in this case. No, and I think that's an excellent point, because with the whole first race studies, it makes sense because you have a bigger, it's like a golf swing. The further you are from the hole, the more a slight correction makes a big difference. And so, no, I appreciate it. It's a longer lever arm. That's why we did the study, because it makes sense that it's far away from the center of rotation of the joint, so you should inflate much more. And so that's the hard part. I mean, the reality, I think he did have issues. The hard part is he did have issues with the ankle. He explained to me, and he was sort of informed post-facto, oh, maybe we should have done the ankle first, which again is not something I agree with. Oh, okay. Because I believe in doing the foot first, but no, I appreciate that input, because certainly, you know, his foot's rigid, but if we can even unstress a little bit the medial ligaments of the ankle and try to preferentially load even a little bit the medial plafon over the lateral plafon, that may go a long way with them. And then the only other reality is, to Naomi's points that I love, there's two things. First of all, the fact that a nonunion at the subtalar joint will be a blessing, ironically. And then the second part, that once you correct the foot, the default to saying total ankle, the rest of them doesn't change. You know, it's what I think the usefulness of understanding what's healed and what isn't, is the extent to which maybe you can accept not everything that's non-united needs to be made united, especially, you know, given the number of joints. At the end of the day, getting them aligned is more important than getting them united. And then the second part is, you may consider, you know, for someone like him, the bad, quote, badness, given a social situation and other demographic situations of a pan-tailor fusion may not be the end of the world, or accepting some degree of nonunion and doing some sort of TTC in forefoot. I think there's other permutations that we wouldn't be ideal, but that may be a safer bet in him than relying on a total ankle when all is said and done with this amount of deformity. And so I really appreciate everyone's input and the role of, I think, even how we think about nonoperative management with medial posting for the ankle, rather than the hind foot is in and of itself a gem to be taken away. So thank you. A question from Sam. What if the subtalar joint is fully fused? Dan, did you get an axial or hind foot alignment view? No, we haven't. He sort of even deferred initial films. He wanted to meet first, and he said he had external weight-bearing films. And so we're sort of, I'm seeing him back and getting sort of newer films, because even these are a couple of months old, getting a weight-bearing CT scan as we're trying to move forward with the immobilization. But that's a great idea. We're very lucky that we, you know what I mean, are able to get weight-bearing CT scans, which I've found very incredibly helpful for these deformity type procedures. And so that's our next step. So Sam, if the subtalar joint is fused, I would look at the hind foot alignment. I don't think there's a single weight-bearing CT scan in San Antonio, sadly. If somebody knows, I'd love to know it. So I have to rely on X-ray and regular CT. I am concerned that the talus is plantar flexed in that subtalar fusion. If the subtalar joint is fused and his hind foot is still in valgus, not relative to the ankle, but just between the calcaneus and the talus, then I think you need to take the hardware out and do an osteotomy to correct the calcaneus back into alignment, as well as the midfoot. And in a general question for people, when we do these big medial column fusions, people who are mobile and hyper, and then we lock them up, I'm starting to think they're as miserable because they're rigid. Then if we'd left him some motion through things, and I don't have the right answer for that yet. That's one of the questions that I've been having over the past year. And I think that's why Daniel goes through this case on us, because a pantelar fusion here is gonna be a catastrophe. I mean, he's gonna end up with the most rigid foot, and that's why we're trying to salvage the ankle. But in my humble opinion, and without looking at a weight-bearing CT, I think this guy had what we call a fusion in sito. So they never prepped the joints. I think they just put on a plate there to bridge everything, and I'm not seeing any signs of any fusion whatsoever. I can even see all the joint lines clearly on the medial side. So I guess it was just an attempt of fixing everything without attempting to prep the joints and fuse them. So you might end up actually with a little bit of motion that would enable you to compensate a little bit on the first try. So Daniel, you need to let us know what the CT scan shows. No, I appreciate everyone weighing in. It's a tough, tough problem, but I appreciate the benefit. This is what the beauty of these sessions is. And I actually, I'll go back to patients and actually tell them that they were presented on Ask the Expert. Oh, I do too. And they totally love the idea. And I'd say it was autonomous. They totally love the idea that, you know, internationally, you know, nationally, internationally renowned. And so anybody who weighed in here, thanks so much. It means a lot to the patients that we take care of. Actually, I'm operating on a woman next Wednesday who I presented on here months ago who had a scarf that went really bad. And, you know, everybody's advice was you can't save the first MTP joint and you're gonna have to fuse her first TMT because that's unstable. So I'm doing her surgery next week and she was very accepting because I'd gone through options in my head. And I said, I presented this, your X-rays. This was an international forum. We got involvement by all these people. She thought that was so cool. Okay, can I just type in and say, I'm coming to all of you for quotes. So Mark, can you clean something up? Before we wrap up this case, any comments from the audience? Yeah, I do have one comment before not showing up. I promise I'll show in the next X-Ray expert. I actually try to prepare this case. But I did a lady recently, a young lady, we've failed. She had a double coalition, Calcane and Avigler and Taylor Calcaneo. Someone resected the Calcane and Avigler coalition. And I went there, resected a big, painful Calcane and Avigler coalition and did a sub-tailor joint fusion because it was huge. And she had the traditional collapse for the coalition. So I thought I did a great job. Put a wedge on the sub-tailor joint and turning the wedge around to correct and bring her into more of errors. Corrected the sub-tailor joint. And six months later, the ankle is worse than this one. And she had zero problems in the ankle before I did the sub-tailor joint fusion. So I actually thought I had done a great job. And I mean, I literally put her into this situation with not enough correction. And I really think that that was, even having the coalition, I think she had some micro motion and some minor motion that would accommodate the bad deformity that she had. And once I went there and fused the sub-tailor joint completely, that was the only successful part of the surgery that sub-tailor joint is fused with the wedge there. And now the ankle was really bad, but I was following it up. So it was acute. So I don't think there's a lot of cartilage degeneration. I actually have an MRI. And then I just went there with answering the last discussion that we had there. I decided to not do anything to the ankle. I went there, did a MDCO, very big push, and did a lapidus on top of the plantar flexion lapidus. I've been using wedges. I've been very aggressive with bringing the first ray down. So I did a first CMT fusion, bringing the first ray down with a wedge, plus the MDCO. And now I'm praying here. So the ankle was gonna be saved. That's a question along that line that I've wondered about is, and maybe we can do a biomechanical study, I found that an opening wedge of the medial cuneiform lets me plantar flex more than a lapidus. I understand you're using a wedge, but let's say the traditional lapidus, because at the end of the day, I can add a bigger wedge than I can resect from the plantar medial cuneiform, right? So it strikes me as a little bit more powerful. And I've done this in some flexible flat foots, and you'll literally, to your point about the power of plantar flexion in the first ray, and to Naomi's point about it, you'll get like, you'll literally get tailor head coverage without a lateral column lengthening. Oh my gosh, don't even tell me that. Don't even tell me that. It's incredibly powerful. And so how do you decide, Naomi, how do you decide between, since you're the, like I said, you're in the- Oh, I'm on the expert list today? Exactly. Yeah, I got it. You'll never accept it. Now you can't get off that list. That's like a buy list. I'm okay. You can't get off the buy without asking a question. What, how do you decide between a first TMT fusion and a cotton? It's, for me, primarily clinical. If their first TMT is unstable, and I know there's people who say you can not clinically test the first TMT and see if it's unstable, but when I take it and check it up and down, reduce their IM angle and it stabilizes. So if their first TMT is unstable, I go through there. If not, I go a cotton. I'm doing one of those tomorrow. It's kind of an interesting foot. I'm going to do Z calcaneal osteotomy because he's big and he needs lengthening and rotation. And then I'm going to do a cotton to bring him down. And he's also ADD and obsessive compulsive. So you get into the psych and everything else when you're dealing with some of these patients. But I think I look at stability. I mean, if my first TMT is unstable, I go through there. I think the cotton gives you more leverage. And I think if you're doing a first TMT, you have to really pay attention to not taking more bone off dorsally because that's easy to do and really focusing on taking more bone plantarly or putting in an opening wedge. I hate to bother you all, but my alarm has been clicking for the last 10 minutes. We went overboard by 10 minutes on this case, but it deserved because it was a very difficult one. But unless we want to go through everybody's cases, we need to move on. So I'll prompt Dan. Thanks a lot for the great case. Thanks, Dan. Oh, thank you all. Let us know what happens. Yeah. And then let's move on to the next case. Daniel Thomas, are you on the phone or the call? Hi, everybody. Yes, I'm here. Go ahead. Hi, thank you so much for your time. My case is a 31-year-old runner. She had a plantar plate rupture, which was repaired by a local podiatrist here in July of last year, 2020. So she's just under one year out. She reports she initially did well with improved pain after that surgery, was able to do some PT, but then around four months post-op when she started advancing her activity, had gradual and progressive return of the pain to the point where she has been unable to walk without a cam boot. She can't get out of the cam boot. She's in so much pain for the past several months and has had PT, the cam, anti-inflammatories, no injections about that joint. The podiatrist got the recent MRI, which showed some increased signal in the plantar plate, potentially consistent with a recurrent tear. Also some increased signal in the first metatarsal head. On my read, when I look at it, I also am seeing potential intra-articular presence of one of the anchors, as well as potential malpositioning of the medial sesamoid. And sorry, I skipped her exam. She is tender all throughout that first MTP joint, very tender, exquisitely tender on the medial sesamoid and on the plantar plate. And she is tight. I can dorsiflex her with pain, with the ankle neutral to about 10 degrees. So this is the MRI shot here, the T1 that I think best shows the... Could you go back to that last MRI cut? Yeah, I think that little circle there within the proximal phalanx to me looks intra-articular. I am trying to get the op report to better understand exactly what implants are there and what that could be. And then if you go to the next image, this is a weight-bearing view of both feet. So it's the left foot that we're looking at. And I do think both, when we look at the contralateral foot, her right medial sesamoid also is slightly more distal than her lateral sesamoid, but I think there's a clear difference side to side. And then you can keep going through the images. There should be, here's the oblique again, showing that potentially intra-articular drill tunnel. And then this is a sesamoid view where I think the medial sesamoid appears to be malpositioned to me. So she's in so much pain. I'm hesitant to do, right? Any revision surgery is gonna be harder than the index procedure, but given the fact that she's 30 and she cannot bear weight without a CAM boot, I need to do something for her. I'm open to other conservative ideas, but at this point, my understanding here, I think she may have been over-tightened and that her medial sesamoid is actually advanced a little bit distally and is in a bad position against the metatarsal head causing that edema that we see there on the imaging. That would also explain her lack of dorsiflexion. So going in, revising that, taking out any component of that anchor screw that is intra-articular and then trying to get a better position of the sesamoid. To be honest, I haven't, I've repaired plantar plates. I've never done a revision repair or anything like this. Usually I feel like you're seeing them rupture and then the sesamoids retract proximally. So this is new territory for me and I'd love the opinions of the group. Okay. So I looked at this and went, phew, great. This is not a good, there's no good answer to this. How did she hurt her plantar plate in the first place? Oh gosh. I think it was a running injury. She's a pretty avid runner. Okay. And so, and I'm asking this, what type of running is she doing? Because is she able to run now? No, she can't. She really can't even walk unless she's in the cam. She's a, it hurts, it's too painful. Okay. So was she, and you may not know, was she like a five minute miler? Was she like a 10 minute miler? Was she running three miles? Was she running 10 miles? And I'm only asking, because when you deal with runners, you got to get into their psyche. You got to find out what they want, where they are. If running is the zen of their life, that if it's gone, life is worth living, that's a different runner. You know, she is a runner, but she's not like an ultramarathon runner. She's not a five minute mile runner. I think she would be happy. You know, she describes running a few times a week for her mental health. Two to three miles, eight to 10 miles. Yeah, I think I get the sense, you know, I don't know her exact mileage and whatnot, but that's much more of the sense I get. I think she's a reasonable runner. Okay. Because my concern is if she only has 10 degrees of dorsiflexion, and she only has 10 degrees of plantar flexion, and looking at her lateral X-ray, her joint space is gone or down. I actually think that you're going in and trying to revise her plantar plate, particularly if she's stable, dorsal to plantar, is not going to do anything. If her goal is to be pain-free, I would, and I am impressed actually by how much ankle dorsiflexion she has here, just on that. But if you look at her, I mean, her proximal phalanx is plantar flexed relative to the metatarsal head. I would have a long and serious discussion with her about fusing her first MTP joint and running in stiff solid shoes. Wow, okay. I mean, everyone else is welcome. I know I'm titled the expert, but I am far from the expert. But I just, if she's only comfortable in a cam walker, which is a stiff sole, I have plenty of stiff sole running shoes. And I will say my own bias, I only have 10 degrees of dorsiflexion in my left first MTP. So I know every trail shoe out there that is stiff. But if she has an interarticular lesion, if you compare her MTP joint space, her left is so much less. Your other option would be to consider some type of MTP implant. And I would either consider the Arthur surface or, and I have not put in any Carteva. I haven't bought into that bandwagon, so I'm not even gonna go there. You don't have any conflict of interest with either? I have no conflict of interest. Sadly, I get no money from anybody. But I think, you know, her joints are arthritic at this point. Yeah, she only has 10 and 10. It doesn't matter if you fix her plant or plate again. I don't think that's the source of her pain. I mean, do you think she could be over-tightened? Has anyone ever seen that? Especially given that her medial sesamoid seems like it's malpositioned. Is there, do you think there's anything to that? That was kind of how I was interpreting. I don't know how it got that far. I mean, it's really hard to over-tighten that far and pull it that. Right. And it's not a normal appearing sesamoid. No. It's got some manipulation to it. Yeah, that would be my question. Is there any chance that there's a fracture there that we, I mean, we don't have all the images, but there's kind of a line there that we don't see, like right here. I'm not sure if you can see my mouth there. So maybe the distal part of the sesamoid, when distal, consistent with the plant or plate, ruptured through either a bipartite sesamoid or a fracture. So I'm not sure if I'm saying too much. Danielle, I would go back to- It should be a reasoning, because like they mentioned. She had a plant or plate injury from running. How? I mean, it takes significant force. She had, let's see. I don't think it was just an injury of attrition. I think it was a, she, it was like a- You pushed off something. Donna stepped off a curb, or it was an acute, you know, low energy trauma, but it wasn't- Look at this lateral. You don't have good cartilage here. I agree with Nomi. I agree. It's- I mean, it might be what the podiatrist, no, this is all stories afterwards. And who actually knows what went on in the surgery at the time? All I have is off notes that may or may not- May or may not reflect the truth. Yeah. What about considering, I mean, based on her pain, Danielle, like if it was more localized to the plantar aspect over the medial sesamoid, if you did a like medial sesamoidectomy? I talked to her about that. That was on, that was part of my plan. You know, she's very nervous, understandably after her previous surgical experience, but I told her I would look at the sesamoid and see if it looked arthritic, especially looking at that line that we were pointing out on the x-ray. You know, it just looks, it looks unusual. I didn't appreciate any, you know, fracture line or anything on the MRI, but yeah, I am concerned that it is arthritic. And I did talk to her about removing it. Do you think if you do that, you're going to get her more door selection? Because what does she need to run? 15, 20 degrees. Or a fusion with a stiff soled shoe. Yeah. I don't think she's going to accept it unilaterally. Yeah. How old was she again, Danielle? She's 31, she's young. That's the problem. If you're choosing a 31 year old, you're going to get IP arthritis down the road in a runner, even with a good stiff soled shoe. I also don't think she's, I certainly can talk to her about it. And I also, like you said, I tell all my patients that, you know, oh, I'm going to talk to the, ask the expert and they just love it. So I will tell her that this is what the experts are thinking might be helpful, but I don't think she'll accept a fusion. So I know what I would offer her, but since we're not allowed to say names, but I would certainly consider an interpositional arthroplasty. Would you do a chiolectomy to help with the, would you do a chiolectomy along with that to improve dorsiflexion or anything like that? No, because a chiolectomy is not going to improve your joint space. I would do a hemi arthroplasty or a total arthroplasty. And that was Sam's question, whether interpositional arthroplasty option. Yeah, I would not fuse a 31 year old. I like to say that I'm not a fuser. So I would not fuse my big toe, first MTP with 31, and it's been 10 years already, unfortunately that it was 31. But I do a lot of interpositions, not for this specific type of case, but I do a lot of interposition with a cell or dermal matrix, not with implants. I don't like implants. And I can tell you that it's, they're happy patients. So I would, to be honest, I like stepwise approach. I would, number one, I would open the joint and see what is going on. Is there an anchor? That's the reason why it's locking up the joint and look to the cartilage, look how bad it is. I would just either, if you're good with arthroscopy, you could even do an arthroscopy if you want to be minimally invasive here just to do a diagnostic thing. The second option, if that is not enough, then I would go for an interposition arthroplasty and a fusion would be my last resort for a 31 year old. But I can't disagree with anything that Naomi said, unfortunately. Yeah, so I'm of your same process of thoughts, Cesar, but my only thing and my own anecdotal experience with interpositional is that they're not gonna do well in high activity runners because there's too much sheer stressing on the graft as the big toe moves. And that's, you know, I tend to find them, they have residual pain all the time with their interposition. It's more for the slightly order, lower demand patient. So I'm going to respectfully disagree a little bit. I have no experience using dermal matrix because it's too prohibitively expensive for the hospital I'm at and, or was at. But there are implants that are out there. Some work better than others. I think this is where you have to really have a conversation with the patient. Fusion will take away your pain. And I agree, she's 31. I'm also somebody who has a maximum of 10 degrees motion at my first MTP joint and have had since I'm 25. So I totally understand choosing shoes, rigid shoes, trail shoes, running in trail shoes rather than flexible shoes. And that may bias my approach to this, but if her concern is pain, I think you have to either do an interpositional arthroplasty or you have to fuse it. If she's stable, you're telling us dorsal plantar, her plantar plate is what it is right now. It's her joint that's hosed. So. Our purpose here, Danielle, is to make you think. You sure did. Thank you. Thank you, everybody. I really appreciate that. The only thing I would add is we ran a prospective still unpublished study that we looked at certain athletic carbon fiber inserts, ones that sort of unlike the traditional Morton's extension or ones that feel like you're walking on an IV. Yeah. Have some flexibility and they weren't designed for this purpose. They were supposedly designed like the Nike shoe to make people run faster or jump farther. And we found that they're better tolerated in first MTP arthritis. This obviously may not apply to a 31 year old arthritic, but if you kind of message me offline, I can give you the trade name of the one we use. And there is, yeah, yeah, sure thing. We've had way more success with that than I've ever had with the Morton's extension. It's sort of built on the same reason they put carbon fiber in skis because it can absorb some energy and then release it. And it's just way better tolerated in athletes for, you know what I mean? Or in anybody for the first MTP than we found the Morton's extension was. And I have no, one of my partners has a little bit of a stake in them, but I have no dog in the fight nor any money. Would you be able to put that in the chat to everyone? Is that allowed? Yes, I just typed that. Perfect, perfect, we'll do it. And then Dr. Shields, would you be willing to share your favorite, like the stiff sole trail runners and running shoes? I'm always looking for recommendations to tell patients. I'm gonna tell you what I tell patients. I don't do brands. Because what fits you, I mean, I had a woman come in today, she was carrying on about Easy Spirits. I don't own a single pair of Easy Spirits because they do not fit my foot at all, okay? If you go into my closet, sadly now I have more sneakers than I have heels. Just saying. So I have New Balance, I have Brooks, I have Solomon's, I have Asics. That's what fits my foot. And they come in 10 and a halfs. And they come in 10 and a half narrows, some of them. So everybody is different, but I tell them to get their elbows up there, take the shoes and see if they bent. And if it's a Skecher, it's an Easy Spirit, it's an Asics, I don't care. It's what fits their foot. Fit Flops work, Avionics work, Merrell's work. It's gotta fit your foot. It's not one brand fits everybody. Awesome. Danielle, very tough case. Thank you for sharing it. Danielle, if you want to message me, I'll share the implant I use, but I can't do it on this format. You will do. Okay. Are we going to Gus next or are we skipping Gus and going for him at the end? Yes, yes, yes, I am on. You want to do yours, since we already did one of Daniel's? Oh, yes, yes, I have one second. Yeah. I'd rather do Daniel's because I think it's a simpler case. So this 16-year-old boy who complained of pain under the sole of the foot and laterally, he tried conservative measures, but it doesn't help. So his x-ray showed fragmented navicular. And now what is the option of surgery? I thought about this fragmented navicular. Is it due to Kohler or it's due to, is it abnormal os navicular? I don't know. Should I treat him as extra articular correction for flat foot? Or he needs some sort of fusion on this side because he's 16 years old. So I was curious, Mohamed, this AP standing, how is this done? Because it looks like the navicular is actually medial to the talus and you're almost seeing an AP of the foot. Yeah. But clinically he is flat feet, he's flat feeted with hind foot vulgus. So what are your thoughts? What ran through your mind as to what you wanted to do? I'm just wondering whether it is, initially I thought of this AVN of the navicular, but reviewing the literature, I found that there's something called os navicular and I think it matches his case. So I'm just maybe leaning toward doing extra articular correction as regard to his age. So if you were to do an extra articular correction, what are you thinking of doing? Because his foot is mobile, I forget to mention that. So I will do just routine AVN procedure to lengthen the calcaneum, tendo achilles lengthening. And then here I will, usually routinely I do in this age, cotton osteotomy on the medial side. Plus, plus, minus medial displacement osteotomy of the calcaneum if there is still some hind foot vulgus. See I found this case incredibly interesting because when I look at this lateral, that is a varus hind foot. Your talus is dorsiflexed, you're seeing all of the subtalar joint. And then you've got this midfoot that just collapses down. And on your AP ankle, your navicular is medial to the talus. So this to me is getting not into just the standard flat foot or standard cavus foot. It's like you have a hind foot varus and you're pronating through your mid and forefoot. And feel free, I'm God and Caesar and everybody else to weigh in on this, because I'm not sure what you do with this. I mean, your talus is dorsiflexed, your navicular is plantar flexed. You have fragmentation, it's like a collars, but it's kind of not. And you have metatarsus adductus. So if you bring your navicular around on the talus, then you've got to correct your metatarsus adductus. And yet, when you look at the AP, if you look at the right versus the left, your left is in more valgus. But when we look at the lateral, we see we're in varus. So I am totally confused by this case. Which probably isn't helping you at all, Mohamed. Do you consider it is molar wheeze, some sort of molar wheeze? It may be. Because your navicular on the left is narrower. And this view, this lateral doesn't look like the other lateral that's later on. Because one of them is weight-bearing, the lateral which shows the whole foot is weight-bearing. The other one is non-weight-bearing. This AP intrigues me. And this lateral, which is non-weight-bearing, I'm almost thinking you may have to do a triple. But I'm not sure that's the right answer. That's why I'm just wondering what the best solution in a 16-year-old. Do you have a CT? Does he have a coalition anywhere? He's mobile, actually. There's no coalition, clinically. But I haven't done... He visited me once, and he will visit me again. Because of the COVID situation, he will visit me again in the near future. Astracnemius, I'm assuming, is tight. I can't remember, but usually if it's tight, I will lengthen it. So you think it is treble fusion? I hate to do a triple in a 16-year-old. And if you do treble, you do extend the treble? You extend the fusion to the cuneiform as well, or no? No, because if you go to that non-weight-bearing lateral, your tail and uvicular joint is your main involvement. Cesar, can you take us to the lateral? Benamgad and Cesar, please weigh in, because this one I didn't know what to do with. I mean, this view is very different from the non-weight-bearing lateral. Let's hear a poll from the audience. Guys, feel free to chime in, please. Open your mics. This is not an easy case. So this is Neil, and I would almost certainly punt on this. Thanks. If he's 16 and I'm unsure, the problem is the two different laterals look like two different feet. I agree. I would have to get a CT scan in order to fully understand that, because that looks completely different to the other laterals. So when I don't understand it at all, I do the, at first, cause no harm, and I would try to punt as long as possible. Because to me, this would be the non-weight-bearing, and the other would be the weight-bearing lateral showing it going up. You also look like your calcaneocuboid joint is short, but this is a veris hind foot on this x-ray. Yeah. I know what you're saying, because you look at that lateral, and you almost have that see-through sinus tarsae, which looks like veris, but I don't know. So do you have, because the heel is elevated, so you have a tight gastroc or tight Achilles, you have a veris heel, and you're pronating through your trans-tarsal or mid-foot joints. Is this more like a skew foot or a serpentine foot? Because you have metatarsus adductus on your AP. Yeah, it looks like skew here. And any history of issues when he was young? Not really, you can see changes in the other foot as well, but it is not as bad as this one. The navicular on the other side in the AP view is not that bad, but not normal as well. I agree. I agree. So what type of prosthetics have you tried? We need you to make a call, Naomi. We need you to make a call. What? We need you to make a call. Make a call. What are you going to do? Send him to Egypt? No, but your first ray is elevated here. So again, this is driving him into valgus. His navicular is driving into valgus. I would try like crazy not to operate. I would consider gastrocnemius recession, Achilles tendon lengthening, maybe a cotton. I might try and fix that navicular, although that's a scary proposition. I really need a CT scan. I'm not going to claim to be the expert on these, but I've done two or three, and I think the answer in my hands would be just like you mentioned, do a gastrocnemius tendon lengthening, fuse the TN and NC joints, and then look at the residual, just like you mentioned, metastasis adductus, and then probably do a proximal basal mid-tarsal osteotomy to bring it out of adductus if I cannot rotate the whole midfoot through my fusion. And I would really get an understanding of what this kid is looking for, because if he thinks he's going to have a normal foot when all this is done, you're doomed to fail. Yeah. But he's got an Achilles or gastrocnemius contracture because his heel is elevated, and your navicular cuneiform joint's not normal. So what sort of fusion, Dr. Amgad, you will do in the medial side you mentioned, navicular cuneiform? I would do a talonavicular and navicular cuneiform, sir, and you can call me Amgad, we're all here on first name basis, but yes, I would fuse his talonavicular and navicular cuneiform. This is going to correct his arch, provide him with midfoot stability. It's going to take from his hindfoot range of motion, but you're going to preserve the subtalar and the calcaneo-cuboid. And then I would intraoperatively look at his residual metatarsus adductus, as Naomi said, and then possibly add a basal metatarsal osteotomy to correct his adductus if need be. Because I think you can correct part of it through the fusion. But you don't add something like subtalar fusion? No, it's going to be too aggressive in a 16-year-old. So I try and buy, preserve as much joints as I can. And I think from what I'm looking at, the apex of the deformity right there is that both the TN and the navicular cuneiform joints. So if you fuse the talonavicular, you're going to lose about 50% of your subtalar motion? 70, actually, yeah, you're absolutely right. I'm going to lose more. But it's inevitable. I mean, there's no way you can survive a Muller-Weiss without fusing that. Can you fuse the NC and leave the TN joint? We have a question from Mark Sanders. Maybe. If you correct your dorsiflexion of your navicular cuneiform joint, you might be able to. But how are you going to address that sag in the navicular, Mark, without the incongruity of the talonavicular joint without addressing that? That would be my question. You're going to be, your big deformity, part of it is talonavicular, but a lot of it is navicular cuneiform. True, true. And if you can plantarflex that first ray, you may bring, and you may have to go back to the hind foot and counterintuitively do a dwire. Yeah, I get what you see. Yeah, I get, you're trying to compensate for that, yeah. So hyperplantarflex through the NC joint and then compensate by doing a dwire, yeah. And a posterior lengthening. This is reminding me of a Muller-Weiss case I did. And in order to prepare for it, I found an awesome article in FAI 2019, which goes through Muller-Weiss. This is just, I would highly recommend reading this before your case. One of the things they talked about- Can you share the link in the chat? Yes, I will have to, let me find the, I just have the hard copy. I'll find the link and send it out because this was just like a wealth of ideas. One of the things they did report on in this article was a study of tailored navicular cuneiform arthrodesis. And because that navicular is so fragmented, they grafted with tricortical iliac crest. And I thought, I think that's interesting because that would help you better plantarflex the medial column, especially because, you know, it looks so fragmented there. I'm not sure you'll have much purchase. Yeah. And I'm fairly familiar with the study. Thanks, Danielle. And that's why I've been going down that algorithm. I think these are hard cases. And I'm not sure anybody has the right answers. If people are successful and get good outcomes, it would probably really help if you posted what you did, because I think we all struggle with these. Okey-dokey. Dr. Makhimer, thank you so much. Thank you. Thank you very much. Okay. Okay. Where are we time-wise? I think we've got 20 minutes left. So we're going to have a Daniel Guss case, and then we've got another Muller Weiss posted on the website that I would like to go through as well. All right, Mr. Dan. All right, perfect. And so this is a trauma case. I thought I'd spice it up. I saw last week, and we're fixing later this week, it's an 18-year-old male, actually graduating high school, recruited soccer player, who is playing some game in a parking lot. And his friend drove off in anger and inadvertently ran over his right foot. He did get dragged a bit, and then resulting in this injury. Severe swelling. Eventually came to the trauma service, was discharged, came back to the ER with pain, and then eventually found his way into my clinic. So these are the initial radiographs and a non-weight-bearing CT scan. The CT was gotten in the ER. I usually otherwise try to get weight-bearing CT scans when possible. And so I would love your thoughts. Obviously, this is a Lisfranc variant that extends well beyond the TMT joints. We often talk about the fact that I think inner cuneiform instability is underappreciated. But in this case, you've also got navicular cuneiform, not only instability, but fracture. I had actually presented a number of Ask the Experts ago when Mark Meyerson was on a somewhat analogous case in which the cuneiform was not fractured. So I thought it was only fair that I up the ante for Mark Meyerson and hand you one in which the medial cuneiform is quite fragmented at the navicular cuneiform articulation. Yeah, this is sad for this kid. I'm assuming you have him on the schedule for open reduction, internal fixation. You're going to span his TMT joints. I would fix his cuneiform fracture. I would try and keep motion at all joints, but I would counsel him that this is a bad injury and particularly for his navicular cuneiforms. He may end up needing further surgery or an orthotic, but he's 18. I would try to avoid fusing everything I could. As far as fixing the cuneiform, it's quite fragmented and common unit and even dusted. I'm sorry, it doesn't have the video. Maybe if we ran through the CT, does that affect your decision? When it's comminuted, is it overall aligned? I tried to put, especially on the sagittal images of the CT, you can see the degree to which it's just multiple fragments are sheared off. This is just an example. What I'm thinking is we use bridge plating. This might be a place to put an external fixator, distract that medial column, maybe put some K wires and reduce that cuneiform, reduce certainly the joint and see how he does. If I'm fixing an 18-year-old who wants to play soccer, I'd give him a chance. I would reduce his joint. I might use a spanning fixator as well as bridge plating or non-compression screws. Let me ask you this. With the data that we know about fusion versus arthrodesis and the fact that we don't generally think of especially the navicular cuneiform joints as one that are critically important for motion, how do you decide the importance of not fusing those joints in an 18-year-old? Does age even matter as we think about just the severity of the injury. And obviously we think about these very differently than the joints we were just talking about that are involved in like Mueller-Weiss with a tail and a vicular joint. I'd love to hear your thoughts of how you decide to fix versus fuse. I know this has come up in previous ones and there's not one right answer, but I'd love to pick your thoughts about that. So I think this is always a difficult decision. I hate to say age matters since I'm more than 50, a lot more than 50, but I also think you have to look at mental age, activity age, and what people are doing. I mean, I have 50 year olds coming into my clinic who I'm like, oh my God, you're worse than my hundred year old patients, you know, and somebody who's a diabetic, smoker, blah, blah, blah, blah. I mean, you just know they're not going to live that long and their expectations for activity are different. So I think you have to look at everybody different. I will say my bias is to try and maintain motion in as many joints as possible for the younger active patients. I now fuse a lot more Liz Franks in the 40, 50, 60 year old group than I did when I first started practicing because we know they're not going to do as well if you try and keep their joint motion. So I think here the question is, if you fuse the navicular cuneiform, how much does that affect it? Are you better off having one surgery, one recovery period, getting him back to his potential college career? And how much does loss of the navicular cuneiform joint motion have? I don't have a good answer for that. So the only thing I would point out is, is that the joints involved, interestingly enough, if our eyes are drawn to the tarsometatarsal joints, as well as the navicular cuneiform joints, but there's a, there's another joint involved, the inner cuneiform joint that on him is also displaced. And so I'd almost love to, so full transparency, it's, it's the, you know, I was, I'm, I'm strongly leaning towards fusion actually for a number of reasons when you think of that. Fusion of which joints? Of the navicular cuneiform and inner cuneiform joints. That's reasonable. Trying to spare the others though. Admittedly, I don't necessarily, I've, I've found that and for better or worse, we, we, we see a lot of Lisfranc injuries and I don't think there's one right answer. And so that's the, the disclaimer is when we think about, you know, could see it, Liam could see his famous paper, what's missed. And because I don't, I don't, I don't think they maybe even wrote it in the abstract, but they very explicitly say it in the text is, is that those were high energy injuries and, you know, and, and most of them were fall from height or MVC. And one of the groups, I think there was no athletic injuries and the other, there was only two. And, and so they're very transparent. And so when we project that paper, we have to remember that to your point about fusion versus fixing. To me though, it's, it's, I almost think about a matrix. I think about the energy of the injury and I think about fracture at the joint space. And the ones that I've routinely fixed and knock on wood have had success with their low energy without fracture. The second you start getting fragmentation at the joint space, we know that one of the primary modes of failure is arthritis, post-traumatic arthritis, at least it was in that paper. And so that's where I found that I don't necessarily use age so much in these joints. They certainly do in the more mobile joints in the foot and ankle. Because to me, just the other day, just last week, there was an 18 year old girl who came in with a five level kind of, you know, lateral complete dislocation, less frank, idiosyncratically playing lacrosse. And she had a severe fracture at the base of the second. And so we fused the medial two columns in order to give her stability, both because of the high energy injury pattern, as well as the fracture. The third variable, by the way, being chronicity, you know, start, you know, our own studies have shown that your ability to achieve anatomic reduction is also very important for outcome. Interestingly enough, we also found that divergent, divergent doesn't do as well with fixing as with fusing. And this is a divergent injury. And so I'd love, I don't think there's one right answer. And I, you know, I think what you said would coach the patient perfectly, but I'd love to hear what others think about the fuse versus fix, you know, without necessarily being biased by what I expressed was my treatment algorithm, because I think there's a lot of wisdom in the group and we can learn from each other. And so, yeah, I think Pamela, I want to, I've heard of Cesar and I'm good. I want to hear Pamela, would you fix, or would you fuse? I just, you just happen to be the next one to the right of Naomi on my screen. No, I also, I also, I'm going to interrupt Pamela, sorry, but you have impaction of your base of your second metatarsal. That's not a normal second metatarsal base. Thankfully on CT scan, it came out. Okay. I didn't include that slice. There's not a fracture. It's, it's projectional here. I agree that this x-ray looks altered. Thankfully the main fragment and to your point on the, the woman I just described that had a complete five level lateral dislocation, she, she had second fracturization and so we fused her. And so I gave you a few minutes to get your answer together. Thank you. I received the text from Mark Sanders saying, what is the downside of an NC fusion? So I think he's on board with a fusion. Yeah, I agree with Dan too. Like I was just looking at that CT that you had and the comminution, I'd be concerned about the NC, the medial NC joint with just fixing it and the arthritis. I don't think that there's a lot of motion through there, just filling it up with bone graft. And then I would fuse the intercaneal form joint too, because I just, I don't know, even for when I do, I don't like them. Cause even when I remove the plate, they still gap. And, you know I don't have a good way. I've been using some products to leave in some internal fixation across the, the Lisfranc medial caneal form, second metatarsal base, just to have some, something inside, even after I removed the dorsal plating. But yeah, I would try to fix the first TMT, second TMT to hopefully see yet, let him have some motion after the hardware's removed, but fuse your intercaneal form and NC joint. But is that third TMT off as well? Yes, it is slightly. His foot is swollen enough that I only get to make one incision. I found that usually it follows the second, if you can reduce. You can do a percutaneous kind of push it over with, with some sort of either free or wood handle and then pin it. And so that was my plan for that one. So Dan, how far out are you operating on this? He's less than two weeks, but, or right at the two week mark, maybe. So this is probably just when he came in the first time he was ballooned because of the crush injury component. And so not compartment syndrome balloon, but enough that you wouldn't love the idea of making an incision. He still had, there was still a sheen to his foot. And so we're doing, we'll fix him about two weeks out. So do you find that trauma, which will reduce a hip, an elbow, a shoulder tends to say, Oh, a foot dislocation. We don't need, we need to let the swelling go down. And so to that point, I've, I've often gone in, in someone who for example, the woman that the young woman that I described, it was a complete kind of dislocation. I went in that night, reduced her. And you can usually just with one KOR hold them reduced at least very close and then come in subacutely. Thankfully, in this case, I've found that, you know, with two weeks out and a fusion type procedure, I think he'll be okay. As far as the NC joint and stuff, you can usually get them, them reduced, but I agree. These are joint dislocations and the idea of leaving them unreduced, you know what I mean? It has, has consequences because ultimately Injury for an 18 year old, as long as you get longterm, the problem is what you've shown is your ability to achieve anatomic reduction also predicates the outcome. And that becomes harder in the chronic. I think that's what underlies a lot of the reasons, even if you fuse why patients that present with chronic list rank injuries do not do as well, because after a while, it's harder to get anatomic reduction. And so, yeah, that was one of the hardest conversations. It's sort of, when I started this, having met him about a week into this path, I sort of told him, listen, I want you to first know two things. One is I'm going to do my best to take fantastic care of you. You're going to have a big, you know, a team behind you. But the second part is this is a life-altering injury. And I think that second part, nobody had told them. And, and, you know, I think he envisioned it getting fixed and he would go back to a collegiate soccer career and that's still our goal for him, but, but, you know, having him understand that this is a life-altering injury in many ways is, is, is one of the most important first steps you can, you can give them as hard as it is. Anybody else's thoughts? I'd love to anybody out. This is so useful. Thank you, Pamela. There's a question for Sam. Do you do a single versus a double approach to get to the planter aspect? And what would you plan to use for the fusion? All screws or plates as well? I think that was directed at the ask the expert, right? Well, I'm going to tell you that I struggle with navicular cuneiform fusions. I still don't have the best approach. I mean, I have tried screws from the cuneiforms and in the navicular, navicular into the cuneiform, plates medially, plates dorsally. I will tell you if you put screws from the cuneiform into the navicular, do not make them converge. Cause you can get a stress fracture where they all converge, which is a bad thing to happen in your navicular. I don't have a good answer for how you fuse the navicular cuneiform joint. I guess staples. I just keep trying things. If somebody has something that works for them reliably, I would like to know it. I think this is the hardest joint to fuse in the foot. And then there's another remark from Mark Sanders who's been texting me directly, not the group, but I'll reiterate what he's saying. When you fuse the navicular to the cuneiforms, do you have to pick out the intercuneiforms or just aligning the cuneiforms with a navicular and fusing them saves you the agony of breaking everything apart and trying to realign them like puzzle pieces, the three cuneiforms. I think it depends. I agree when you start cleaning everything out and you're working through two incisions. I hate navicular cuneiform fusions. I'm open to suggestions. I may be the ask the expert for tonight, but I am not the ask the expert for navicular cuneiform fusions. I've done at least 10 or 15. I've had all heal. You hear me Eddie? Yes. Okay. I've done at least 10 or 15. I've had them all heal rapidly. I'm basically doing it exactly like Dr. Hanson's book, medial utility incision, pin distractor, removing the cartilage, then removing the cartilage, then putting a pointed reduction forceps on the plantar aspect as I dorsiflex the great toe. Basically, I'm leaving it somewhat opened on the dorsum which I fill with which I fill with BMAC and allograft chips and use the H-plate which is proved as far plantarly as possible. I've been fortunate with maybe because of the biologics, maybe because I just followed Dr. Hanson to a T. They've all healed as rapidly as a laparoscope would heal. So a medial approach, Mark, with screws trespassing from medial to lateral from the navicular and through the three cuneiform. They're going through the navicular and they're going through the three cuneiform, at least two of those cuneiforms. I don't pick apart cuneiform one to two and two to three because I figured if the whole thing fuses, it's one bone. If all three naviculars fuse and I have had really good luck with the BMAC and DBM and or cancellous that I got from somewhere or other. How do you handle the ATT? Excuse me, ma'am? How do you handle your intertib? I have no trouble retracting that with a vein retractor. I have not had to cut it. I know it's in the book, but I have had no trouble getting it moved over medially, retracting it medially. Sometimes you do like a banana peel, a gentle periosteal elevation with the tiband tendon and you just peel it off a little bit and you can squeeze that plate on and I can see. My plate is for the most part plantar because I want to get the compression side. I want to compress the compression side of the of the osteoarthrodesis. I oftentimes have it opened and I just fill that gap dorsally, which I like to see because I know I got a good reduction. If I see a dorsal gap, I fill that with bone as if it's a stress strain relief bone graft. To that point, it's funny that you mentioned it. I have a bootleg copy of Hansen's book too. I've used that technique with success. In this case, for better or worse, I get one incision. I'm going to make a dorsal over the Lisfranc interval and extending proximally and planning to use screws. That would be something now when we're talking about the Lisfranc, what I'm referring to was basically doing the navicular cuneiform, which I could do that. Then if I needed to make another incision, I might make another incision over two. My incision is medial, so I could probably make another incision over the second metatarsal to deal with the second tarsal metatarsal, but I can get C1 back to C2 from the medial side. That seems very, very reasonable. Like you, I usually don't prep the inner cuneiform joints, but in this case, I have to, because that's part of the issue. Using a screw construct that pulls cuneiform to cuneiform and cuneiform to navicular, doing the latter one first so that I don't ruin my ability to compress. To me also, the vascularity, preserving. I think the debate for fuse versus fix, the TMT joint in this case is more predicated on vascularity. I want to preserve that capsule from the first TMT joint in order to maintain as much vascularity. If I start fusing in three directions around the medial cuneiform, I worry about maintaining its blood supply. My exposure to medial cuneiform is just the medial surface. Yeah, perfect. Maybe a little dorsal, just enough to move TA out of my way. To Naomi's point, I offered him a plane ticket to Egypt, but he didn't take it. He can go to Oklahoma City. That's close to Egypt. Oklahoma and Iowa. He can come to Houston. It's probably hotter than Egypt. It's at least after Memorial Day. You're absolutely right there, Mark. I think we've come to 9.33, an hour and a half, a little bit past the hour, half the hour mark. Thank you so much. It was such a great session, guys. Lots of tough cases. I have to thank you all for pitching in with your cases, for the very wealthy discussion. Thank all the attendees as usual. Thanks, Shelly, from our staff. Last but not least, I'll hand it over to Cesar for closing remarks and for Naomi, our guest of the day, whom we enjoyed tremendously as usual. Well, I think we should have Naomi first, because then we have the picture. We have to tell people before they start dropping out of the call. We already lost two people, so please don't leave before the picture. We need the picture. Naomi, go for it. All right. Everyone, turn on your cameras. God, I don't know how to do that. Wait a minute. Naomi, close your eyes while we take pictures. Go ahead, Naomi. Yeah, yours is on. Okay. How do I take a picture? No, Cesar is taking a picture. I'll take the pictures, but you have to do the closing remarks. Do the closing remarks. Okay. I think this was great. Wait. This was a great session. Thank you, everyone. Let's move 100%. That's nice. That's perfect. Let me take pictures of that. I have pictures. I've been on too many Zoom calls. Well, this was excellent. Thank you so much, Naomi, for sharing your expertise. I think it was very fun. We all learned a lot every single time, but it was amazing. We'll start with the pictures. Let me see if we can put more people here. Maybe I think I'm already in. So I want to say one of the best things about this is it's not just all about who is the expert. It's about sharing everything, because we all have different backgrounds. I would kill to have a weight-bearing CT scan, and I'm so proud of the people who do, and yet we all are seeing these crazy patients and these crazy problems that we're trying to deal with. So having a forum, I mean, I practice by myself as far as foot and ankles, so to be able to share, that is so valuable, and I really, really appreciate it. Thank you for joining us today. Don't forget to claim CME credit on the chat box posted by Shelly Eschner. Follow the link to claim your CME, and next month we have a mini-me series with Dr. Mark Easley and Konstantin Dimitrakopoulos, so feel free to join us, and looking forward to seeing you all. Go crazy! Go crazy! Go crazy! We have about 1,022 pictures. I'll share. Thanks, everyone. Thank you, everyone. Good night, everyone.

video

discussion

complex foot case

runner

failed surgery

revision surgery

fusion

first metatarsophalangeal joint

treatment options

trauma case

Lisfranc variant injury

fractures

fix