So let's let's start this. So good evening to all the attendees. We're gonna have a very exciting night. We have cool case discussion. I'm gonna do just the housekeeping and I'm gonna give to Amgad Haleem to introduce our faculty for the night for the SP expert. This is the second meeting that we do. So the first one we had Dr. Luchon. So the rules are that we can only discuss cases that were posted in the AOFS connect website. So unfortunately, and for protection of data and patient regulations, hyper-compliancy, we're not gonna allow people to share screen or show images that were not reviewed in our website and approved to be discussed today. We're gonna go into the order of the posts in the website. So I'm gonna, we're gonna share our screen with the questions and with the cases. There are some cases that I would like to, I'm not sure if the people that posted are already online, but for example, the first case that was posted by Dr. Michael Strauss from California Huntington Beach, we don't have the images. So we're not going to be able to discuss the case if they're not complete. So I would invite the people that submitted the cases, but we're not able to attach the figures to try to do it again. And then we can go back and discuss the cases. So the other thing is let's try to behave the same way we would behave in a, you know, in a friendly webinar, but respecting patient information. Let's behave the same way we would behave in a grand round or something like that. That being said, I'm gonna pass the word to Amgad Halim from Oklahoma to introduce our faculty, our guest faculty. Thanks so much. Thank you so much, Cesar. I'm gonna ask you to allow me to share my screen if you don't mind. Excellent. Okay. Our guest today is Dr. James Brodsky, who is a native of Houston, Texas, where he graduated with highest honors from Bel Air High School. He graduated magna cum laude from Harvard University, where he studied both pre-medical sciences, as well as receiving an honors degree in history and literature. After his medical training, Dr. Brodsky and his wife, who is an ID physician and a native Texan herself, returned to Texas to pursue a doctorate in return to Texas with their family to practice both at Baylor University Medical Center. Dr. Brodsky served nine years on the board of the directors of the AOAS, including as president of the society from 2005 to 2006, where he moved the AOAS headquarters to its current location in Chicago and adapted a new management model for the executive staff and board. He served on numerous committees at BUNC, the AOFAS, the Texas Orthopedic Association, and the AOAS, and for a decade on the written exam task force of the ABOS. He volunteered for over 20 years at the Dallas VA Hospital in patient care, resident teaching, and as chief of the section of foot and ankle surgery. He was elected to the prestigious American Orthopedic Association in 2002. He is the recipient of over two dozen grants for research and education. Dr. Brodsky received the teaching excellence award from the orthopedic residents of UT Southwestern six times. He has received the IFAS prize for the best basic science study in 2008, and was co-author of a study on star total ankle replacement that received the 2009 AOFAS man award for best clinical study. Dr. Brodsky was also nominated as the AOFAS 2020 pillar of the year of the society, and I'm quoting from the AOFAS nomination the following. James Brodsky is the consummate orthopedic surgeon, an enduring leader in orthopedic foot and ankle surgery. He has worked tirelessly to advance our standing of complex pathology from Charcot Arthropathy to total ankle arthroplasty. Ever ready with a clever witticism, he always stimulates his fellows and colleagues to ask tough questions and seek the tougher answers. Above all, Dr. Brodsky is a teacher leading by example and inspiring others to be better. In addition to a busy clinical practice, Dr. Brodsky has been a lifelong teacher and professor for medical students, orthopedic residents, and fellows from across the US and around the globe. He founded the Baylor Foot and Ankle Fellowship nearly three decades ago, and remains its driving force. He is the author of over 60 articles in peer-reviewed medical journals and 30 chapters in medical textbooks, including the major texts in foot and ankle surgery. He continues an active program of clinical and basic science research, the latter primarily in the study of human motion, where he is the medical director of the human motion and performance lab at BUMC. He has done visiting professorships and lectureships across the USA, including Oklahoma University, where we had the pleasure of having him for visiting professor grand rounds in 2016, as well as in Europe, the Middle East, Latin America, Japan, Australia, and New Zealand. He is an honorary member of the orthopedic foot and ankle societies of Australia, Brazil, Spain, and Britain. When he came to OU as visiting professor in 2016, where we can see his picture there, I had been in practice for only nine months. Needless to say, I was pimped on my cases and roasted by him as lavishly as my residents were. Yet at the end of these three days of the VP course, I had learned from him as much as I had learned in a whole year of fellowship, and we parted as close friends despite the vicious roast. I cherish him as an orthopedic prodigy, mentor, role model, and above all, a dear friend. So without further ado, I would like to introduce Dr. Jim Brodsky. Dr. Brodsky, welcome to the Ask the Expert series of the ALFAS Young Physician Committee, and thank you for joining us today and generously giving your time and expertise. I'll hand it over right now to Cesar once again to start sharing his screen and moderating the first case of the day. Yeah. I don't think they should let you tell that many lies in such a short period of time, but go ahead. You're really embarrassing me. And I know that you asked me to, did you also get an expert to do this? Well, other than you, I don't think we have anyone else. I think it's Cesar. All right, go ahead. Oh my gosh. No. So here we go. The first case we're going to do, Dr. Brodsky, unfortunately we have to skip some cases that we didn't have the whole, the images, but as I said, we can have the images. Does everybody get some Zofran from being nauseated about all that crap about me? It's okay. Is it okay if I drink during this call? Go for it. Go for it. It's allowed. You are allowed. So Dr. Brodsky, the first one comes from Kenneth Haida from El Paso, Texas. So thank you for lending us your expertise and your time to help us with our difficult cases. I have a young patient. I've been debating on how to approach his young 20s with bilateral hallux valgus and arch loss. He surprisingly is not in a lot of clinical hindfoot valgus. I suspect more is present than what I appreciate. However, our radiology department and I are odds trying to get the appropriate hindfoot alignment view, and it's able to perform a single limb heel rise with some arch reconstitution and no posterior medial ankle pain. He previously received custom orthotics and his flat feet don't bother him anymore. However, his bunion department is driving him nuts and he is to the point where he can't tolerate closed toe shoes for routine periods of time. The radiograph shows a severe hallux valgus deformity with a great toe pronation, overriding of the second toe, abdomen support foot pronation with a cuneiform overlap roughly 30 to 40 percent tailor-headed coverage, and loss of the mirror's angle with the midfoot break center at the navicular cuneiform joint. A derogative view of the first metatarsal suggests to me that this is a congruent deformity. I have asked a few colleagues and looked at a few papers and it seems there's no consensus on how to approach this deformity. I have two questions. The first being, what is your approach to surgical treatment of hallux valgus when a flat foot deformity is present, especially if it is asymptomatic? And second, what changes, if anything, when it's an atypical flat foot such as this? Currently, I'm planning a medial distal displacement calcaneal osteotomy with abominal lymphony, a medial eminence resection with medial closing wedge osteotomy with hopes of regaining some length in correcting with a lapidus and extending the fusion to the navicular cuneiform joint to correct the midfoot break. Recommendations I've received are MDCO without MC fusion and foregoing addressing the flat foot altogether. Thank you for your thoughts and insights in advance. And this, let me bring the x-ray. Oh, that might not work. Let me go back. That was bad, bad move. We have the AP here first, Dr. Brodsky. I can zoom in. AP there. Lateral view. Okay, there's also this kind of fluoroscopic image. Right, looks like a stress view. You see the surgeon's fingers at the top. Mm-hmm. So that's it. Okay, well, what's everybody else think? I like to hear about it. Go. There's a lot of people who are turned off. Naomi, you're on mute. Yeah, so we encourage everybody to unmute and please try and pitch in as we speak. Okay, so you have an increased DMMA that I think you need to correct by some kind of distal procedure. Oh, that's good, César. Because your joint is congruent. But you have pronation, rotation, and if you're unstable at the first MTT, I think you need to correct that and do a distal procedure. What about the flat foot? I think it's a great question. I also have those questions when I see patients where you do think that the medial column instability is close together with the flat foot deformity, but there's no pain. So I think it's a great question. And for us to learn with all of you guys, when do you pull the trigger for everything? When do we have to give a better hindfoot alignment to kind of protect your forefoot from the injury? How much valgus is he in clinically when he stands? Well, that's a question for Dr. Haida to answer, and his microphone isn't working on his computer. He might be able to type in the answer for us. History says that not a lot of valgus. Less than he would expect. That's what I understood from what he wrote. So then I would stabilize the first TMT joint, correct your bunion distally, and that should, because the navicular is not uncovered. Dr. Bradsky, kick in here anytime you want. You know, I'm having fun. Go ahead. Yeah, I think his deformity is occurring from the first TMT and his hallux valgus. So a question, is there a role for a biplanar correction through the TMT joint? It's too bad the x-rays will cut off. Actually, you know what, I don't think it's too bad. The x-rays will cut off. Actually, yeah, yeah, that's better. That's better. Try to make it larger. No, it's good. Here you go. What do other people think? Come on, let's pick some names. Yeah, let's call on people. Okay, Noah. Noah is, I think, Noah, you're on? Yeah, he unmuted. Yeah, Noah, hey. Okay, what do you think? So I guess it's the question of the hallux valgus with valgus deformity of the midfoot hindfoot. Yes, overall. Okay. I mean, I think that it kind of depends on what's behind the patient. If it's mostly the hallux valgus, then I think that perform a good aggressive scarf with good correction. And I think it's not critical to address the hindfoot valgus. I think, I don't know, I think there's a lot of variation. I don't know how many, how much people, how aggressively, you know, we treat the flap of deformity with a bunion, but how old is this patient? Young. 30s, I think you said, right? 20s. Early 20s, okay. 20s, yeah. 20s, yeah. I mean, I don't necessarily see, if it's really just the hallux valgus that's bothering the patient, I think it's okay to have the patient undergo a scarf and then have the patient in an orthotic. And if there's really more sequelae of hindfoot valgus, such as posterior tib, et cetera, then maybe something else down the line. Well, I think this could be an army problem. I mean, Hyde is on the phone, but what about Joe Bellamy? Joe Bellamy is a Navy guy and I think it could be totally different if it was a Navy guy. Yeah, I'd probably tell him just suck it up. Wait, where's your video? Oh, it's not working. You look good. I know, all dark. How you doing Joe? Living the dream. Where are you? Indiana. I should have known. Go ahead. Yes. Okay, so how would it be different if he was in the Navy? Oh, I don't know that it'd be different. That's unacceptable. Of course, it would be different. I mean, it's all dependent on, Navy's pretty restricted on bootwear, so we don't have many options. We've got one set of boots, so kind of the goal is make sure they fit in the boot, but I'm a less is more kind of guy. So what would you do? I don't know that I would do too much in the mid, but especially if it's bilateral, if that's just a standing posture, I would consider, I mean, I agree you have to do something proximal to correct it, but kind of in your own words, beware the boy bunion. So I'm not a big Lapidus guy, so I think I would probably something proximal, whether that, depending on the choice, I still do lots of scarves and then try to translate it distally, as well as a little plantar when I do it, but it may fail. Mustafa, is Mustafa on? He is. Yes. Aren't you in Baltimore? Yes, sir. Okay, wow. What would they do in Baltimore? I'm sorry, I just joined. Oh, good. So here's a picture of a fellow with a flat foot and a big male bunion, which some people think is congruent, but we haven't discussed it. And the question is, should you fix his valgus hind foot, or just fix his bunion, or both, and how? You have 20 seconds to respond for 15 points. Otherwise, your team will be penalized. He's mainly symptomatic over his bunion? Yes. Dr. Haida, who's on the call, said that his valgus doesn't seem to bother him that much, and isn't that apparent, but his bunion is driving him crazy. And Joe Bellamy said the reason it was driving him crazy is he's an army guy, and he's not as tough as a Navy guy, but I didn't say that. Joe said that. Go ahead. I mean, if he's not bothered by it, if it's not that severe, although looking at that AP, there is probably about 25% TLRN coverage, but I would say if it's not bothering him, he's an army guy, maybe just address the bunion. This is a wide-arm angle, so I'm going to go proximal. Haven't done much proximal osteotomies. Done more lapidary in fellowship, so probably that would be my go-to, and then I'll... Yeah, I mean, I need to talk to the patient and counsel him. We've done multiple patients like those, and we've added MDCO. The lapidus gives you some correction to the midfoot. You can plantar flex through the lapidus to get a correction to the Miri's angle and the arch, so I'll need to talk to him. So it would be lapidus plus or minus MDCO, depending on my discussion with the patient. And what would you think the patient would say that would change what you pick? Well, I'd have to tell him why I would want to address the flat foot, even though he might not be symptomatic, in my opinion, to decrease chances of recurrence. I'll have to talk to him about the post-op protocol, which I'm not doing those percutaneous lapiditis, so my patient will be non-weight-bearing anyway, so even adding an MDCO I don't think will change my post-op protocol. So, basically just explaining why I want to correct the flat foot while I'm doing his bunion. Okay. But you would fix the flat foot? I would tend to, yes. Yeah, okay. And Matt Conte is on the call, I think. I am here, yeah. Yeah, turn on your video. No, I just came from the OR, so you don't want to... Totally we do, yeah. What's the New York recommendation for this case? Well, I came in... No, no, ask the thing. What's the special surgery recommendation? Yeah, only special surgery. We do things differently, so... They're special. Well, I think... Sorry, I came in halfway through. Can I see the lateral? I mean, I think the... And his complaints are, again, we said his complaints are just pain over his medial eminence, but he has no problems walking, marching, doing his physical. Cesar, what's your understanding of Dr. Haida? Yeah, the pain mostly located over the bunion, no pain on the hind foot. That was my understanding. And the valgus clinically doesn't look that very exciting. It's more about the flat knee than a real big hind foot valgus. Sorry, I was able to finally connect my headphones. There's a bunch of questions that have come up on the chat. Yeah. Cesar, you want to go through them, or Dr. Brodsky, actually, you want to go and- I want to go through them, but we have a couple of issues. One of them, who is Sanders? Is that... Which Sanders is it? Well, the question is, okay, so Dr. Sanders asked, does the patient have a gastroc contracture? Oh, it's Mark Sanders, okay. And then Bentley said, let's talk about the sesamoids. So we do have to talk about the nature of the bunion itself. But assuming that we have two problems, is there some consensus that we can reach about whether or not we should fix the hind foot? Because that's what Dr. Haida was asking us. Is there data? Yeah. I mean, we know that when the hind foot is in valgus, right, a hind foot valgus is going to put more pressure on the medial border of the foot, right? And push the first ray which direction? But the lateral x-ray doesn't show it to be in valgus. Doesn't show the hind foot? No. Show us the lateral. How do I get rid of the chat? It's not in valgus. You see the subtalar joint. That's not in valgus. How do I make the chat move away? Oh, never mind. I got it. Well, all right. How many people think the hind foot's in valgus? Well, okay, Naomi, is it in varus? I think it's neutral, maybe towards a little varus, and he's pronating through his midfoot. Okay. I don't know. I don't see a subtalar joint like that when I see people who are playing on valgus foot deformities. On the lateral view, it looks like any deformity is at the navicular cuneiform joint. And can you rely on that? I mean, how do we know that he's not rotating his tibia? We don't. We can't. I don't know. Well, we can a little bit. We don't have a perfect lateral of his talus. I would say it's also not a perfect weight-bearing lateral because the fibula looks like it's tilted to about 11 o'clock instead of ... Who's speaking? I don't have it. It's Bentley. It's Bentley. Oh, hey, Bentley. How do I put it back on speaker view? Oh, here it is. I get it. Nope. We have a pretty good lateral of the ankle. Well, the question is, do we have data and do we know that if we fix the hind foot valgus that it would reduce the forces on his hallux valgus? But Cesar has said he does not have a significant valgus deformity clinically. Yeah, that's what Dr. Haida said is his case. Okay. So, then does everybody agree that the hind foot valgus is a red herring or should we pin Dr. Haida down on the fact that he has told us via chat that the soldier does not have much hind foot valgus, but he wants to do a calcosteotomy and some other stuff for the hind foot. So, now- I think Dr. Haida can speak now. I think he's got these headphones to work. Dr. Haida? Yes. Yes, sir. Are you guys able to hear me? Yes. We can hear you. So, the reason for the calcaneosteotomy is I read a recent paper in addressing flat foot deformity. They didn't address whether it was conventional or atypical, but they addressed their bunions and then solely did a medial displacement calcaneosteotomy to protect for any forefoot pronation. And then one of the recommendations I had on this case was to address the forefoot with a lapidus procedure and then a calcosteotomy without addressing the navicular cuneiform joint, which appears where his deformity is coming from in my interpretation of the films. And but since the symptoms are primarily coming at his bunion, do we or do you think therefore or is that what you're saying, Ken, that that's going to prevent recurrence of his valgus or reduce his risk of recurrence? That's my concern is that if I don't address his midfoot deformity, he will be at a higher risk for recurrence. The fair, I mean, that's a fair worry. I don't know the answer to it. Does anybody know the answer to it? Maybe Ken is the one who knows the most. Mohamed, you want to say something about this case? Yes. I see many patients like this here in Egypt and I discussed one of them with Dr. Liuchon in the last Ask the Expert session. I'm always, if the patient has symptomatic flatfoot and symptomatic hallux valgus, the choice is easy. I correct both of them because both of them are symptomatic. The problem if the patient has symptomatic hallux valgus and significant but asymptomatic hindfoot deformity, then I always take a lot of time discussing with the patient that if I don't correct the hindfoot, there is a high risk of recurrence in the hallux and usually I succeed to make the patient decide to do both of them. So usually if there is significant hindfoot deformity with hallux valgus, I correct both in the same session. I don't know if this is the right thing or if I do the hallux, will the recurrence rate be high or not? I don't know. But usually I don't do hallux surgery alone if there is significant flatfoot deformity. Cesar and Halim, anybody else want to weigh in on that issue? I think it's quite a good question. Yeah, if Cesar may allow me to interfere here. So I'm afraid that yes, the hindfoot valgus is going to cause forefoot pronation and in the presence of first-rate hypermobility or TMT instability, that's going to push the first TMT up. So I would be, and in the presence of a wider IM angle, I'd be more inclined to go proximal as well. So I would address his hindfoot. I would do an MDCO and then I would do a biplanar osteotomy of the TMT joint alapidus and try and hyperplantar flex it. It's going to create a Z deformity and that might exacerbate the collapse of the NC joint afterwards. We don't know. But we all know that for this guy, I think he's going to be looking at an NC fusion at some point if he continues to collapse through his NC joint. And I would caution him about having to go back and do something about this later on. Interesting. An interesting thought. Can I make a comment? Yeah. Hey, y'all. So I think that all the points about addressing the hindfoot are really important in the setting of a incongruent bunion deformity where you've got laxity of the capsule and you've got sort of your classic adult bunion deformity. But in this case, and I'm not sure if we've come to a consensus, but when you look at that AP, it certainly looks like a congruent deformity with an elevated DMAA. It's a- Show us the AP. Okay. It's been like this for years and years. Now show us the stress view. Okay, thanks. So I would just comment that if you think it's a congruent deformity and not a joint laxity, you don't have an insufficient medial capsule causing this problem, then it would seem to me that if you sort of address the deformity with an extra articular correction, meaning not a capsule or reconstruction, but just through your osteotomy essentially, that addressing the hindfoot would be unnecessary because you're not worried that you're going to then, because you don't have a capsular problem as of yet. I'm looking at that joint and I understand why we're calling that congruent, but I think to me, it looks like the articular surface of the metatarsal head is just extremely broad. It looks to me like it's subluxed and still congruent, but it's not in the right place, if that makes any sense. The articular surface is smooth, but I don't think that the joint surface, and part of the reason I say that is because of the position of the sesamoids, the sesamoids have drifted with the metatarsal, with the proximal phalanx. I don't think the proximal phalanx is resting on the metatarsal head articular surface where it's supposed to. I would tend to agree with Bentley that there is some subluxation to the joint. Otherwise, what we're saying is anytime there's an increased DMAA, which is pretty much every male bunion of this magnitude, that it's not only sitting on the laterally displaced articular surface, but that it has no flexibility. I do agree with what people are saying when they say that it's congruent, that I don't think it's reducible. I don't think you can correct it through the joint very much, a little bit. Let's go back to the lateral. Can you make that band? Wait, wait. I want to make that band go away, Sasha, that shadow on the bottom. You did it a while ago. Yeah. If you make this bigger, there is evidence that this patient does have a supinated forefoot, right? That would be the result of a valgus hind foot. There's a little bit of wedge-like opening at the base of the first TMT. Probably not any dorsal shift of the metatarsal or weight bearing, but the general position on a lateral should be parallel dorsal cortex of the first metatarsal with the second metatarsal. The elevation and the divergence of those cortical lines corresponds a little bit, I think, with the plantar wedge opening at the first TMT joint. There is some supination or elevation of the first metatarsal. Then go back to the AP, and it is a big male bunion. You know that what Jacob Zide was saying makes a lot of sense, which is you're not going to get very much correction through the joint, and we need to do a rotation of the bones around the joint. I don't see why there's particularly one way to do it. I think a lapidus is perfectly reasonable, given the supination you see on the lateral. If you pronate or plantar flex the first ray, it'll push the hind foot a little bit out of its valgus or pronation. I think that's perfectly reasonable. The dilemma in increased EMAA, of course, is that when you correct the first metatarsal varus, you make the articular placement worse. The solutions that people have already said, I think, make perfect sense, which is either you do a two-level correction, which is a medial closing wedge distally with a lapidus, or what Jacob Zide and I tend to do a lot is a scarf osteotomy rotated into varus, so that the lateral translation of the metatarsal corrects the first metatarsal varus, and the counter rotation of the shaft in varus realigns the articular surface more distally in varus since it's pointing in valgus. In a male bunion, I personally would almost always do some type of osteotomy of the first proximal phalanx. When you do that, you have the opportunity to correct it in four planes. You can rotate it. You can plantar flex it a little bit to make sure the toe comes down. You can displace it side to side, and you can rotate it, and you just have to have in mind, I think, the possibility to do all of those to get it pretty straight. The soldier's probably hurting because the thing sticks out and mashes on his boots, so correction of the prominence is the most important thing. I would disagree with Dr. Haida. I would not resect the medial eminence, but that's my own personal bias in bunion surgery. If you believe that bunion hallux valgus deformity, one of its components is an increase in the size of the bone, then I think in those rare cases, you can take some off, but I don't believe that that's very often the case. I think it's primarily a malalignment, and that the primary thing we do is to realign the bone and or the joint. I want to play devil's advocate. If he's in the military, he's having to wear rigid leather boots that he doesn't get to choose what brand he wears, and his pain is mostly medially, why not do a silver and just correct it? I think the answer to that is simple, that the prominence that he feels is not an enlargement of the metatarsal. This is his bunion. It's this. It's the fact that the angle between the segments creates a corner, and the way to get rid of the corner is to realign the segments to one another. He doesn't have an excrescence. He has something that should be straight is angled one segment relative to the other, and I can't use my pointer on this, but it's the angle between the segments that makes it stick out. You can't resect enough to get rid of the corner. Yeah, no, I appreciate it. You're very devilish, Naomi. I think we probably should get any final comment from Cesar or Hal, so that we can look at the other cases. My thoughts about these are similar to what Mustafa, probably because we have a fellowship in common. I do think that, in my mind, it's a three-dimensional deformity. I do think that the instability of the first ray and the valves of the input are happening in this case here at the same time. So I have a tendency to also correct the whole thing about the whole tripod. So I would go with lapidus plus minus of distal closing wedge, like we already discussed, and an aching, and I would do an MDCO. That would be my... That would be... I would talk to the patient, of course, as we discussed here already, but that would be my plan. Any other comments? Any final comments for this case? Maybe Dr. Hajdeb, do you want to do some closing remarks about your case? I would just ask... Let me make sure my... Okay. I'm off mute. My only thought was, with the mid-foot break, Dr. Halim had mentioned that... I think Dr. Halim had mentioned doing the navicular cuneiform infusion at a later date. Would anybody consider doing that now, since it wouldn't restrict motion too much, and it would just be an extended plate or screw construct? This is Matt Conti. I know I don't have a lot to add to any of this conversation, but just we happen to have just studied this at HSS because the guys at HSS don't do navicular cuneiform fusions almost ever, and Dr. Dolan does it very, very rarely. So we looked at if you, because people often have the apex of their deformity at the NC joint, what happens if you just do a TMT like Lapidus procedure on those patients? And what we found was that actually most of the patients don't end up at two years, don't end up having significant further breakdown at their NC joint. And those that do, when we looked at their post-operative outcomes, they actually do fairly well. So the conclusion that Dr. Dolan had from the paper that we're just putting out was that even if patients do have a little bit of deformity at the NC joint, they tolerated a little bit better than maybe at some of their other joints. So that's been our experience. Thank you for that. I appreciate that because one of the recommendations I had was the calcaneal displacement with leaving the NC joint alone, and it was the person who had trained me to fuse the NC joint. So it did make sense. Yeah, happy I could help. Okay, I think we should be moving on. Yeah, I'm going to give it to you. That's a very nice case. Thank you for that. No, no, Cesar, you can keep the screen. We have Dr. Sarah Gally with us. She can unmute herself and I'd like her to present her case to Dr. Brodsky, and then I'll be moderating any questions. So Dr. Gally, please go ahead. Are you guys hearing me? Yes, we can. Okay, great. So this is a patient I actually haven't seen yet, but I've heard about extensively because he's our local Arthrex rep. He's seen a bunch of people in our community. But this is a 35 year old guy who sustained an open distal tib-tib fracture in 2016 falling off a roof prior, obviously, to work his Arthrex career. He was treated elsewhere with multiple surgeries from my understanding. Ultimately, he was left with a rush rod and a cibula and treated with definitive external fixation in his tibia. And brain came off. He generally did reasonably well, but he's been left with this varus malunion of his tibia, which doesn't really bother him. But he has secondarily started to develop pretty significant arthritis of his tibiotalar joint, which is now what bothers him. And he saw my foot and ankle partner who referred him to a traumatologist for addressment of his varus malunion. And now my trauma partner and I are talking about options. Meanwhile, the patient's also going to see a local limb deformity specialist to discuss options for treatment as well. And so a couple questions for the group is, you know, my trauma partner very much wants to save his joint and I'm a little bit inclined to think the joint is beyond salvage at this point, despite him being a 34-year-old male. I'd included a couple cuts from his MRI scan, which shows fairly pan-talar and tibial changes to the joint. And so kind of what we're planning, if we're in, you know, my trauma partner and I are talking about whether or not since his primary complaints relate to the ankle joint, doing anything, I think we need to address the deformity, but should we stage it? And then what my role in the joint replacement is, because he wants to save the joint, I'm a little bit of the mindset that the joint is beyond saving and we're really looking at joint sacrificing procedures, primarily fusion. And so would you do deformity correction and effusion at the same time or am I off base and this joint deserves saving? And then also, I don't have a ton of experience in, you know, tibial limb deformity realignment. And so what's the panel, anyone with experiences advice would be on, you know, correcting this deformity as well. Okay, Dr. Brodsky, you want to pimp us? Yes, sure. I don't know everybody, so we could, I tend to ask the people who I know, but Dan Guss is on here, we could ask him. Let me just unmute myself. Daniel Guss from Boston. I guess that's the risk with putting your real name, as opposed to, I realize now why people use fake names on the internet. I think, I'm a young person, my inclination is always to try to save the joint. If you can, I think one thing that would be useful is, is first of all, obviously seeing a lateral and understanding what the deformity is in an orthogonal planes, but also getting, I find MRI can be a hard thing to definitively know how much arthritis they have. I think it's, it's often well supplemented by a weight-bearing CT scan so that you can truly see where he's arthritic and then it's probably worth, if he's truly symptomatic, doing some sort of distal realignment osteotomy to see whether you can save it. Bruce St. George has an amazing paper that was written many years ago, where he goes with his brother through the mathematical modeling that you can use to try to understand how to correct these deformities in three dimensions, which is a paper everybody should save. But I would try, first get a weight-bearing, to your point, see if it's salvageable. That's the first thing. Is it a salvageable joint? There does on weight-bearing CT seem to be areas where there's, where still space preserved. And I would get a weight-bearing CT scan to better understand what it looks like under physiologic load and then make a decision from there based on orthogonal views. So, and Dan, do you have an opinion in the realignment, you know, of your preferred technique for doing it? We, the thing I worry about the most is when you start, because here your instinct is let me do an opening wedge and put in something like allograft or autograft, you know, that's when you, you know, they have to be ready for a long haul and then you do risk the risk of nonunion. Often if you can make an oblique osteotomy, because usually the deformity is not just in one plane, it's usually multi-planar, if you can make an oblique osteotomy and rotate them to correct, or kind of both the AP and the lateral, and you'll have to obviously do an osteotomy to the fibula as well. You can't just do the tibia since there's a deformity that'll otherwise wedge you there. It will lock you into its current position. And what do you do to try to to measure, quantify, or even just get an idea of which way this is rotated to conceive of your 3D correction? So that's where kind of 3D recons can actually be very useful. That's the other advantage of the weight-bearing CT scan. And then as you did, getting full-length films, but also getting an orthogonal. We haven't seen an orthogonal view, a lateral if you have one. And I apologize, he hasn't actually come to see me yet, so I don't have those images. He has a non-weight-bearing lateral. It's the only actually dedicated ankle films, and then he has this weight-bearing radiograph. Dr. Sanders has a very nice comment. Would you unmute yourself and echo it for us, Dr. Sanders, and make a point there? His comment is, this was a compound fracture of the tib-fib, and there may be skin issues after surgical treatment for realignment. What about a proximal tibial osteotomy to realign the limb through normal soft tissues remote to the fracture? As with that, as what might be done for knee arthritis? Okay, who wants to answer that one? It's not at the CORA. It would not be appropriate. You have to do it distally, and it's not good bone. And probably, Dr. Fantry, you have an opinion on what you would do with this case? I do. I do. Well, we were thinking you would have an opinion. I certainly always have one of those. It's not often correct, but I have an opinion. Well, that goes for all of us. I do do a fair amount of trauma and some deformity correction. I would agree with Dan Guss. I would do an osteotomy through the tibia and the fibula, and I think I would try and see if you can do enough of, you know, an opening wedge, medial osteotomy. If you want to do that, it's probably easier if the skin is reasonable medially, and see if you can correct that without really addressing his ankle at all, and see if you can correct it enough to offload the arthritis he's getting through his ankle, which I think is certainly possible, and based on the images that you showed, I think that I would try and save this joint before fusing it. I'm not saying he won't end up with a fusion. I just think that given the imaging you showed, even if he buys, you know, another five or ten years, he'd probably be happier being 45 with a fusion than 35. Yeah. Would you propose going back? I don't know what his skin's like, but would you propose going back to the side of the deformity to correct and try to make your correction there? One of the things I'm looking at is the fibula, and I wonder if by making a longer oblique osteotomy of the fibula, if you could lengthen the fibula and use that to push the lateral talus away from the joint, because it looks to me like the fibula is shortened, and that's part of the reason why. I don't know if that's why, but it doesn't help the lateral aspect of the tibiotalar joint, and possibly by using the fibula to lengthening in that position, that it might help you. Well, I don't think it helps his gutter arthritis, the fibula, right? So I would agree to lengthen the fibula or make a long oblique cut, but I don't think that changes the varus. No, but I'm just... So Alex Rabinovich, what would you do in a Canadian system with this if it was a public patient? Good evening, everybody. Can you hear me? Yeah. Yes. Sorry, I'm late here. In the Canadian system, of course, this will have to wait, but once it gets down the line in my hand, I would probably consider an external fixation here, and I would do it in a staged approach. I would try to avoid the bad skin through the osteotomy, put an external fixator on it, align it, and take it from there. Simple, cheap, and relatively straightforward to do. Of course, it depends on the skin quality, or as my mentor told me, the soft tissue envelope. What do you think? We have a comment that says, from Dr. Daniel Scott, if you realign him first, would make your fusion easier or might get him long enough to be a candidate for a total ankle replacement? Yeah, definitely right. That's the Canadian approach. Make it straight. Straight and narrow. I guess I have a question with that. His primary complaint does relate to the ankle joint itself. Would you do any osteophyte resections, or would you even expose the joint, or would you, in isolation, just address the deformity and then maybe do a corticosteroid injection of the joint? Aside from that, would you leave the joint entirely alone at the first procedure or do any sort of adjunct procedures at that time? Great question. I think you could always be excused for scoping the joint first to get a true assessment of how much arthritis he has at the time of the index procedure. Can I ask a question? Is there a role for, and that's something I might do with this patient, stress ankle x-rays in Varus valgus? Because I think, primarily, if you look at his long-standing films, he went into valgus to compensate for the Varus distal tibia. So I think if you realign the tibia, his ankle might realign and go slightly back again into Varus, and that might offload his lateral side. So my approach in this would be pretty much in line with the Canadians. I would go ahead and do a percutaneous osteotomy, fibula tibia, and put on a spatial frame, and that will also enable me to correct not only the biplanar, but the triplanar deformity with the rotation. And once I get the alignment correct, you never know. Sometimes the ankle symptoms are going to be offloaded. And then re-attack him again in the second stage for the ankle, if need be. And would you debride the joint at the time, Hal? Yes, sir, I would. I would. Probably arthroscopic. I know this is going to be frowned upon, but in young patients, post-traumatic, I would even give him a chance for a distraction. Since I'm doing a frame, I would probably span the ankle and try and distract him after debriding the ankle arthroscopically. And would you make your phone number unlisted in order to do that? I will, and I know we had that discussion in VT Grand Rounds 2016, and I got really fried on it. I don't think it's a matter of fry. It's just that patients really take a long time with distraction. He's going to be in a frame for the spatial frame correction for his alignment for two months. So I would span his ankle and distract it that same amount of time, and it's going to be a hinged frame, which would allow him to move his ankle as well. Let me remind you guys, I see him almost two to three times a week in the OR working with my sports partners. Does that change anyone's thoughts on frame distraction? Yes. Yeah, I agree. Correct the ORS. But without leaving the distraction aside, I think definitely correcting his alignment first is going to put him in a better position for whatever procedure you're going to do next. So this is Naomi. I think correcting his alignment is good, but let's go to the lateral MRI. This joint is trashed. So do you do many favors by operating on him, doing all this stuff, and he eventually ends up with an ankle arthrodesis? I'm playing devil's advocate. I agree. He's embarrassed. That should be fixed. But he has no, he has no congruent joint surface for 50% of his joint. Would you not be better off realigning him and doing a fusion? And letting him get on with his life? I mean, that's a fair question and that's at the heart of the debate and I think one of the reasons Sarah Gally is presenting it. So since we know what the two sides of that argument are, instead of voting who sees it one way and who sees it the other, let's have a vote. How many people are certain that the way they see it will turn out? One side of the aisle says I'm sure that if I realign it his ankle symptoms will get less with a little debridement or at least tolerable. The other side says his ankle symptoms are going to be miserable no matter even if I do realign him, so I might as well fuse it now. Okay. How many people are sure that what you think will turn out? So how do we vote? I am sure or I am not sure. Okay, I'm not sure. So I'm, I'm not sure. So put on your video and raise your hand now if you are sure. Nobody's raising their hand. This is really a bummer. Okay, so could it be possible that one view, especially since you're going to see him all the time, is to ask him what he hates more? Because after all we present cases, it's really fun to wonder how it will turn out and to try to do the right thing. And it really is important for our surgical narcissism to try to do the right thing and a certain amount of surgical narcissism is necessary in order to put your ass on the line constantly doing what we do with hard cases, so nothing wrong with that. But since we don't know and since Dr. Galley is going to see him all the time, would you have an objection to letting him pick? Who would have an objection? What if he said, I want one and done. I want you to just straighten it out and fuse the son of a gun. How many people would tell him, no, I won't do it? Just wondering. It's a good case. And the technical side of it is very challenging. Dr. Zide presented a case like this in our conference a few weeks ago and in counterpoint, I showed him my results of a case like this that I had done seven, six, seven years ago. Not a great result. But the patient was happy. Happy enough to do his other side. So I think it's a very tough case and I think it's a great case for this discussion. I don't wanna leave other people's cases out. Should we go on, Cesar? Thank you guys so much. Do you mind commenting how you would correct it if you would correct it? I'd love to hear from you. Maybe I'd refer it to Hal. Let him put a spatial frame on which I have no clue how to do. Okay, Cesar, you're on. Okay, let me find the next one. Yes, the next one is Dr. Shields. This one, yeah. Not this one, this one is yours. And so- Not this one. This one, yes, posted on behalf of Dr. Shields. Okay. But there's a case above that. Yeah, that's MGADS and we skipped my case in MGADS just because we don't wanna, we want you to answer the question from the other attendees. Okay, so this is an 18-year-old. Here we go, sorry. You had bilateral fourth metatarsal, brachial metatarsalgia, whatever it is. So I lengthened her other side last year. This year I did the corticotomy, put her X-Fix on. She did great. I had a pin through her toe into her fourth metatarsal head, so she went dorsiflex. So she's now two months out. I pulled her pin at six weeks. We lengthened her about 20 millimeters. You can see the regenerate there. And then she comes in complaining of toe pain. And her fourth MTP is plantarly dislocated and she has secondarily dislocated her PIP joint dorsally. I am like, look at her fourth toe, her fourth PIP, proximal phalanx. It's down there. And there's her second or fourth PIP. It's dorsally dislocated. At this point, and that's a rigid deformity at the MTP joint. I can't reduce it in the office. She's having pain. She won't even weight bear on her foot because it hurts too much. I'm like, I put the pin in so it went dorsally dislocate. I don't know how many plantar MTB dislocations anybody's seen. I can't find any literature to talk about that. So I have her on the OR for Monday to remove her X-Fix, reduce her MTB joint. I'm not quite sure how. I think release her FDB, FDB, maybe her FDL. I don't know. I don't know if this is a lack of her extensor function. I didn't know what to do with this one. So I posted it and EMGAD was like, well, let's take it to this expert session. I'm like, okay. So he helped me post the photos. Thank you. So that's a hard case. Dr. Gotha, do you have an idea? Well, I've got my five-year-old daughter with me. Well, does she have any idea? I think that's a good idea. We involve ribbons and screws of varying colors. I think this is a tough case. I think you'd almost treat it like a reverse hammer toe. So you go in, I think you have to release, your extensors, release your flexors. You have to do an MTP capsulotomy. And you might possibly also have to almost like pie crust your planar plate to bring the MTP joint back in alignment. Even though you just went and lengthened that fourth metatarsal, I think you might potentially have to do a distal shortening osteotomy to get the joint relocated. And then possibly- I pulled her pin, your K wire two weeks ago. Two weeks ago, her toe was in good alignment with a K wire down it. But now it's non-reducible. So I think at this point you have to, I mean, you could potentially try a manipulation under anesthesia. I don't know how successful that would be, but I think you just have to go and unfortunately, bring her back to the OR. And like I said, kind of treat it almost like an inverse of a hammer toe where you have a planar plate disruption, but here you have the dorsal capsular, which might need to be amputated. Dr. Shields, there's a question from Alex Rabinovich. Does she have extensor function now? I can't tell because her MTP joint is fixed. She has no active, I can't tell because I can't passively extend her MTP. I pulled her pin two weeks ago. Her, when I put her pins in, I, for the X fix, I made sure they were lateral to her EDL. So one of my thoughts is, you know, has she scarred her EDL down? And now we're getting FDB overpull. I don't know. So let's hear from other people who haven't said anything like reading names. Like Kevin McCarthy, do you want to comment? Yeah, can you hear me? Yeah, tell us, where are you, Kevin? I'm in St. Louis. Okay. So I have never seen a plantar MTP dislocation. I have never either. This is why I posted it. The specificity of it, only being two weeks, makes me think you might be able to get away with not doing any bony work. So that's my first thought. But I think you probably have to open it up and release something, whether that's lengthening a flexor tendon or perhaps, yeah, pie crusting the plantar plate. Well, I'm thinking of a PIP arthrodesis to get the PIP reduced. But she's 18. Does anyone else think that this is from over-lengthening? Yeah. Yes, I agree, yeah. Sometimes it happens, and it has to do not only with over-lengthening, but the rate of lengthening. Sometimes, and we published on that with the HSS group, sometimes when the rate of lengthening is exceeding, yeah, and that's what we're seeing here. So you cannot see the third ray, but I would tell you it has to do with the rate of lengthening rather than the ultimate length. Because what's going on is it's a race between the elasticity of the tendons and the lengthening of the bone. And we found from the previous studies that actually you're increasing the contact pressures on the MTP joint, and just like others mentioned, you're tethering the tendons and the soft tissues, and that might cause an imbalance, whether it's on the extensor versus the flexor side. Okay, Hal, but you have a comment. When you look at this AP film, do you, or someone else, Heidi is next on the list, but look at the length of four relative length of two. Can't you make some inference from that? Yeah, but I always like to look at the Maestro's line and look at how it transcends from four to four to five. Well, in Maestro's line, is four ever equal to two? No, no, never. So then can't you make a comment that four is relatively long if it's almost as long as two? Yes, of course. And I was looking at the list and the names. Heidi, do you want to comment on it? Hi, I kind of thought the same thing. I wish we could see the third, but the fourth does look a little bit long. I would agree with that. I'm also going to tell you this girl lives five hours away. So her mom would go to the hospital and take photographs of her x-rays because the hospital would not allow me to get real-time access. And then she would send me the x-rays. We actually slowed down her lengthening instead of four times a day to three times a day. I do think she's relatively long. I did her other side a year ago and she's done fine with that. So there are some social and distance and economic issues that were in play here. I really don't want to do like a metatarsal shortening. I recognize I may need to do that. I'm just kind of at a loss. I mean, she's eight weeks out. It's a hard case, Naomi, because I think the plantar plate is the thing that's preventing you from reducing it. I've had plantar dislocation of the MTP and I've never had what I thought was a great result. I've never really had a good way to fix it until we began to shorten the metatarsals. I think you have a very tough situation on your hand. Okay, so I have to shorten the metatarsals. I think you might as well bite the bullet and just do it. I don't have the experience. I'm taking her fixator off on Monday and trying to reconstruct her MTP joint because I don't think I can let her go. Well, could you take a little bit out, put a plate on it when you take off the fixator? What do you mean? Well, the dorsal capsule is no match for the plantar plate. You'll never be able to do anything to the dorsal soft tissue that'll match it to keep it reduced. So it has to decompress. So it's hard. It's just a tough situation. Okay, so what are you saying I should do? I mean, I'm really- Shorten the metatarsal. Okay. I just don't think you're gonna get a... I don't think you can do that. We're only- It's a bummer. It's just be more of a bummer later. We're only seeing this in the AP view. And I don't know if an oblique, is there a chance that the distal portion of the osteotomy is elevated? And as you, could that be a cause for plantar flexion of the MTP joint? That's a good question. I think it is a very, very valid point. And I agree, because we found that when you plantar flex the ray with lengthening with the orientation of the fixator, you dorsiflex the MTP and vice versa. So the vector right there might be- If you look at the lateral, all the metatarsals are pretty much equal. Clinically, I don't think she's plantar flexed or dorsiflexed. Okay. Okay, well, it's a- It's a hard case, and I really appreciate your showing it. People get a lot of respect for showing their own hard cases. So let's go back to the PIP joint. Would you- On the lateral, the PIP is totally dislocated. Oh, yeah. Clinically it is. But you can't reduce it as long as the MTP is in fixed flexion. I understand that. So once I reduce the MTP, would you fuse the PIP? Would you try and- I would fuse it because the plantar plate of the PIP is long. Okay. And I don't think it'll represent a significant disability. Okay. But I appreciate and respect the fact that you presented the case. Just real quick, this is Kevin McCarthy again. Would you do a while instead of going back through your prior osteotomy? Because it's easier and more reliable healing. I don't know, Naomi, what would you do? I don't want to go through the regenerate. Exactly. I was just going to say that. If you look at the AP, she's going to be very close to the regenerate. I mean, to put the mini rail on like I did, I mean, these pins were like a millimeter apart. I lengthened this about 19, maybe 20 millimeters. And again, because of distance, there's a delay between when her x-rays and when mom sent them But yeah, I agree. I think she's probably over lengthened. But I can't shorten the regenerate. I don't even know how good the regenerate is. She's eight weeks out. I'm going to take the pins out. If you have to wait and just take it out, wait, do nothing until you have better bone. Not do anything to the MTP till your bone gets better. Yeah, but she's two weeks out from her dislocation. Toughy. I don't know what the right answer is. Anybody else want to comment on this? Because of the acute. I can take that. Okay, go on. Hi guys, Noah Chinitz here without a whole lot of experience in these. I just recently did a bilateral one. And I had a discussion pre-op with a patient and she didn't want the X fix. So I just did a single stage lengthening with a fibular dowel from her leg. And I ended up getting about 12 millimeters each. And it worked out good. So I do think this two centimeters is somewhat long. But I agree with you that the MTP should be reduced soon. In other words, if you wait for a longer regenerate to solidify, then you're just left, it's gonna worsen how stiff the deformity is. So I agree with Dr. Brodsky. I would try to shorten this right away, take tension off of the MTP, release flexors and do a PIP fusion. I think you can take out some of the regenerate and just put a plate on top. You're gonna remove the X fix anyway and let the regenerate sort of further solidify. So with a plate on top of it, it would. And I think if you were to shorten the fourth metatarsal and then do that PIP fusion and release the flexors, I think it'll work out. Okay. Appreciate it. Thank you. Well, that was a very, very nice case. Well, thank you so much, Dr. Shears. Thank you. Yes, thank you. I'm just showing my failures. That's how we learn. Yeah, well, I've had a lot of learning then. But I really appreciate that Amgad figured out how to post the pictures. Oh, it wasn't a big deal. It's very user-friendly. We're gonna get you to do it next time. Moving on, we have Dr. Mohamed Abdelelah Mokhtar from Egypt. You can unmute yourself and present your next case. Where is it, Amgad? I think the next case that we have here is... The other one is Pam Lukes. No, Noah Chinnitz. Oh yeah, sorry, I missed that one. Okay, yeah. So let's do Dr. Chinnitz and then Dr. Mokhtar. Sorry about that. Dr. Chinnitz. Hi guys. Anyway, this is just a general question of a controversial topic, not a zebra case. Like the others presented here, but something which I'm always just trying to find the holy grail answer for, which is the middle-aged Liz Frank. What's the time? So this is a 47-year-old, but this is really just sort of, of course, a jumping off point. But this is a 47-year-old, relatively active female who had presented, I think, two and a half months maybe after this injury. It was initially missed. No weight-bearing x-rays were gotten, et cetera, et cetera. So should it be fixed or fused? And then if those who decide to... And what's really the time limit? Like what's the time limit for recommending somebody fixing versus fusion? When do you cross the cusp of just saying, okay, we're gonna fuse this, it's been too long. And then if fixing, if fixing, do you use a screw versus suture button versus bridge plate? But perhaps my bigger, but I'm not so sure anybody has major right answers for any of those. But perhaps my bigger question is, well, let's say in these patients, even if you do it acutely, let's say you bridge plate the patient with a dorsal incision and you hold everything tight and you try to let things heal. Well, then what happens when they start complaining of pain down the line? Is it painful hardware? Is it the fact that they had a trauma and then a surgery to the foot, which is a second trauma within one episode? And then what's the answer to that? Or do you fuse if they're painful down the line? Which basically means that I've sort of come to the philosophy that either I'm gonna try to percutaneously fix these, if they're acute enough, of course, percutaneously fix these or fuse them through a dorsal approach. But not put a relatively big whack on the top of the foot in order to bridge plate these, because then what do you do with the question of if they're in pain a year or two out? Okay, well, someone tell us the answer. In a patient at this age group, I would fuse. One surgery, one and done. Me too. Who said me too? Bentley. Okay, well, we need to hear from young people, younger than me. As a 37 year old, I do not want my list rank fused. So if this is a 47 year old, 47 is really old, Dr. Fancher. So Dr. Thomas, what would you do? Oh, hi, everybody. I'm in a 47 year old with this deformity, I would lean towards a fusion. I agree with Naomi, it's one and done. I'm sorry, I missed how far out this was, Noah, but I think it was over, yeah, three months out. So I think at this point, she's already going to have cartilage loss. I think she's already going to be moving along the spectrum of developing arthritis in this joint. So I would fuse. Okay. I don't know Laura Bruce, but you're on the list. Are you there? I would say fusion. Where are you? Fusion. Where are you Laura? Nevada. Nevada. How does it change if it's one week out or if the patient's 25? Well, and what if you fused anybody, Laura? How many joints would you fuse, which ones and in which order? And if you don't want to answer, someone else has an opinion, but. Ben Haida has just written, they fuse everyone who's more than six weeks out. And then he would fuse the second TMT only. Does anyone disagree about which joints to fuse? I don't know. Adam Mandel is on the list. Could we see an oblique? Is there one loaded? I don't think we have an oblique. Adam, can you hear us? Yes. Can you hear me? Now we can. Go ahead. So I'm from just outside of Boston. So in a case like this, I mean, you know, I would certainly lean towards fusion. You know, acutely, I would certainly go percutaneous on this, but you know, this being, you know, eight or 10 weeks out, I would open it up. I would, you know, really evaluate the first TMT. I would do, you know, see if that's unstable or not. If it wasn't stable, I would lean towards plating that. I would lean towards, you know, fusing the second. And I'm more of a staple person. I would staple it. And if you did it percutaneous, relatively acutely, what is your percutaneous fusion technique of choice for you? Well, I don't, I don't perk fuse. Well, percutaneous fixation, how would you do it? Just screws. I mean, you know, most of the time I'll do a Lisfranc screw and then I usually do an intercuneiform screw. So you wouldn't have a problem putting the screw across the joints? Across the intercuneiform joints? Well, which joints would you fix percutaneously if it was acute? Yeah, just the Lisfranc interval and the intercuneiform interval. Interesting. That's interesting. And going down the list, Dr. Lonergan. Again, I think at six weeks, I would be leaning more towards a fusion. Acutely, I would try to reduce the second TMT joint plate and come back later and take that plate out. Well, my, one of my questions is, does anybody or who is concerned with the alignment of the first TMT? Yeah, I was, I think the first TMT, it's gotha, by the way. I think that first TMT looks laterally subluxed. A comparison weight-bearing view of the other side might help illuminate whether that's truly the case. Okay. The x-ray machine just broke. We only have an x-ray of the right foot. So is it off or is it not off? Well, if you look at the lateral aspect of the joint, if you look at the lateral aspect of the articular surface of the base of the first metatarsal relative to the metocuneiform, That's why I was going to point to that with his pointer. I think laterally, if you look at the lateral, I think it looks laterally subluxed. And so if this patient came to me, I would probably, at three months out, 47, I'd probably fuse first and second. Her second already looks a little bit arthritic as is, so. Okay. And when the patient has a non-union of one because she's got stimulating circumstances and her non-union hurts, how will you explain to her that the pain from her non-union is nowhere near as bad as the pain would have been from her arthritis? So I'm not sure what your question is. It's bad luck. Well, my question is, let's say that you fix it. I'm just, Dr. Goethe and I would, so let's say you fix it. She's tough. So let's say you fix it and she does get arthritis. I mean, I agree with you in a sense that like if you do a fusion, you're risking a non-union. If you do an ORIF, you're risking a return to the OR for removal of hardware and then possibly addressing the arthritis. So the question is, what does she hate the idea of more? Right. Or which choice does she hate more or do you just hate doing these cases? I love these cases. Okay, good. It's the invention of the state. Since you love doing these cases, let's say you fixed it and she's going to get arthritic. Which joint's going to get arthritic first? Symptomatic arthritis or radiographically? Both. But the issue is in three months, the ligaments are done healing. No, no. I'm torturing Dr. Goethe. Please don't interrupt. Okay. I won't interrupt. Just feel free. Okay. I feel like this is like a fellowship reunion, actually. Listen, you know, we're all friends. It's always like that. My bet is I'm just going to say the second because it's always the second. I agree with you. I think the second. And what do you think the interval would be at which her arthritis would be sufficiently symptomatic to then require secondary reconstruction with the fusion? I'm going to go ahead and ask the expert on that one. I don't think it's predictable, but I think you could be anywhere from six months to never. I think you're closer with never than you are at six months. I mean, I certainly, you know, I'm old. Lost a lot of hair from these kind of cases. And I think the interval at which, you know, the post-traumatic arthritis becomes symptomatic could be very long. And I've certainly had many, many patients who come in at two decades or one decade. I think if she gets a nonunion, it's going to hurt her like crazy from the beginning. I didn't say whether we should fuse it or not because I think it's a fair controversy. I'm just talking about having had the experience of making every frigging mistake possible, no matter what I picked. If you were to do an ORIF, what would your construct be for this case? Well, as you know, the most important thing is to fix the first ray. And that if the first ray is not reduced, it's going to be worse. And that if the first ray is not reduced, the foot will collapse in abduction. This has got two, maybe three millimeters of abduction through the first TMT. First TMT has a long axis dorsal plantar and a very shallow curve medial lateral. So it's really slippery and unstable. It never moves in valgus like this without going in extension. So two or three millimeters of displacement, as we see it on AP, means that she's basically got a supinated forefoot, and the foot will collapse if the first ray is not reduced. So I would reduce the first ray first. And my particular bias, which I'm not saying that I'm right because I don't know, but I would bridge plate it. Would you put anything across the Lisfranc interval? A screw or a tight rope? You've got to do something to reduce it. I agree with that 100%. But I think that I can show you many cases in which you reduce the second TMT joint where it, quote, keys in, and you've keyed in the whole thing in abduction. The whole thing will sway and still, quote, key in. And there is separation between the medial and middle cuneiform. So if we don't reduce the medial ray, the medial border of the foot with the first ray, and we have to be really careful to do it exactly right under fluoro, then we'll get an abducted and supinated forefoot. And so I would do it under fluoro with provisional fixation with smooth wires and probably a T-shaped plate to have rotational control. And to me, that's the most important part of the case. Now, if I elected or if you elected to fuse it, I would say that's fine. But you've got to reduce it the same. And the landmarks for reducing the fusion, getting the first ray down and reestablishing the medial column is a little bit harder once you've taken the subcolonal bone off. You can do it, but you have to really work at it. And the goal, the place to have your eye on is the reduction of the first ray. Hey, Dr. B. J.T. Prather here from Savannah, Georgia. So you are still alive. I am still alive. That is awesome. I remember a rodeo rider who we had a similar case with, and you were preaching on the importance of reducing that first TMT, and we made a medial incision to be sure that that first TMT was reduced. Is that something that you would do in this case, even though it's a little bit subacute? Of course, I don't remember what we did. Yeah, nope. But the main thing to me is to be sure, because I don't think that a great surgeon is somebody who always gets it right the first time and has gold in their hands. A great surgeon is someone who is conscientious and checks their work and pays attention to the details. And unfortunately, the attention to detail is the difference between how the tissue gets handled and how good it turns out. So if I need a medial incision, I don't have any problem with it. I think the advantage of looking medially, the disadvantage is you've got to watch out for the anterior tip insertion, and you end up probably cutting some more of the medial capsule and making it more unstable in the direction you don't want to. But it's hard to judge the position of the TMT from the top, which is why you get so many malunions of first TMT fusions, and they always go in extension. We did do the medial incision. Did you? Yeah. It looked great. You got a good result. Okay. I think we'll move on to our last case, and I think we have time for one more. Cesar, do you want to moderate this? No. We have to do it quick so we get one of your horrible cases. Oh, well. I want to hear what Chris Zinga says about your horrible case. I'll save mine to another. Oh, no. We're not going to let you off. Okay. Well, but Mohamed, I'd like Cesar to moderate this one because it's also a very interesting one. I think Mohamed can turn his mic on and go for it. Okay. Can you hear me? Yeah. Yes. Okay. Thank you, Dr. Brodsky, for the nice discussion. What time is it in Cairo? It's now 4 a.m. You look good. Oh, you see? You've got people staying up till early morning for you. Okay, go. So this is one of the tough cases I met three or four years ago. She's 19 years old female with a history of metatarsus abductus as a child, which was managed non-operatively. Then when she is 18, she started to have a heel valgus. She has bilateral accessory navicular. She has bilateral valgus, lateral ankle pain, some medial ankle pain, but not like the lateral side, and a painful helix valgus on both sides. And the X-rays show that she has some tyronevicular uncoverage here with accessory navicular and with this metatarsus abductus. And clinically she has significant valgus, about 20 degrees of valgus, hind foot. So now she has hind foot valgus, forefoot abduction tyronevicular uncoverage. And then instead of forefoot abduction, she has metatarsus abductus and dialogues. So what would, so I would describe this as zip deformity. So what would be your opinion in managing such cases, Dr. Brodsky? Well, let's open it up to Dr. Zengas to tell us. Okay. Not telling us. All right. Well, Brian Ding, you want to tell us? Can you hear me now? Yeah. Sorry. I had issues with the technical difficulties. I don't pretend to know the answer to this one, but I feel like all of the midfoot and forefoot problems are compensatory for the hind foot. So I think you got to start from the back and move forward. So addressing the hind foot valgus, which will hopefully address her ankle pain. And do we have a lateral? We don't have it posted. We don't have it. Okay. So, so Mohamed, what's the main symptom? So sinus pain. And how looks pain bunion. What was the first pain? Sinus tarsal pain, anterolateral ankle pain from the valgus. I think it's from the valgus. And pain over the bunion. How it looks. But her bunion doesn't look that bad. The bunion doesn't look bad, but clinically the patient has metatarsus adductus. So all the forefoot is adducted and hits against the shoes. So she has pain over the bunion. Okay. So going down the line, Dr. Henning, you want to comment? Or Dr. Cassell? Hi, I'm Nick Cassell. I'm at Georgetown. And I did my fellowship with Cesar in Baltimore. I think you definitely have to address the hind foot first. I think you need an MDCO with a lateral column lengthening to bring around the hind foot. And then you have to address the bunion probably with a lapidus. And the question is, do the second and third metatarsals get in the way? And do you need to do lateral closing wedge osteotomies of those to basically correct the entire skew foot? It definitely is a big surgery, but all of those procedures sort of have the same postoperative protocol, six weeks of non-weight bearing and then six weeks of weight bearing in a boot. So I don't think you're losing too much by doing all of that. Does somebody want to comment? Thank you for that, Nick. But Nick, what about the component in the midfoot? In other words, Naomi was saying that the patient, I think it was Naomi said, the patient doesn't really have how it's valgus. So why is the medial border of the foot symptomatic? And anybody else can take a turn on this one. I've just been going on the line meeting people I don't know, but Mario Arturo, do you want to talk about it? Okay. Matt Conte, what do you think? Well, there's been a couple of papers published on metatarsus adductus and there's been good results with realignment arthrodesis of the second and third TMT joints. And actually, I think, I don't remember the authors, but they recommended it actually in their patients with significant metatarsus adductus to do, they had better results when they did realignment arthrodesis of the second and third TMT joints. And so not to, I don't want to say it again, but we just looked at this at HSS again, and we did just a lapidus for patients with metatarsus adductus, maybe not this severe, but found that our results were pretty similar to results in normal patients, but they have a little bit of a higher non-union rate and maybe a trend towards lower outcome scores. But I think you could get away with doing your reconstruction of your hind foot and then probably have to do a lateral column lengthening. And then I think you could probably get away with your lapidus procedure. I know there's nothing, we don't have a lateral, but maybe get a weight-bearing CT scan too might help just look at the alignment of the first TMT joint. But in a flat foot, I mean, there's typically some instability in the first ray anyway, frequently. So I think doing a lapidus would be appropriate. Go ahead. Would you consider going through the midfoot and doing a closing wedge osteotomy of the cuboid and an opening wedge of the cuneiforms and using bone graft from the cuboid to go to the cuneiform so you realign through the midfoot because your TMT joints aren't abnormal? Thank you, Naomi. I was just going to ask this question. Thank you. I want to add something else. Matt mentioned, I think it was Matt or Nick that mentioned lateral column lengthening here. If you do a lateral column without doing anything in the forefoot or midfoot, you're going to put this into more forefoot varus. It's rather important, even though it makes sense for the hind foot. I don't have any answer for this case. I think it's a very, very good case for us to discuss and get the inputs of all of you. So if we did these things, we're sort of conjecturing because we don't have CT and we don't have a lateral ray graph even. Is it necessary to do anything to the first MTP joint? No. Mario Adames, comment? I'm sorry. So the question is, the first MTP is really aligned well. Would you do a bunion procedure to the joint? I think the first metatarsus is too long. This is the problem because this is the patient that has the pain in the first metatarsus. You need to shorten this. Maybe don't do the length. I do the osteotomy of the cuneiform for the correction, the alignment of the first metatarsus and shorten at the same time. And I win the adduction and I win the alignment of the first metatarsus. Maybe in the right side, I do the osteotomy of all the metatarsus. This is the Herman Herden osteotomy. And I need to do the correction of the lateral column of the cocaine osteotomy. And I think I stop this. And maybe in the second time, if you need to do something more, I do it in the second time. Because I think it's too long of the first metatarsus. It is a long first metatarsal. So Annie Xu is next on the list. Annie, do you want to say anything about this case? Hi. I actually agree. I actually didn't. Where are you, Annie? I'm at Boston. I'm still a fellow. I was puzzled. I understand this patient has bunion pain. But the bunion, the deformity doesn't look that severe. It's just the length that's a little bit unusual. So I wonder if the pain is more related to the alignment and not so much just the length of the metatarsal itself. That's a good point. So who wants to wrap up this case? I think we should make the moderators, Dr. Cesar Neto do it. Yeah, as I mentioned, I think that's a very, very challenging case. I don't have the answer for this one. I would go with the symptoms for sure. I agree with Nick that you have to do something in the hind foot, but I would be worried about even though there's a, in the skew foot deformity, there's the hind foot fungus. Unless I would do a big correction in the midfoot or in the proximal aspect of the metatarsals, I would not do a lateral column lampening because it's going to make the forefoot symptoms worse because we're going to bring them into more forefoot bears. So I would really focus on probably doing MDCO and then I would be debating and asking the experts like Dr. Brodsky to help me with what I would do in the midfoot. I don't, I don't, my experience with this very symptomatic skew foot, it's not very important. So I would, I would debate something as we discussed here doing something, I agree with Naomi, something for the midfoot would probably be my answer. So I would go with an MDCO and a correction of the midfoot deformity, but I wouldn't touch the forefoot. I wouldn't do anything with the first MDP as you mentioned. And Hal, do you want to say something? Actually, I wanted Brian Ding, Dr. Ding to elaborate on his comment there. He has a very interesting comment. I don't know whether he can unmute and share his thoughts with us before I comment. So my thought was that we're looking at this picture in two dimensions for a three dimensional structure that's mal-rotated and it's mal-rotated in many places. And some of the mal-rotation I think is compensatory. And my thought is that, so if we start unwinding it from the back, from the hindfoot, then we're going to end up with a bunch of forefoot varus, of course. And if we don't address the forefoot varus, then we're just going to have recurrence of the hindfoot valgus. So again, my thought is, well, you start at the back, you try to try to decrease some of the hindfoot valgus, your choice of how you would like to do that. And then you got to drop down the first ray, which you can do. My preference is doing a chrysentic in the sagittal plane so that you can sort of dial down and drop the first metatarsal and dial in how much you want to drop it down to recreate the tripod. And as we know from doing chrysentics for bunions, you can incidentally introduce a secondary deformity in the opposite plane of what you're trying to actually correct. And in doing so, you may incidentally correct some of the metatarsus primus varus through your chrysentic osteotomy in the lateral side. And I don't know, like I said, I don't have the, I don't pretend to have the answer. That's just my initial thought, just looking at APX rays without a lateral to know what's going on from that projection. Mohamed, congratulations on giving us a very hard case. I just want to share how I thought about it in the beginning. I thought the hindfoot valgus should be corrected, like everybody said, with medial translation calcaneal osteotomy. Then the patient doesn't have pain over the accessory navicular or the steric navicular uncoverage. So I decided not to do any lateral column lengthening because like Dr. Cesar said, if I do lateral column lengthening, the forefoot adduction will be severe. And then I decided not to do anything for the adductors. But for the halox, I did a lateral closing wedge. So I moved the first tray a little bit laterally and I shortened the first tray a little bit with the lateral closing wedge and I fixed that with a plate. I discussed with the patient that the result is not guaranteed. But yeah, it's good that I can tell you the feedback, that the feedback was okay. And the patient came one year later to do the other side. So until now, she's happy. But I don't know later on how symptomatic will be this steric navicular uncoverage. She is young, she is now 21 or 22. When she came first time, she was 19. So I don't know after 10 years, 15 years, will she still satisfied or more problems will appear? I don't know. Sounds like a practical solution. Well done. All right. Do you want to look at one of your cases? Unfortunately, I think we're running out of time. We're closing up to our mark here. So Cesar is going to have some announcements and then we'll have our closing remarks. Dr. Brodsky, any comments from you? Yeah, this is fun. Yeah. So I'll leave to Amgad to do the closing remarks. But I just want to say that we just launched the International Ambassadors for the Young Physicians Committee. It's an initiative inside the committee for especially to get international people that are a great part of our society, and I include myself on that, to participate more, not just in the conferences, but in the website and this very cool platform that is AOFAS Connect that led us to this very cool webinar where we're having the pleasure to host very important surgeons of our society. So we got 25 names from all over the world to be ambassadors of the Young Physicians Committee, and they're going to help us to advertise the website, advertise AOFAS membership, and kind of foster participation, interaction, connection through the website. So I think it's a very cool thing. It's very exciting for the society, especially during the coronavirus time, but we don't want this just for the COVID time, we want forever. So I would like to thank the International Ambassadors, including Mohamed, that is one of them. It's a great pleasure for us to have you guys involved, and we're sure that the society will be well served by the ambassadors. And I think that's it. I'll get back to Amgad for the closing remarks, and we're all important. Nobody leaves. We have a traditional picture that needs to go to the website. So we're going to open all the cameras, we're going to put the cameras all together, and we're going to take a screenshot, multiple screenshots, okay? And feel free to do whatever you want to do. Everybody make sure that they're modest though. Yeah, so do you want to, Amgad, how do you want to do? Do you want to do the picture first, and then you do the closing remarks? Let's do the picture first, go ahead. Okay, so I will ask you all to bring your cameras on, and let's wait for all of you guys, and we're going to do some pictures here. So let's do the first one, kind of serious, and then maybe then you feel free to do whatever you want to do, okay? So starting now, here we go. Hang on, close out your screen share, and then all the photos will show up. Okay, there you go. Just give me one second, let me get back. Okay, go for it, pictures, screenshots, don't stop, keep going. One like the other thing's a good one to put in the website, so thumbs up. Someone needs to take the picture, so I have to stop the thumbnail. I'll do it. Are you going to do it? Do it, Shelly. Yep, hang on. Hang on. Awesome. Okay. Awesome. Well, on behalf of the LFAS, I'd like to thank, first of all, all our participants. This wouldn't have been a rich discussion without your participation. Dr. Brodsky, thank you so much for giving us your time and your expertise. As always, it's been insightful and painful for us, but it's a lot of fun. I didn't say anything. I would like to thank the LFAS staff, and hopefully we're going to be hosting another one next month and with more cases to come. So, thanks all one more time. Great job. Thanks to AssessOut and Hal for putting together, and thank you, Shelly and Sher for doing all the heavy lifting. Happy to do it. Thank you, everybody. Nice to meet new people. Thanks. Bye. Bye.

distal tibial fracture

varus malunion

arthritis

tibiotalar joint

joint preservation

fusion

weight-bearing CT scans

deformity correction

ankle joint offloading

external fixator

stress x-rays

ankle distraction

skin condition concerns

osteophyte resections

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