Welcome, everybody. My name is Abed Halim. I'm on behalf of the AOFAS Young Physician Committee and Chair Pamela Look. I'd like to welcome everybody to this inaugural event of Ask the Expert. This has been the baby of the Young Physician Committee, and we're thankful for everybody who's shown up to join us in a discussion. A couple of housekeeping points before we start. We're going to all try and comply with HIPAA, so all x-rays should be anonymized. We're not going to be disclosing anything in terms of any conflicts of interest or any manufacturers or technology. The way this is going to go is we're going to start by cases in order of posting. We're going to have Dr. Cesar Neto, who is going to be moderating the session with me, share his screen, and we're going to keep going back and forth between cases. We would like the participant who posted the cases to present the cases themselves to Dr. Sean, and after each case is presented, if we have any other questions, we'll open the panel for a live discussion. That being said, I'm not going to formally introduce our expert of the day. I was an AOFAS Traveling Fellow in 2017, and I had the privilege of visiting a number of centers of excellence. Dr. Saltzman, Dr. Younger, who's with us, Alastair Younger, who's with us right now, Dr. Bruce St. George, and I thought after that experience, I saw it all. Then I had the privilege of spending a week with Dr. Sean in Baltimore, and it was another eye-opening experience. For me! That is not true. We always say surgery is humbling, but when you think you know most of it, I don't say know all of it, but then comes someone like Dr. Sean and then opens your eyes to another world. We're honored to have him here today. I'm going to hand over the microphone to Dr. Cesar Neto, who's the task force of this forum chair, and he's going to be formally introducing our expert of the day. Go ahead, Cesar. Hey, guys, can you hear me? Excellent. It's my pleasure, even though I don't think. Shelly, you need to make me a presenter so I can share my screen. It says, host disabled, attendee screen sharing. I don't think he needs introduction, but it's more my pleasure to introduce him. Now I can do it. Let's do this. Share screen. You guys see my PowerPoint? Good. Okay, let's do it. We're having this after a lot of planning and work in the Young Physicians Committee, like Helene told us. We finally are here, so it's a great pleasure for us to have Dr. Sean as our first guest for this Ask the Expert. We think it's a great opportunity for all the AOFA members to have the chance to discuss cases with the experts. Dr. Sean is currently at Mercy Medical Center in Baltimore and also at NYU, both New York and Baltimore. Who is this guy? I'm going to go first, going with what he says. He's the director of the Orthopedic Innovation Institute of the Mercy Medical Center. He's a faculty of the MedStar Union Memorial Hospital. He's a professor at the New York University of NYU Langone, associate professor of Johns Hopkins, associate professor of Georgetown, and officially the faculty of the University of Maryland. Who is this guy? I'm not sure if you can hear it. So, he became really famous with this, so he, when he was singing with the Foo Fighters at Plainway Park in Boston, so that's, that's the Lushon that most of the people know. And can you guys hear what he's saying or no, otherwise I'm going to pass this. I'm not sure he can. Can you hear the videos or no? Can't hear the videos. Cannot. Cannot or can? Not. Not. Okay. So, this was the address that he was talking about taking care of patients at AOS as the opening ceremony for AOS, that he was part of it and gave a very cool speech that I would love to share with you, I can share with you guys later. But this is him a long time ago, with the dark hair, this guy got to, was president of the UFA that we all know, this is where he stands with research, so it's a great innovator, great researcher. The last time I checked on him on Club Med, but this is really who he is, is a normal guy that cleans his swimming pool for us. And the toilets. Oh my gosh, that I wouldn't tell, I wouldn't share with them. Okay, okay, I won't share. He's cooking us the turkey, beautiful turkey with Erica, very good food for Thanksgiving. He's a very simple guy, very humble, amazing, this is Dr. Sean doing what he loves the most, that is teaching people, interacting with medical students, fellows, international fellows. You can tell us how many fellows you have trained today, Dr. Sean, you probably know the number, I don't have that number. And this is Dr. Sean, just a funny guy, he's just the best person that I've ever met, to be honest. You can't get him to speak any bad of anyone, he's just a positive guy, just positive things. He's a photo boomer, you can see him in the back there, you can't have him without doing that face at the back of your pictures. I had the pleasure to start with him in 2014 as an international fellow, and then finish with him during my last clinical fellowship in Baltimore, 2018-19, this is our picture with the tongues sticking out. This is during my graduation with the bow tie, that is another famous characteristics of Dr. Sean. This is him taking care of my family, with my wife and kids, with my dad, with my mom, with the drinks, we're not going to talk about the drinks, it's probably not the best time to talk about drinks. This is Dr. Sean in Brazil, during my PhD, so he went and met my friends and where I came from, this is my last day in Baltimore, before I left, he's really the Superman in my opinion, there's no better person, and better surgeon, in my opinion. So very good to have you here Dr. Sean, thanks for being who you are, and thanks for everything you did for me, you do for me, you do for all your patients, all your colleagues, and all your fellows. Well thank you, and please deposit the check, okay? Deposit the check. Just one correction. A thousand dollars doesn't last forever, so just deposit it. Just one correction, Fufite became famous after you. After him. By the way, I'm in my, this is where my band practices, my house, I usually am in my other part of the house, but my son's band is playing today, and it's so loud that I actually had to go to this place, anyway. So thank you all, Cesar, it was a great pleasure to work with you as a researcher and clinician and fellow, and Halim, it's great getting to know you over the years, and I love, almost everybody on the webinar is somebody that I've paid money to before, to say that they are a friend of mine, so thank you, and I appreciate you all coming in and looking forward to getting the cases going, but again, really, I love what I do. I can't be more happy, so thank you for letting me be so happy. Okay, we're getting started, and the first to go is Alex Page, Alex, you can unmute yourself, we're going to make it more interactive by having the presenters present themselves. Alex Page is with us online, so we're going to give her the floor, Cesar, you can keep sharing your screen, how this is going to work is, we're going to keep Cesar's screen on for sharing, and he's going to go to Alex's post, and Alex can present the case, and we can roll through the x-rays as we go on. Okay, sorry to rotate it, this is one of those cases that came in last Friday with the same perfect timing for this, this gentleman is, actually, I think that the, he's about a 45-year-old or so, schizophrenic, well-controlled type 2 diabetic, who about two years ago, listened to the voices that told him to jump out of a moving car, so he was treated in another state with some type of an injury that I assume was perhaps an open ankle dislocation, just based on what I saw. There was no instrumentation when I saw him, but he had a prolonged course with a deep infection MRSA, and you can see the telltale little staples in the soft tissue there. He came to my practice, he was about, I think, about eight months out, the free flap covering basically the entire anterolateral portion of the limb was still pretty new, but he'd had fairly advanced AVN of the talus, looked like it was involving maybe 50% of the central portion, but with preservation peripherally, and in a lot of pain. At that point, he was well-controlled, hemoglobin A1c was 7.9, he negative on all the infectious indices, he was back living with mom and dad, well-controlled on meds. So I went ahead and did an anterior approach to clean it out, because I couldn't really do anything laterally to violate that. I took out a good portion of the talus and went down to the subtalar joint, had bleeding bone from the periphery, bleeding bone from the tibia, bleeding bone from the calcaneus, left it full of graft from the proximal tibia and all of the magic engines that you can spend thousands and thousands of dollars on, and put a rod up. And then, well, prayer is not your best option for a surgical plan, I kind of waited. And he seemed to do okay, no signs of infection, nothing at all, at a year out, which was when I'd seen him last prior to this past Friday, he was really having no pain, using a cast boot for most ambulation, just because I didn't really trust it. But I hadn't seen this much absorption. And then he came back to me, would have been about three months from my previous visit, because he'd started having sudden increase in pain over a couple of weeks, and these were the films. So basically, at this point, we've got a guy, no signs of infection, nothing at all, he's going to get new labs and everything, but nothing clinically to suggest infection, who has a nonunion of a TTC fusion, probably progression of avascular necrosis, with not much talus left. He has a free flap that's now two years old. So I could potentially sneak, I think, around the back if I wanted to come in at a transfibular. And he's got a broken rod. So what's the best thing to do for this really nice guy? Yeah, great case. So you have a few questions here. It doesn't look infected, but it could still be infected. We know that. Oh, we'll set up, yeah. So you do the workup, it may be equivocal, or it may be negative, and it still may be positive when you get in. So you almost have to be thinking you have a low grade infection almost no matter what. So it doesn't mean you can't do internal fixation, it just means you got to use it and be cautious. If it does come back suspicious for infection, no question, my move would be go in, take out all the hardware, debride, pack it with antibiotic beads. I love calcium sulfate beads with gentamicin, vancomycin. They will generally dissolve between four to eight weeks. And during that time, they're continuously giving antibiotic in a very high local concentration. So it will kill, even things that it won't kill intravenously, it will kill locally. So packing them up the tunnel of the rod would be good. But again, if you have the infection that's more overt than a covert infection, taking everything out includes also taking out that talus, unfortunately, packing the beads in, and then you have a floppy ankle. And of course, in the face of infection, the best move there would be putting on a frame. So I would do a ring fixator with multiple pins in the midfoot, forefoot and heel with a ring and then one or two rings above and squeeze the heck out of it. And then wait for your cultures and put them on IV antibiotics. I wouldn't hesitate to re-debride, depending on what the infection was, and just pack more antibiotic beads. And then at three months, when the frame starts to get loose and soupy, then re-debride again, take off the frame and put in some internal fixation. You probably will win with that approach. Now, when you take down the talus and you have a go to the lateral view, Cesar, if you don't mind, when you take down the talus, in this case, you're going to have a misshape between the distal tibia and the subtalar joint. So you've got to do a cut. And I believe I could do this. Let me see if I could do this, Cesar. Let's see if you could show us how I make a cut. Let's see. Actually, maybe give me the screen. No, it won't work. Can you see my cursor move or no? Yes, I can. Okay. So you make one cut here that's going to be parallel to the subtalar joint, and then one cut here that's going to be parallel to Gesane's angle. Okay. I guess I can't see it moving. I see the cursor, but it's not moving. So one. Yeah. So your cut, your anterior cut is parallel to the anterior process of the calcaneus, and your posterior cut is parallel to your posterior facet. And there's going to be a bit of a hole, there's going to be a little bit of a gap between the flat end of the tibia and the sinus tarsi. And in that area, do not put any bone graft right away. Leave it open, pack it with beads. But when you go in to remove your frame, go in to that site, your infection should be under control, and harvest a bunch of iliac crest or proximal tibia or wherever else you can find autogenous bone, mix it with some vancomycin, and pack it in the sinus as well at that point. You don't want to pack it, in my opinion, in the face of infection. Now, let's say it comes back, no infection, looks really good without any evidence of infection. Still, go in with the idea that it may be infected, take out the hardware, get cultures, then give antibiotics. You're going to have some struggle taking out this hardware, by the way. It's not always so easy. There's some tricks to taking out the hardware. You might have to bang it out from proximal, from a hole in the tibia proximally. Hopefully you could grab this and pull it out, but sometimes it's truly incarcerated. But then go in to the talus and debride. If the talus looks good, you might be able to salvage some of the talus and pack iliac crest bone with the antibiotic beads, the calcium sulfate beads with vancomycin, with iliac crest, and then you have to decide, it doesn't look infected. You could put in another rod. That's if you're confident it's not infected, knowing that it may be infected on a surprise. But if you do it with the beads and pack it with tons of iliac crest, then you probably will get away with it without having to shorten the leg as much, and you use whatever the autogenous bone locally that's healthy, and you may win. If that turns into another deep infection, well, then you take out the rod and you do a more aggressive debridement and you go to the plan B. I would love to be able to save some of this guy's talus, but if it's infected, if it's lousy bone, you're going to have to lose it. I think it's more infected than ABN, but it could be anything. Any other questions that you have on that one? You think things that you wanted to ask about, take out the rod. Make sure you know the company. You put the rod in, so you know the company. Yeah. I know the company. Yeah. All right. Well, no, I appreciate it very much. I'm hoping it's not infection, but I'll certainly get that work up. Yeah. One other thing is that someone may ask why I am bothering to save that talus. So it is a good question. You have a flap on, and if you take out the talus and you scrunch it in, your wound's going to pucker out, and it's going to be harder to close. The tissues may be pretty woody, and you may compromise your flap. So if that's the case, which can happen for sure, what you may want to do is take out your talus, close your wound, then put the frame on, and you can leave it distracted at first if the wound will buckle open. And then in the next two weeks, let the wound heal, and then you compress it. So sometimes in a case like this, you take out the talus, and that wound will not close because it's telescoped in and it's shortened. So if you do that, don't worry. Stitch it closed, leave it distracted, and then you can compress later. Aleem, you do a lot of frames. Is that a good trick? Definitely, sir. I totally agree. And I had a question. There are a couple of questions in the chat box for you on this one. So one is for me, what is the antibiotic dose of Venk and Gentamicin you use per batch of beads? So I use one gram of Venk and 240 milligrams of Gentamicin for one package of beads. It's one kit. They do make a very large kit, which they use, I think, for spine and total hips. So the doses are different there, but the standard one we use for foot and ankle is that. Okay. And then there's another question, what are the thoughts about Femoral Head Allograft? And that's from Cesar. Cesar, okay. So it's a great question. So it could be a really good choice. If this was a total ankle, if this was a healthy patient, I would love that. But it's infected, it's diabetic, and it's dead bone in the face of some very compromised situation, I would probably, I would definitely avoid it. We had at Mercy, they did a study looking at Allograft for voids, and in diabetics, they had zero percent healing. Now I haven't had zero, but it is definitely low. So a healthy patient, even with infection that's controlled, you might be okay. But this patient, I would say don't do it. Another question may be one of the cages. So they make structural cages that you can use, you can pack with bone graft. You can pack that bone graft with antibiotic beads, and it may be okay. I don't have personal experience with it, but it does accommodate a rod. It is extra hardware in the face of infection, I'd probably not do it. It's very expensive for that. So I would go with the shortening, I think is your best bet. That was actually Daniel Guss' question, foregoing the infection, do you ever use the metal cages? So thank you for jumping ahead and answering this. There's another question. I read his mind. I read his mind. Who is your mind reader? There's another question that was sent to me to ask you from Mohamed Mokhtar from Egypt. Yes. Dr. Shawn, if you do tibial-calcaneal fusion, would you fix the remaining tailor head to the anterior tibia? Great question. So in this case, it does look like the tailless neck and head is healthy. So if it was, I would resect the neck at the body neck junction, slide the tibia down and get that surface to go on a raw surface of the front of the tibia. I'd shave down the front of the tibia and crosshatch it and try to get more bony healing. I wouldn't necessarily put a screw in at the time if it was infected, obviously, I'm going to use the frame, squeeze it. But at the three-month point when I'm most likely taking the frame off, I will throw a screw in between the tailless neck and the tibia. And you could throw that in like a home run screw from posterior to anterior. I like doing that. If the bone is mush, then you're going to have a hole there. Your navicular will float freely and the foot may supinate. So I don't like that. So if you have that situation, you need to translate the foot more posteriorly, which will make the wound even more difficult to close. So good question. Another one, I think that's the last one, Sam Alatar from Ohio, Toledo. If not an infection, would you consider lateral plating? I love plating. I love multiple screws. I like the rod the least to begin with, but it is a great load sharing device. The rod is a great load sharing device. This guy was schizophrenic. Maybe he's under control and you may not have great compliance. So load sharing device there may be the best option initially. So Alexandra's choice I think was best. But I prefer multiple screws and then I supplement with a lateral plate. Now in this particular case, we are sure it's not infected. It's the best case scenario. You can do, let's say it is the best case scenario. You can use the plate and screws, but I worry that again, even in the biology being okay, that this guy being a schizophrenic may be a little bit more of a risk and maybe the load sharing would be better. But plate and screws is a good option. Well, thank you, Alex, for the case. It was a very, very nice one. I'll hand over the moderation to Cesar for the next one. Great. Thanks so much. Here we go. Well, the next one, we're going to discuss Osama Eladar case. I know he's here because he just submitted a question. So Dr. Eladar, if you want to turn on your microphone, I'm going to open your PowerPoint here. Give me one second. Sure. I might have to share this again. Here we go. I'm going to stop sharing and I'm going to re-share it. Here we go. Just confirm that this is the right presentation that I have here. Yeah, that's the case. Yeah, yeah. Excellent. So you're in control now. Go for it. Can we have everybody introduce themselves before introducing their case? All right. My name is Osama. I am an assistant professor of orthopedic surgery at the University of Toledo in Ohio. I mainly do foot and ankle, but I also do some sports medicine. We forgive you. I am a close friend of Dr. Halim. He was my senior resident in Egypt, basically. Okay, okay. That's more due for forgiveness. Yeah, I think that's a bigger issue. So that's a pretty healthy 54-year-old male patient. He has had a chronic bilateral foot pain for more than 30 years. He also had this deformity, basically flat foot, that got progressively worse over the year. The right side is more worse. His main issues is he works in a factory. He wears boots. He can't find any shoes anymore to fit his deformity. He also can't find even regular shoes because of the severity of the deformity. He has never had surgery before. He has never had any bracing because, basically, he can't find any brace that would accommodate the shape of the feet. And yeah. And the only comorbidity is he's a smoker, but he did quit smoking now for almost three months in preparation for the surgery because I told him it would be a massive reconstruction that we would be requesting a lot of bone healing to correct his deformity. And I took clinical photos because it's very impressive. Again, no history of trauma, no history of surgeries before. So that's the first one. Let me go to the next slide. How do I... Yeah. That's the... Actually, that shows that his talus is completely out of the talonevicular joint, and his calcaneus is completely dislocated laterally under the fibula. If we keep going. Here we go. Yep. Again, very impressive how much... I call it exostosis or even HO. I'm not sure what is that. I'm not sure what type of bone is that. And then the next one. And that's his lateral x-ray. He has it on both sides, but the right side is more severe, and we are starting with the right side. And that's his AP, and again, the talus is completely outside his talonevicular joint. Completely dislocated. And that's his... Actually, his calcaneus is completely dislocated laterally underneath the fibula. I do have cuts. Hopefully, this... Yeah, I do have this... Here we go. CT scan. And I do have coronal and axial cuts as well. So we go to the next one. I think that's the same. Let me go... Yeah, let's go to the axial one. This is a typical sports case in Toledo, Ohio, right? Halim trained you well. Yeah. Yeah, it's essentially a lateral of a foot. Yes. Yeah. Yes. And then the last one is the coronal one, which would also show his calcaneus and talus much. This is it, what do I do? Yeah, yeah, it's a toughie. Okay, you have a- I'll stop here. Okay, let's see, all right. So, yeah, so unfortunately for this guy, and this is pretty critical, you know, he is used to having, besides pain, he is used to having some motion, right? Yes. He's not totally stiff. No, his ankle moves, actually, his ankle moves. This is a really critical issue because you can make this guy with some magic, and I'll tell you how I would do it, but you can make this guy look good, and you can make him wear shoes, but he may not be happy because you will most likely here have to do a TTC fusion, and so the TTC fusion here is going to be making him, you know, very, very stiff, and I think that, you know, he may not like his function. He may really be disappointed with it. We did discuss, and he's accepting that he will have an immobile ankle, so he will trade the motion loss for the pain relief and deformity correction. Right. Is he also prepared for shortening of the leg? Yes, we did discuss that we would need to do some shortening. Okay. I would say those would be the two biggest things. Then the third thing along the lines of the fusion is you have to explain to him, okay, you will be stiff, but what does this mean? You know, so I tell the patients, because those joints that are moving but painful are no longer going to move, other joints in your foot may start to become painful. Now, we are going to lose the triple joints. We're going to lose the ankle, but we are going to have midfoot joints, and those midfoot joints may become painful, so in 10 years, I will tell these guys very clearly, in 10 years, we may have to deal with doing more fusion, so, you know, it's not a threat. You don't want to scare him, but you really want him to know that that's part of the equation here. Okay. Now, in terms of approaching this, you know, you're going to end up doing a big lateral approach and a medial approach, and basically, I make my incision along the back edge of the fibula and go to the subtalar joint towards the calcaneal, sorry, to the calcaneal cuboid near the fourth metatarsal, okay? So all the way along there, and then on the medial side, you're going to make an incision that's going to start at the medial malleolus and then go down to the navicular cuneiform joint. Now, if your ankle joint doesn't look so bad, go give me the AP of your ankle again, AP x-ray, if you don't mind. Sure. Yeah. There you go. So the ankle itself really doesn't look terrible, right? Yes. So that's, I would start with the hindfoot joint complex, okay? So the hindfoot joint complex here needs to be reduced, but let's say his ankle looked horrible, then I would start at the ankle because it's still less deformed, but I would start with the ankle, clean that up, and then go to the triple joint. But here, your ankle will be pretty easy to deal with, and you'll use your ankle to balance out whatever you can't balance out through your triple, okay? So you want to go in laterally, you want to take all that heterotopic bone off, and I have a case just like this, and I was looking quickly to see if I could pop it up, but let me just focus on you. But I went in with a chisel parallel to the fibula, a big, broad chisel, and just removed that bone, that extra bone. So then you're looking at the calcaneus and the fibula, and then sneak in to the subtalar joint, and it's gonna be really hard for you to find it, but you'll find it with a cob, get into the subtalar joint, and then just free it up. Don't bother doing any big resections of your subtalar joint, just go in and free it up. You want to make that space, that talus is way over medially, and the calcaneus way over laterally, so you really almost have to go over the top of the whole calcaneus to get it. Free it up, use laminar spreaders, maybe a Hintermann distractor, and don't do any bone cuts, just resect the osteophytes and heterotopic bone. Then go medially, and on the medial side, you want to go into your subtalar joint, go into talon-avicular joint, free that up. You free everything up first, and the reason we do that is you have good subchondral plate and if you free it up, you'll have a better chance levering apart the bones, levering against subchondral plate. You start to resect the bones and it becomes mushy, and then if it's mushy, you will have a harder time working with. Once it's freed up, then you'll see how much it lines up and how much you're struggling and where it's struggling. So if you still have your, give me the AP foot, so the talus head here is a big problem. You don't reduce that talus head by resecting it most likely, you will not be able to slide it in, but free it up first, okay, because you have a good navicular and you want to save navicular because that bone is precious. Talus we could do without. So you would first, after you free everything up, resect your talus head at the neck to see if you could then slide it over, that will free you up, and that'll also then help you to reduce your calcaneus back underneath your talus, okay? Most likely, you will be in good shape with that and life will move forward. You'll have to do some fine tuning to get the foot to be plantar grade, put some temporary large wires there, like five millimeter wires to use like the six, five, seven, two, seven, five screws, okay, but don't put the screws yet. Just get your fixation, two screws and some tailor maybe, one or two, four O screws from the navicular into the talus neck. You've resected the talus head, okay, and now you're kind of close. You won't be perfect because you have a genuvarum, the way his legs are coming in and you've got to be careful. You want to put him still in a plantus position because he's got the varus coming in, his feet have to go into some valgus. So then you want to work at the ankle, chisel out the bone around the ankle and then play with it, get your alignment. You're still going to have a valgus. In the end, you may have 15 degrees of valgus. You may even have 20 degrees of valgus, but the feet should be straight. The talus should be in line with the navicular. If you like everything, go ahead and put in your screws through the tibia down into the talus to the calcaneus. Usually I use three or four screws to go from the calcaneus to the tibia and from the tibia to the calcaneus and then several screws from your navicular into your talus. The cuboid calcaneus I think is also arthritic, so prep it and do it. But sometime, yeah, maybe not so bad. You may not have to do this joint. You may not have to. Question, Dr. Scholl, do I have to free it up because that's how I get the foot subtle? Like don't I have to do some freeing of the CC joint too? Maybe, maybe not. It will probably move once you go in the subtalar and take the, you will see some motion in CC. So you don't have to free up CC until after you have played with your talus head and I would cut that. Then you could decide with your calcaneus cuboid what you need to do. One other thing that is a possibility and I've done it, but I don't, it's hard to know for sure if it would work with him. You may be able to save his ankle joint. So don't necessarily plan on fusing it. I would, I mean, plan on it, but don't necessarily go to fuse it because you may be able to move everything back underneath and the talus dome looks good. Do you have an MRI of his talus dome? I do, but I don't have it in the presentation. Does it look okay? Ankle looks okay. So you may have a chance of saving that ankle and if you do, he will love you forever and he will be a much more functional person, but you got to prepare him for both. All right, question. Do I have to involve plastic surgeon with the case? Should I anticipate any wound issues or? You know, if his skin is pliable, I've never had a problem. How's that? Okay. He's healthy. He used to smoke. I think no, but if you want to be on the safe side, he was a smoker. Yeah, it may be some redundant skin issues. You could have him have a consultation with plastics. They don't have to do anything. They just know him. He knows it's a risk and then your duty is kind of done. If you need him afterwards, there's no panic. So I think it's a safe idea to do that in advance so that the plastic guy doesn't see your patient and go, ah, Sam's always sending me his garbage when he does these crazy surgeries. And you know, the patient sees this and is like. I have already, yeah. I have already sent him some, so. It's always polite. If you think his skin is a little bit questionable, send him to the plastics guy and just say, we'll meet and hopefully never need to use your services. All right, last question. Clearly, because of the dislocation, the chronic dislocation, I am expecting there will be a lot of the skin if I get his foot reduced immediately. Should I excise extra skin? No. It's gonna be a lot of skin. Yeah, I mean, the biggest issue is dead space management. So I rarely, rarely excise. The only time I will excise is a case where there's a chronic ulcer with a skin like that. And that has worked, but I would sooner just leave the skin. It generally does shrink down and it will make it a little bit easier to heal. There's gonna be less destruction to veins if you just make an incision versus doing excision, you'll remove some veins. So I would say don't plan on taking a wedge. The other trick is, as I mentioned, I don't think it's gonna happen in this case, but rarely you have a severe deformity and you try to reduce it. And in reducing it, you see you can't close your wound. In that case, I will use the frame, keep it deformed, put the frame on, let it settle down and then do an acute correction at two, three weeks in the clinic to get it reduced. Rarely, but it is a nice trick just in case you have that hole that was reducible when the foot was deformed, but not reducible when it's corrected. I think this will close. Thank you. I think even you have a shot at saving his ankle. So it looks pretty bad, it looks bad, but if your MRI looks good, I think you're gonna win. Thank you so much. That was helpful. Thank you, Ola. Great case. And the guy plays basketball, right? Yes. Let me see if we have any questions here because Dr. Sean answered the question we had about what are the options to save the ankle? Not sure if you, do you wanna make any other extra comments for saving the ankle, Dr. Sean? Yeah, so the one on the right, going back on this CAT scan makes me a little concerned, you know, the cysts and the impingement on the medial side, on the right, the image on our left, essentially. It does look a little worrisome in the medial corner. Yeah, I think if the MRI looked okay, it may still be worthwhile to try to save the ankle, even if it's not a perfect ankle. But you prepare the guy for the fusion as is right. What do you think, Alim and Cesar, you think you could save that ankle joint? 50-50? I would, yeah, I would say 50-50 chance and I would do all my best to save it, sir. And I have a question for you. I posted for Cesar on the chat box, if Cesar could read it. Sure, so the question is, any thoughts about gradual hind foot distraction with spatial ring fixator followed by internal fixation? Yes, I have thoughts. And I just- Could you do it? And I just expressed them. No, sorry. Now, that's because I don't do limb lengthening transport anymore. I did that, I stopped doing it like 27 years ago. I started practice 30 years ago, so 26 years ago, I stopped it. But I do think you can free it up and essentially what I was describing, if you do all your resection and you're freeing up and you can't close the wound, leave it deformed in the frame and then you do an acute correction. It's very easy, it requires no sophistication. You don't need any programs, you just shift it over and squeeze it together. So I don't think I would bother, I would not bother with a gradual distraction, gradual correction. But again, if I had the wound issue, I would do what I said. Yes, sir. Okay, and we have another question from Nasef Mohamed. Dr. Sean, could you elaborate a bit more on lateral incision and how you might plan it to be able to attack both the extra bone and subtalar plus minus the CC if needed? Right, so the incision begins posterior to the posterior edge of the fibula. Okay, so it's not directly over the bone. This guy's a smoker, if he has a wound complication and you're looking at the bone, that's worse than if you're looking at the skin behind the bone. So I prefer that. And then I go below the tip of the fibula, hugging the tip of the fibula, kind of along the area of the course of the sural nerve, and then go along the sinus tarsi to calcanea cuboid heading towards fourth metatarsal. You may not have to go all the way to fourth metatarsal. If you don't do the cuboid, calcanea cuboid, you don't have to go that long. And that'll give you a big flap, and then you resect all that extra bone, and then you start to work your freeing up, and then you go to the medial side. We don't have any other questions here in the chat, but I mean, the idea here is to be interactive. So is there anyone that wants to turn the microphone on and ask a question right now? Feel free to do it. So I'm going to give you five seconds or 10 seconds to speak up, or do I have a question? Cesar, they could use the raise the hand function. I think, you know, in Zoom, there's a little raise your hand function, right? Do they have? Yes. Oh. Look at you, Dr. Shawn. Now you know all the cool gadgets about Zoom. Okay. Well, maybe- You can raise your hand. Yeah. Hey, I don't know if we have it in this one. Nevermind. We do have it. Okay. It's under, yeah. Thank you. Keep going reactions. All right, but- Well, any questions? Everyone's being polite, which is beautiful. So I do have a question, Dr. Shawn. Why not? I mean, I agree that you need to go laterally because of that amount of extra bone on the outside, but why not attack this mostly through a long, medial approach? Well, so your main work, I would say the bone resection part will be medially. Medially. Take down the HO. You're taking away the talus neck to get that head, to get that head away so that the navicular sits on the neck. The reason I freed up laterally is because you can really get lost. And if you don't free up, you will not lever up the talus on top of the calcaneus. And that is going to be really hard to do, but you want to free that up from the lateral side and push it over. And also on the medial side, you're going to go in the subtalar joint too, free that up there all the way to the navicular cuneiform joint. So it's a pretty big incision. You're going to do most of your initial magic of the reduction on the medial side. But if you free it up, your magic will look like sawing a lady in half versus, you know, some, you know, getting your head eaten by a lion. So you would start medially, then do some work laterally, and then go back medially and finish. Is that the- Lateral, lateral. First, lateral first. Lateral first. The reason also I do it lateral first is you can put the patient tilted and then do all that work laterally, chisel down the bone, free it up. Then you drop the beanbag a little bit, and then you go medially, resect your bone, free it up. And then it's easier for you to come back to the lateral side, just put your screws. So I think that's the way I would recommend doing it. Sometimes if it's less severely deformed, you can go medially alone. But this one, the calcaneus is underneath the fibula. So the incision there is important. There are people who have reported complications from that lateral wound, by the way. But it's worked well for me, but the plastic surgeon will like you better if he meets him first. Excellent, thanks for the answer. We do have one more here from Ivan Matos. If you remove a lot of lateral bone, how do we know that we still have a heel, or a calcaneus, I'm assuming, after that? So you're gonna go down with your chisel, paralleling your fibula. And then you're gonna stop. You're gonna follow the fibula, and you're gonna see where the fibula ends. So you're gonna be cutting until you meet the tip of the fibula. So you'll be following that, and then you're done. So you're not, if you start from below, you won't know where to, you don't know where to go. So I start from above, keep working until I see the tip of my fibula. And the tip of the fibula will help you to know where the hint of the subtalar joint begins. See that? See the tip of the fibula? That tip of the fibula lets you know your orientation for the subtalar joint. So you resect all that big lip of bone laterally, believing as much bone in the calcaneus as possible is important. Great case. Show us. Something like this? Then you get here, and then you go to the other side? No, then you go in with your periosteal elevator, and you go underneath the fibula into the sinus tarsae, and you free that up. Make sure your talus is free from the calcaneus, and you put in your cob, and you lever it up just to free it up. And then when you go medially, it will be even easier to finish that levering, but you really have to lever it up to push it over when you're on the medial side. So you use your cob as a ramp. So when you're pushing your calcaneus from lateral to medial, and your talus over laterally, you need that cob to help slide it. Otherwise, it's very tricky. It's actually a lot of work. But, and I'm worried about his right ankle. The other ankle looks better, but you'll see what you can do. He might be very happy with some pain in his ankle to have a little motion, but very good pace. One more, one more from Daniel Guest. The role of Achilles release. When, and if you would do it, and I would ask another question, is what time? Would you start with Achilles and the lymphony to help with your reduction, or you would wait until you need it? Yeah, in my experience, in this case, it's so bony. So I would do it if I felt I needed it. If I couldn't do my reduction, there is a chance that you will still fight against the tightness of the Achilles when you're trying to shove it over. And so doing the Achilles then is a good idea. I'm thinking you're going to be resecting bone in the final analysis that it won't necessarily need the Achilles release, but it is possible. Okay, any other questions? Raise your hand or speak up. Oh, I want to say one other thing. Sometimes you don't do the Achilles because you could do the reduction. Obviously, if you can't do the reduction, do the Achilles. But at the end of your case, you may find that you still have a tight Achilles, or you may just have a gastrocnemius contracture. So most of the time I do it at the end, but if I'm struggling to get my reduction, I'm going to do it during the case. But don't do it at the beginning because your deformity is so bony. So I think just reduce your bony. Excellent. So I'm going to hand over to Amgad again to moderate the third case. Yes. Is that you? Uh-huh. And I need you to zoom in a little bit. My presbyopia is not helping me read the name. There you go. Oh, sure. There you go. Our next case is by Dr. Altug Tandriovar. You have the microphone on the stage, sir. And I can see you're on mute. And I can see you're from Kankaya Hospital in Ankara. Is he with us? Did he make it through? I'm trying to look for him among the participants, but we have some unnamed participants, so I don't know whether he's on. Yeah. He might not be with us. Okay. Should we go through the case, or should we just move on and then go back? Maybe somebody else who's online has another case. Yes, I agree. I agree. Let's move on. Yeah, we can come back. It's just a new case, though, but let's go on. Okay. Next one. Go for it. Yeah. This is from Dr. Mohamed Magid Mkhaymar. And Dr. Mkhaymar, if you're online, please go ahead and unmute yourself and present your case. This is a super cool case, by the way, also. Why don't you... Is he there? We're looking. All right. Why don't you start to present it? Because I think it's... We will. Unless we have another... Do we have another case to follow this? Yep. Okay. Do we have another case to follow this? Yep. We have one from Dr. Mohamed Mokhtar from Egypt, and I believe he is with us online. Let's go with that. Dr. Mokhtar, unmute yourself and go ahead. How are you doing? Fine, thank you. Good to see you. Ah, me too. Thank you very much. Thank you, Dr. Sean, for this great effort. And thank you, Amgad and Dr. Cesar, for organizing this webinar. Yes, Amgad, thank you, my dear friend. Of course. So it's a great pleasure to share with you some experience and know your opinion in managing tough cases with the combined hind foot and forefoot deformities. So for example, we have this patient who is 25 years old with severe pain in her hallux. She is complaining of pain and disfigurement. She sent me a photo from the beach and saying, yeah, can you see how ugly my toe is? But she has also pain. On examination, she has severe flat foot deformity, accessory navicular, and forefoot abduction. But she doesn't complain about her flat foot. And she didn't even know that she has flat foot before the clinical assessment and the clinical examination. And these are the X-rays are here. If you scroll down, please. The X-rays, yes. So there's tyronavicular uncoverage, severe hallux valgus deformity, accessory navicular, it's not very painful. She claimed that only with pronged walking she has pain in her accessory navicular. On the lateral view, there is a clear flat foot deformity and this is the accessory navicular. So my questions to Dr. Sean in planning these cases, the patient was discussing why should we do flat foot correction with the hallux? I have problem only with the hallux. And the most time taking in the conversation was that we have to correct the hind foot deformity with the forefoot deformity. We cannot do the forefoot alone. So what's your opinion and how you manage and how you convince the patients like this that we have to correct the hind foot and the forefoot deformity? Yeah, this is a great case and not uncommon. So yeah, this is a tough one. So most of the time, the patient will have the, say a moderate hallux valgus and a moderate flat foot and the discussion is easier. And you could say, all right, we're gonna just do a simple distal osteotomy or a scarf osteotomy and we'll watch your flat foot and we say, it may recur because you're a flat foot, but you don't have pain, you don't have a lot of deformity and we should be okay, but be prepared, it may recur. So I think that in a moderate hallux valgus and a moderate flat foot, you could have that discussion and give the patient the power. Decision making, sharing is really okay there. Now, what if you have the severe deformity? Go ahead, yeah. Yes, to cover this point, if the patient has mild hallux, a moderate hallux, a moderate flat foot and you want to manage the hallux alone, okay, would you do an osteotomy or a lapidus procedure? So, I would generally do what was indicated just based on their foot alone, not the flat foot, I mean the forefoot alone. So, let's say they are not diffusely ligamentously lax, they have a moderate hallux valgus, they have no instability of the first MTC, yes, they have say 15 degrees of heel valgus, yes, they have a low arch, they have no pain, they have full power of their posterior tip tendon, again, no instability, no arthritis. I would do either a distal osteotomy if it was a mild hallux valgus or a scarf osteotomy, which I don't do, but that sort of thing. I do a Ludloff osteotomy for something that's moderate to severe and I would not do the fusion. That's my preference, but I know this is open to debate and people would say, oh, flat foot, give them the midfoot fusion, it would give them more stability. I say yes, if they are unstable, otherwise, if they're not unstable, just because they're flat, I wouldn't do it. The question is, the people who say we do lapidus in these cases, is that to decrease the rate of recurrence, if you don't correct the infoot and you have a high recurrence rate, so we do lapidus to avoid recurrence. What's your opinion about this? It will help in terms of a midfoot collapse or midfoot instability, no question, but let's say you don't have it, okay, then I would not do it because I still think you can have a hallux valgus recurrence, even with your lapidus. I personally would go for a good aggressive metatarsal osteotomy and leave the joints. I'm a joint saver. I will do anything to save a joint, but this is my personal philosophy and I know not a lot of people agree that you should avoid the lapidus in this case, but I would avoid the lapidus unless it was unstable in the first MTC. Some people in this case would say, oh, in your case that you're showing here, he's going to be unstable. Okay, maybe, but just your moderate hallux valgus with a moderate flat foot, I would do a Ludloff or scarf and not do the lapidus to avoid a recurrence because I still think you have the risks. Then if they drift, you could convert to a lapidus or you could do another osteotomy. I think that your chance of recurrence is not greater because you did a joint sparing procedure, unless of course, the joint's unstable. Now, in this case, this is a different story. This is a severe hallux valgus. This is almost 80 degrees or 70 degrees of hallux valgus. This is in the category where a proximal osteotomy may not be strong enough. The IM angle here, what's it measuring, 25 or something, right? It's a big number. I don't know if it's 20, 25, but it's high. I don't know if you can measure an angle, but I think in this case, I would be a bit more inclined to do a lapidus just because of the severity of the deformity. If I had a 15 degree IM angle, 15 to 20, I'd probably do my proximal osteotomy. If it's over 20, then even if it was stable, I might be doing the lapidus for that reason, okay? In this case, this woman, I wouldn't fight her. She doesn't have a lot of talonevicular uncoverage. You see her talus looks like it's maybe 20% or 10% uncovered, right? A weight-bearing CAT scan would be interesting in this case, but I think that this is her congenital flat foot and it doesn't bother her and it's not going to bother her. Yes, it does increase your risk of recurrence, this more severe flat foot. Two reasons here, I would do the lapidus, but not so much because of the risk of recurrence, but predominantly because of the severity of the angle. And I would not fight her on the flat foot. I would tell her I recommend it and at least do a calcaneal slide. But if she's fighting you, you just share this responsibility with the patient and you say, you may have a recurrence. We do need to fuse. In this case, I would fuse your midfoot. I think this is going to be better to fuse, but that's for severity of deformity. I would make this a very parallel IM angle, like a zero. Okay. Even with this severe hind foot valgus, you would leave it like this. You know, clinically, she has severe hind foot valgus. Yeah, no, I agree. And clinically, I would be inclined to encourage her to have a correction. But if she's fighting you, I would say, just tell her, we may have an increased risk of recurrence. And if you're okay that this recurs in five years or something, okay, fine. I recommend doing it because it will reduce the risk of recurrence. But we could do it without it and just be careful. I don't think you're condemned to failure here. I think you won't have the durability in this case. But I would definitely be inclined here to do the lapidus here. And it's going to be, you know, I think you'll get a nice correction here. But yeah, the recurrence is still going to be there because of the flat foot. Okay. If you convince the patient to, I did, at the end, I convinced the patient to do the hind foot and the forefoot at the same time. So if you do this, would you remove the accessory navicular and reattach the tibialis posterior as a part of the reconstructive surgery, even if it's not painful, or you would leave it? So if she had, if she had good posterior tib tendon power, you can cross the midline fully. I will now show you my AOFAS socks. Hold on. I have the exact same ones on. Buy the socks, buy the socks. When I test them, I make sure that they could cross the midline, not just against my hand, but they cross the midline. So if she could cross the midline by 60 degrees, I probably wouldn't touch a non-painful ostinavicular. Especially in a case like this, it doesn't look like there's a lot of uncoverage. However, if she had 30 or 40 percent uncoverage, then I would be more inclined to do a kidney procedure, take that out and advance it because I think that needs to be tightened. And I probably would do a flexor digitorum longest transfer. Again, those are cases where they have more weakness of the posterior tib and more uncoverage. But I think in this case, I would just maybe go with a calc slide. And I think that is reasonable. Or yeah, I'd probably just do a calc slide. Maybe you could add a small hintermenosteotomy between the middle facet and posterior facet. I think there's, I don't think you have to go wild on this particular flat foot. Were you thinking, what were you thinking for the flat foot here? Double calc? Yes, I did. I did a medial translation calcaneal osteotomy and lateral column lengthening. I removed the accessory navicular and reattached the tendon and I did lipidus and aching. I think it's reasonable. Was her power good or not so good? Her posterior? Power of the tibialis posterior? Before surgery. Yes, it was good. It was good, but I was afraid that with the accessory navicular, she has pain later on, so I added it to avoid pain later on. I think it's everything in one surgery. Yeah, I think it's reasonable. It will definitely protect your total reconstruction. And if she's not too angry that you pushed her into having the surgery, it's fine. But if the patient is still debating whether to do the bigger surgery, I think you're better off not pushing them. Okay, good. Now, I will show you the post-operative x-rays and the follow-up, but I have a question here because I had a technical problem during the lipidus. Okay. I corrected the intermetatarsal angle. I prepared the joint, corrected the intermetatarsal angle. I did plantar flexion of the first tray to compensate for the supination, and then I fixed it preliminary with K-wires between the first and second metatarsals, and then I put a plate. Everything is okay. Then I removed the wires. Then the first tray moved medially a little bit. The intermetatarsal angle was not straight, a little bit widened, and then I thought that I should have done a modified lipidus fixing the first tray to the second. I did this in later cases, but then I ask you a question. When do you decide that this patient needs a modified lipidus with fixing the first tray to the second tray or not? How do you decide this? Yes. You made a mistake that is common, which is when you reduced your first metatarsal cuneiform joint, you were also reducing the first ray to the second ray. Either it's first metatarsal to the middle cuneiform or the first metatarsal to the second metatarsal, and this will fake you out all the time. When I first learned lapidus, that was a realization that if you have some sort of fixation between one and two or between the first ray and the middle ray, you will reduce the angle. You will do a beautiful fusion at the first MTC, but as soon as that screw starts to cycle to failure, you will have a widening. My recommendation is when you do this correction, only do the correction and hold it between the first metatarsal and the medial cuneiform. Don't involve the middle cuneiform or the second metatarsal. If you do that, you will look at your correction intraoperatively and you'll really know what your reduction is. I will tell you that if you have an okay reduction and you put a screw in at that point between the first and the second, you'll make it perfect every time, but it will be faking you out. I pretty much always do it that way. Just reduce the first to the middle to medial and then I check my x-rays. I do all the correction with that alone. I never typically go to the second ray, but sometimes it is very unstable with that and you feel it, you play with it, in which case involve the fusion. If you're really struggling with your reduction, then go ahead and prepare the joints for the fusion because it will make it easier for you to reduce it if you do that, but I'd rather leave the first ray separate from the second ray, but I don't like to put that screw across unless I'm planning to do the fusion because it will cycle to failure and when it cycles, it will either break, the patient will be unhappy, they'll have some pain, and they'll widen out. So you mean fusion between the base of the first metatarsal and the base of the second or between medial cuneiform and medial cuneiform? If you're going to do the modified Lapidus, I would do it in a case like this. You have enough of the second metatarsal available to just prep the second metatarsal and fuse the first and medial cuneiform to the second without actually going to the middle cuneiform, but sometimes just based on the anatomy, you actually even need to do the first metatarsal to the second metatarsal and the medial cuneiform to the middle cuneiform, but most of the time you don't have to do it at all. Don't fake yourself out with the screw there at all when you have your reduction. Your reduction and fixation should only be first MTC. If you still are unhappy, cut more and get proper alignment. Okay, a nice trick. So I should avoid putting K-wires between the first metatarsal and the second metatarsal in the preparation. Only the first tray and then put the plate, yes. That's a nice trick. I feel strongly about that, yes. We have a couple of questions on this case. I'd like to fire them at Dr. Sean. The first one is from... Just one thing, just I measured here. That's why I was away a little bit. 20 degrees the intermetatarsal angle, just so if you want information. Yeah, I think, yeah, I would go lapidus based on that. Thanks, Cesar. The first question on this case is from Dr. Akramuddin. Would you consider a sinus tarsy implant or an arthritis sprue with a lapidus arthrodesis, considering this is a flexible plasplanus foot type? So it's a good question. She doesn't have much symptoms. You're fighting her. You feel you want to do it. She doesn't want it. You can do the lapidus with an arthrodesis sprue and say, look, it's simple. We don't cut your bone. It may protect your correction, but it may give you some pain. If it does give you some pain, we remove the arthrodesis sprue and we do a calcaneal osteotomy, et cetera, et cetera. In other words, you could say, let's do this. Give me compromise because if you feel so strongly and they feel strongly, this is a good compromise. Then they know that it may not succeed in an adult. The arthrodesis alone is iffy. Many of us have had good cases with it. We've also had less good, but this may be a good compromise case. The second question is from Dr. Nasef Mohammed. Thoughts on obtaining a sesamoid view or a weight-bearing CT, which I think you elaborated on, and check the rotation of the hallux and thus the site on a lapidus, plus or minus a soft tissue medial release? Yeah, I think this would be a really interesting case for the weight-bearing CT. I know at Mercy we're doing it for these cases at other centers as well. I think we need more information about these cases. I think if you have a weight-bearing CT and you could get it for cases like this, we will advance our knowledge down the road. I think for the future, it's good. We don't really know what all the answers will be at the end. I like it and I do think that you do need to rotate. I always do the lapidus with the rotation. Even before this became popular, I was rotating it. Okay, can I share the screen to show the x-rays? Yes, we're going to have you do this at the end. I want to finish the questions of the panel so that we have the pre-ops here before moving on to your nice post-ops. Sam Alatar is asking the instability of the first TMT is very subjective. If the patient has generalized ligament dyslaxia, would you go to a lapidus? Yes, especially maybe, okay, in this case specifically, ligament dyslaxia, for sure lapidus. If it was less severe and she's very ligament dyslaxia, I would also do lapidus. So instability, arthritis, ligament dyslaxia, those are, I think, good indications for the lapidus. I believe the next question from Dr. Nassif has been answered. In doing the lapidus, what are your thoughts on fusing the middle or second cuneiform? I believe you've answered that. The next one is from Dr. Fernando Vargas. In a lapidus procedure, which fixation do you recommend? A plantar plate only, screws, or a combination? My standard is to use three screws. I use usually four screws. I use one from the dorsal aspect of the first metatarsal going plantar and proximal. Second screw is pretty much parallel to that, beginning at the medial cuneiform, heading into the base of the first metatarsal. Those are my two standard screws. Then typically, unless it's a young, healthy person with great bone, typically I'm then adding a third screw. The third screw is put in from the plantar base of the first metatarsal going into the cuneiform, or from the cuneiform plantarly going into the dorsal aspect of the first metatarsal. You have to be careful not to hit your screws. When you're putting your screws in, if you're catching the other screw, it may suddenly gap your fusion. Be careful. I think that's my first way to do it. If the bone is really poor, and I put two screws in, and I'm like, that was really unsatisfying, I will then use a plate and not bother with the next screw. I usually use a dorsal plate there because I have good compression. I use the plantar plate in my Charcot, in my rheumatoids, in my steroid patients, my lupus patients, my sicker patients, more because of a rocker bottom foot. I do my approach plantar medially. I take a small wedge and put the plantar plate. It's great, but I think you don't need it for most of the flat foot or most of the degenerative cases. Then there's this final question from Sam. In doing a lapidus, do you get most of your correction or the wedge through your medial cuneiform cut and preparation or on the other side through the base of the metatarsal? This is a great question. This is a tricky question. If you make a wedge on the base of the first metatarsal, and then you rotate it, now you've done some crazy things to the geometry. Don't do it. You're not smart enough. It's too complicated. Make a perpendicular cut to the base of the first metatarsal. Then you could rotate that against the wedge on the medial cuneiform, and you won't suddenly end up with your metatarsal going where you don't want it. Make your wedge on the medial cuneiform. Thank you. I think these were all the questions we had on this case. If we have the option of having Dr. Mokhtar share the screen so that he can show us what he did quickly, and then move on to the next case. I believe that requires host privileges from our moderator or host, Shelly. I'm doing it. I'm doing it. Okay, Cesar, you're in control. Good. Thank you very much, Dr. Shun, for this nice discussion, nice tricks. I'm very happy with this discussion. Thank you very much. Dr. Shun, do you need a drink after all this talking? I have an IV in, but I know I'm all hydrated because my Foley catheter is functioning. Periodically, I give it a pull to make sure, but it's fine. Thank you. These cases are really interesting cases, so I appreciate you guys putting them together. Looks good. I did medial translation, calcaneal osteotomy, Hinterman type lateral column lengthening, lapidus, tibialis posterior. You can see the ankle reattaching the tibialis posterior and the lapidus, and then aching osteotomy with baleonectomy. This is the clinical picture after three months. You can notice that the first day is a little bit embarrassed, not parallel to the second. That was the problem I had intraoperatively, but the patient is satisfied, and here is the medial side and the hind foot. She is satisfied. Back to your lateral x-ray, just one quick point here, and I think hopefully will be a good point for you. You have your medial calcaneal slide very nicely fixed, but that screw, if you run it axially from the tuberosity towards the calcaneal cuboid joint, then you get a two-for-one deal. A two-for-one deal, everybody loves that. You use a long screw with long threads, so you get compression approximately at the medial slide, and then you bridge across your hinderman osteotomy with the threaded portion of the screw. Therefore, you fix two osteotomies with one screw. One will be compression approximately, and the other one will be holding it in its proper position. When I do my double calc, that's the way I always fix it. One seven-five screw and long thread, it's usually a 65 or 75 millimeter screw with the long threads. Dr. Schon, do you prefer metal wedges or allograft bone wedges? I prefer allograft bone. In Baltimore, we have really good bone bank sources. There are national bone bank sources, but our hospital has really good companies. I wash them out again, and I use the frozen, not freeze-dried. Freeze-dried is radiated, and it becomes more brittle. I like the ephemeral head and neck, and I cut my wedges. I suck it, wash it, and then I take bone marrow concentrate, and I infuse it in my piece of bone, and that has worked really beautifully for me. I don't use the wedges, but I know a lot of people do. I like my bone. Very nice case. Thank you. Thank you very much. Thank you, Dr. Amgad, my dear friend. Thank you very much. Thank you, Shelly and everybody. Thank you very much. Okay, we're moving on to the next case. Shelly, are you going to move on the screen, or should I share my screen? One moment here that I've got to take back controls. Yes. Oh, what we should do at some point is we should get everybody on their video, and we should do some screenshots. Yes. Can we do that? We'll do that at the end, of course. Okay. Caesar's back. You know me, I gotta always take pictures, right? Of course. That's, you know, it's not the virus that's gotten me down. I'm not depressed because of the virus. I want you to know, you know, it's terrible. It's bad for business. It's bad for everything. I'm depressed because I can't take pictures. I lost the academy. That's 2,000 pictures that I couldn't take. Okay. Caesar, are you going to move us on, and you're going to moderate the next? I'm not the host still. Yes. Yes, someone needs to give it back to me. 2,000 pictures of yourself. Of course. Of course. I mean, you know, first of all, I don't have to pay myself, you know, and when I take pictures of other people, I'm usually paying them. I'm sure you know that. Muhtar, I think you're going to have to make host, assign host privileges to either Caesar or Shelly Eshner again. Yes. Stop sharing your screen, and then, yeah. You go to participants. Click on participants on the bottom part of it, and then, you find my name, and then, you just hover over my name, and you're going to see more, and then, you say, make it the host. Sorry. Does anyone know any good songs? All right. While we're doing that, you can see my screen. I will show you. Here's my equipment, and I'm going to go outside for a second and get bitten by mosquitoes, so I get West Nile virus. There I am outside. All right. All right. You want to see my toilet that I cleaned? I think I'm back. That's good. Next. I'm back, so you don't, you can't get to the toilet. Okay. Okay. Okay. Okay. So, maybe I'll go back and just see if, for some reason, people that would just jump the cases, they're here, so Dr. Alto, turn me over. If you're here, let me see if I can find his name again. I don't think he is here. Yes, but not Carmen Altman. Carmen is my wife. I'm using her computer. Okay, so he's not. I am Abraham Altman. Hi. Carmen is my wife, and I am using her computer. Okay. Yeah. Do you have a case? No. Oh. Okay. Then we go again to Mohamed Magid Mechemar. I'm sorry, Halim, correct me if I'm wrong. I might be wrong. Mechemar. It's going to be difficult for you. Okay. Mechemar. Yeah, that's good. Why don't you go through his case, then, for Dr. Sean? We don't have any other. Do you want to go do yours, Amgen? Dr. Sean, what do you prefer? No, let's do the OCD. I think it's going to be an interesting one. Well, okay. Yeah, that's good. I think that's a good idea. We could ask for everyone on the call to raise their hand if they want to do OCD, or they want to do- OCD. OCD? OCD. OCD it is. Okay, OCD. Good. All right. Let's do OCD. So this came from Mohamed Magid Mechemar. Dr. Lucian, I hope you're doing well. I would like to have your opinion on this case for the Ask the Expert session later today. The 25-year-old female occasionally plays sports with an OCD of the medial talus for nine years. Complaints of pain on the medial side of the ankle and conservative measures have failed. What do you suggest as the best treatment would be? Arthroscopy versus open, drilling versus fixation, mosaicoplasty, micro fracture, I'm assuming, and bone graft. Photos and videos are attached. So first picture here. And what was the age of the patient, 25? 25, female. Okay. And let me play, let me see if I can play the video here. Nope. Here we go. Nope. It won't play, but we, I think we get, we have a good sense of it. Okay. So this was, this is a large lesion. That's it. That's the video. Sorry. Okay. Here we go. Yeah. A very large lesion, maybe, maybe even two centimeters front to back, maybe eight millimeters deep, maybe a centimeter wide. I mean, it's a big one. And you already started to get a little bit of an osteophyte in the front of the ankle. So this is the real deal. This one is going to go badly and needs to be fixed. I wouldn't just, you know, just say, okay, we're just going to go easy on this one. I think this one is structurally important. It is a case that I personally would do something differently than maybe what they would do around the world. What I personally would do is do a scope, get a quick sense of the whole joint, maybe do a little synovectomy, but then I would go right to open it. Intermedial approach, take out that little osteophyte, plantar flex the ankle. And I would be looking at the defect. If the patient is ligamentously lax, you can see almost to the posterior aspect, just with the extreme plantar flexion. If you can't, then you could take away a little bit more bone from Hardy's notch. If you take away that little bone from Hardy's notch, you should be able to see almost the whole lesion. If you still have trouble, you could use a distractor, a hindermen distractor, and further plantar flex the foot. So I haven't done a medium allele osteotomy for one of these in about 18 years. So I like to do it that way. It just avoids additional morbidity from the screws, from having a mismatch in the osteotomy, or just the trauma of doing an osteotomy through the joint. So then scrape it out. This piece is probably not fixable, but sometimes miraculously this piece looks good. And if that's the case, you could lift it up, scrape it down, pack some bone graft, and I will take little dowels of Iliac crest bone graft with a small trefine, like a Jamshidi needle. And you could take two millimeter diameter cores of Iliac crest bone and slide them in and then tamp the piece down and fix it. Problem is fixing it is not so easy. You could use a headless screw or you could use a dart. That's where your challenge will be, but you may be able to do it. I don't think you will, but you may. So just have that available. Assuming you can't and the piece is just degenerative and the cartilage on the surface is no good, then I take the piece out. I would take Iliac crest again with my little dowels. So I do it percutaneously with this Jamshidi trefine. I pack it in the hole. I tamp it down. And then I use a juvenile particulate cartilage allograft, which is available in the States. It's average age donor of three years. And I like the material. I put it in with some fiber and glue over Iliac crest bone and then seal it with some fiber and glue on the top. Dorsiflex the ankle and then take some bone marrow, concentrate, close everything up. After the bone marrow is finished concentrating, I inject it in the ankle joint just to make a better environment for the healing. Now, if you don't have that, you can use, there's other cartilage substitutes you can use. There is an adult lyophilized cartilage. So it's decellularized. My product that I use is cellularized, which I like. It's a debate whether it's worth it, but I like it. I've been happy with it. You could use the decellularized graft, which is very fine like sand. The pieces are mixed with some BMAC bone marrow concentrate and some fiber and glue, and that'll resurface it. You could also resurface it with, I don't want to use the product name, but it's a porcine allograft or there are other periosteal grafts or allograft materials you can use. Another alternative, if you have no product for resurfacing, you can use, and I did this in the old days back when I was just starting practice. We didn't have anything fancy. I took iliac crest bone graft with periosteum and I molded it to fill in this hole and I tamped it in place. And I tell you, it worked pretty well. And there was just a paper in Foot & Ankle International. They just came out with it. And I think it was this last month, right? It's the Dutch group. What's that? It's the Dutch group in Netherlands. Those guys. Where are they now? Where are they now? Anybody from Netherlands here? No, they haven't showed up. Too late. That is a nice technique. What their technique was, and I encourage everybody to look at the Foot & Ankle International, because it was a nice technique. They took the bone from the tibia and they made a cylinder and they dropped it into the hole. And essentially, it's like what I used to do with the periosteum from the iliac crest. And it's local graft. You use a nice, large dowel and you put it in. I think they had some nice results. I don't remember the details of the results, but I think it was consistent with my memory of my old iliac crest blocks. Now, the last choice, and I do really think it's the last choice, is an allograft block. Yeah, allograft block would be the last choice. And in between that, maybe I would do an allograft oats. But I don't like the allograft oats. John Kennedy, he's had nice experience with the oats. You guys worked with him recently. Was he allografting or autografting? Autografting is my experience with him. Yeah, I don't know if he does any aloe anymore, but the auto is the best because that is living cartilage. And if you could get a shape match, that's fine. But in order to do that, you have to do an osteotomy. Yes. I know he does this as his go-to, no question. Yes, he does a medium alveolar osteotomy and he can take up to three plugs. And he does the trefoil shape or the trefoil formulation where he just, you know, cuts a little bit off each cylinder so that he doesn't leave any spaces between the dowels or the cylinders. Yeah. So this is a good case. Very nice. Any other comments or questions from the people on the call? I mean, we could have... Yeah, we do have some questions here. Sure. So the first one comes from Sam Elatar, probably. How about posterior medial approach, even though lesion is more posterior? Yeah. So a posterior medial approach is great. But if... So we did a study on the plafonplasty where we took away a little section of the front of the tibia over the talus. And we saw that we have access to 75% of the talus without an osteotomy. So what about the back 25%? So here, the back 25%, you can imagine if they had an OCD in the back 25%, you could go at it posteriorly. But here you have, this is in the front 75%. So I don't think you need it. And I think you might struggle with this one to be happy with your exposure going posteriorly. That's my opinion. One more from Marcelo Jara. What do you think about the ankle HEMICAP system? When do you think it's indicated? Yeah, very, very good question. So I think it's, I would still say the jury's out on it. There have been some experts that have done this very well. I think Dr. Van Dyke has been happy with it, I believe. But I think it's challenging to do because if you make it a little too high, you have high pressures and it's not soft. So it could create lesion on the other side. So if you countersink it, that's better because you have springy cartilage around it. But is it going to maybe catch? Is it going to create some unusual fluid mechanics in the joint? So I think it's still questionable whether that is a good procedure for a standard surgeon. I think for a surgeon who is used to using the product, I think it could be a good alternative. But I don't know a lot of people using it for this. I would reserve it for a failure after maybe allograft. We do have one more here from Nasab Mohamed. We actually use a reverse periosteum flap from the lower tibia so the cambium layer is superior and add fibrin glue over the bone graft. Any thoughts? Are there any, one more from Nasab. Are there any specific parameters rather than the depth, width, and containment that might sway you into a microfracture versus a grafting technique? Yeah, I'll answer the first one first. So I think that is interesting and the reverse, the cambium layer may be better. But the practical part is if I have my iliac crest graft or if you take your distal tibia graft, it's connected. So yeah, it may be superior to flip it, but then it's free. And if it's free, you got to sew it and get stressed out because this is not easy to sew. So I take my piece of bone with the periosteum attached and that's good. Now you can fill it with autograft and just a separate approach to the distal tibia or iliac crest and take the periosteum and flip it. But I think this is a harder procedure. But yeah, you could do this, but I think it's just easier for, to just take the piece and flop it in. But I'm not sure if there's any studies comparing the two different techniques. I believe biologically the cambium layer is better. Now, so depth and width, any other specific parameters to decide whether we're going to do a microfracture versus grafting? Yeah, so I think I alluded to it. If I see, let's say this was less than a centimeter wide, five millimeters deep and maybe eight millimeters front to back. Okay, this is not a big lesion, right? So this might be a microfracture, but why would I choose in that situation, which is a small OCD, but a large small one, why would I do a grafting? The answer is when I see a little osteophyte, when I see some structural changes happening in the joint, when I'm worried about there being more instability, a precursor to arthritis, then I go with the grafting. If the joint otherwise looks totally normal and it's one centimeter by one centimeter by one centimeter, okay, maybe you could just do the microfracture. But the deeper lesions also I tend to graft. So in my experience, I would say four millimeters, five millimeters deep is the cutoff for microfracture. And anybody with one centimeter wide, one centimeter long, four millimeters deep, they could possibly get microfracture unless they're showing signs of joint abnormal mechanics like this one was showing some early arthritis in the 25-year-old. And this is very, we talked about this in the consensus meeting. Halim, do you remember what was our consensus? Yes, sir, I was just going to allude to it. So yes, the consensus meeting held in Pittsburgh in 2018 had a whole supplement in Foot & Ankle International come out with all the guidelines and the numbers you've mentioned, sir, are the correct ones. So they are these dimensions. I don't think if we mentioned in that consensus whether we would add an additional tendency to go towards a grafting procedure because of seeing some early arthritis or some structural changes. You're absolutely right, we did not. We just commented on the depth and it was five millimeters as a cutoff in terms of depth. So once I start to see those osteophytes, my desire is to go with the grafting. Very valuable insight. We need to bring back the consensus team. Yes, it's coming, I believe. More pictures, more pictures. I don't think we have any other questions on the chat. But again, if anyone wants to turn a microphone on and ask a question or raise your hand or post a question now, we can do one more. Halim, why don't you share your case if nobody has a case? Sure. I think that's going to be the grand finale. Well, I saw my son John Wong was on earlier from Ireland. Did you guys know I have a son named John Wong? Well, you have a lot of sons. I saw him. I don't know if he's still here. He probably went to bed. Okay, I don't see him. Okay, go ahead. Cesar, can you go to my case? Yep. Where are you? By the way, this site is really great. I love this site. And I think if we can start to make this used and people know to go to it for their cases, it would be a lot of fun and very educational. For me, I wish going back 30 years ago, we had such technology and the ability to share. We had to take all our x-rays with pictures and whatnot. It was a really big hassle. So this is a great thing. So thank you guys for putting the site together. Thank you AOFAS for curating it. And thank you all members for not writing bad words. Thank you for being the first to kick this off. Fantastic series. With my kickoff socks. Hello. Which are available in the AOFAS store. Buy the socks. Well, I am looking while you're getting the case ready. You got your case ready yet? Cesar is screwing it up. Yeah. Can you see this? Yeah, I can see it. Okay. Okay. Let's go. It's a little bit of a long history. And for the x-rays, we're going to go in reverse order. When I uploaded them, for some reason, the very last ones went first. But I'll go through the history briefly. There's something going on here. I'm not sure exactly why it's reading. Let me just refresh this before you start. Here we go. It might be good now. Here we go. Can you see this? Yes. So this is a 55-year-old female presented to me in April of 2018. So she's been with me, come on, on two years now. Poorly controlled diabetes at presentation, hypertensive, morbid abuse. Her BMI was 54. And charcot arthropathy of bilateral ankles and feet. She had relatively successful... 54. Yes, sir. Is that big or not big? It's very big. I mean, for you or for... She's five foot tall. Okay. 54 is pretty... That's impressive. Yeah. Go ahead. Yeah, that's big. That's really big. Yeah. She had relatively successful management conservative treatment with an Arizona brace on the right side and she was presenting for her left side. She had two prior surgeries on the left at an outside hospital. The first one was in 2016 when she had an attempted TMT fusion, tender Achilles lengthening and hammer toe correction. Her TMT hardware failed and got broken. She returned to the OR for repeat attempted fusion that failed again with continued degeneration of the talus and the navicular with the outside surgeon. She denies any history of infection of her surgeries in the past. She came at that time point complaining of inability to walk due to instability at the ankle. So actually had progressed and the chiropractic changes had involved the ankle. She began about February of 2018 experiencing this instability gradually progressed to the point where about a month prior to my visit, she had started being non ambulatory, unable to weight bear because of her ankle. Can. Yeah. So she sought medical advice elsewhere and she was only advocated a bologna amputation. They didn't think it was salvageable. She was totally against it and she wanted to save the limb just because of the mere involvement on the collateral side. And she was told she was not going to do well with any prosthesis given her BMI. Her labs were borderline. Her CRP was elevated. Her ESR was border was also borderline high normal. I did a consult with cardiovascular medicine and I have a limb preserving team that they said she had good vascularity. Her celiac albumin total protein and AG ratio and total lymphocytic count were normal. I told her we're going to lay off until we get her A1C. As we all know now, the recent recommendations are A1C below 7.5. It was eight. Now it's down to 7.5. So I attempted my first stage surgery when her A1C went down to 6.3 and that was three months later. We removed all the hardware, did an IND, a sequestrectomy. I did a manipulation of the TMT joint and the navicular cuneiform of the telenovicular was completely unstable and non-united. I took samples and she tested MRSA positive. I took all the hardware out. The initial phase was just a debridement. I staged it. Two weeks of antibiotic holidays after the six weeks and then the labs were still elevated. So just like you said, sir, went back again and did a second stage IND, repeat the ID antibiotics for a second round, gave her another antibiotic holiday and the labs normalized to make sure this time I did an indium labeled bone scan, which is I tend to resort to and it came back negative. So I went in and did a third stage with a TTC fusion with an alizarofring external fixator and a hybrid fixation revising her tarsal metatarsal joint and navicular cuneiform with midfoot beams and autographed. This was complicated by medial wound dehiscence at six years. I repeated the IND, put a wound back on and then kept her in the frame for four months. As you said, the frame came loose. The pins started seeping. The pins started knocking out. I got a CT and it showed 70%, almost 70% fusion across the TTC fusion. So I can go through the remaining of the history as we go through the x-rays, Cesar. So if you don't mind, the pictures are marked one through seven. So go back. Right here? No, actually go back a little bit more. So yeah, go to the right. This is one. Is it one? No, no, no, no. Yes, that's number one. Okay, then this is not the number one. It got uploaded. Yeah, so this is number one right there. On the right hand side, we can see the ankle. This was in four of 2018 and I have each x-ray labeled chronologically. So we can see the ankle there. We can see the robust midfoot plate with the broken screws and failed fusion. And then you can move on, Cesar, to the next one. No, that's the very last. So go back the other way. Left. So this is after removing all the hardware. Yep. Sorry, go back to the CT with the 3D reconstruction again. Yep. Sorry, it's all in haphazard now order. But this was the CT after removing all the hardware. And we can see the deformity. And then you can go back to the Lizarov frame. There's going to be an x-ray in 11 of 2018. Yep, there it is. So here is the one. There we go. So this is what I did. Flat cuts, preserved a little bit of the talus. Dr. Sean went through a lateral approach and then put screws across the syndesmosis and fixed the midfoot with a single beam. So this is what it looks like. Nice. Let's move on, Cesar, to the next one, which is going to be. Did you use antibiotic beads at that time? I did not. But I took frozen sections. I would tell you that I do a lot of frozen. So I took cultures and they came back negative. And I did a frozen section from the remaining fibrinous tissue and it came back negative. But I've been resorting to the antibiotic speed since my visit with you. I would have used it because it just isn't worth it. Otherwise, you know, you work so hard to get here. And it just gives you a longer dose of antibiotic coverage. And the likelihood is high. There's still some low grades, something. Yes. Okay. But this is great. Yeah. Move on. It says it before this one, January, there's another one without the hardware, without the TTC nails. So I took that laser off frame off and I manipulated her inside the surgery. And this was it. And I didn't get a lot of motion in the ankle, to be honest with you. It didn't look perfect. Cesar. Yes. The one you were at. Without the hardware. We're just the two cynosmotic screws without. Nope. Not this one. Hmm. It's my bad. Everything got loaded in a haphazard order. Yeah. This one there. So I, you know, I think the midfoot sort of tended to fuse or settle down. I didn't get a robust fusion of the ankle and we can see some scar tissue there. And I think that's my fault. Yeah. So the rest of the ankle didn't move much. So I thought, okay, let's get her in a below knee cast. And then transition into a fracture booth and keep her and start dynamizing her and walking and Walker there. She did well for three months. So that was in August of 2019. And then the next one is going to be the one when it started to drift. So there's going to be another x-ray Cesar without, with the, with this implant. And that's when I went in and I put in an antibiotic coated TTC nail. And there was a very small crack. If you look at the lateral up there, the posterior cortex, there was a small crack. But I thought I had two diameter lengths above it. So I wasn't concerned about her stress riser. So I just kept the nail, but I think the antibiotic coating was a little bit. Fake. And as was, as, as I was putting the nail in, it just cracked the posterior cortex there. And then the next one is going to be, which is going to be the one where she's going to be in a below knee cast. And that's going to be in April of 2020. But nevertheless, this is her last x-ray in April of 2020. I'm not sure we're heading in the right direction. I can see. Again, I'm not seeing that, you know, Well spot welding. I'm not seeing a lot of fusion. So my questions are in my PowerPoint. Number one, was this salvageable? Was this at, you know, salvageable or worth the attempt? And then number two, was this at salvageable or worth the attempt? And then number three, was this at salvageable or worth the attempt? And then number four, was this at salvageable or worth the attempt? And then number five, was this at salvageable or worth the attempt? And then number six, was this at salvageable or worth the attempt? And then number seven, was this at salvageable or worth the attempt? And then number eight, was this at salvageable or worth the attempt? And then number nine, was this at salvageable or worth the attempt? And then number 10, was this at salvageable or worth the attempt? And then number 11, was this at salvageable or worth the attempt? And then number 12, was this at salvageable or worth the attempt? And then number 13, was this at salvageable or worth the attempt? And then number 14, was this at salvageable or worth the attempt? And then number 15, was this at salvageable or worth the attempt? And then number 16, was this at salvageable or worth the attempt? And then number 17, was this at salvageable or worth the attempt? And then number 18, was this at salvageable or worth the attempt? 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And then number 64, was this at salvageable or worth the attempt? And then number 65, was this at salvageable or worth the attempt? And then number 66, was this at salvageable or worth the attempt? And then number 67, was this at salvageable or worth the attempt? And then number 68, was this at salvageable or worth the attempt? And then number 69, And then number 70, was this at salvageable or worth the attempt? And then number 71, was this at salvageable or worth the attempt? And then number 72, wa block and systemically it's not a big hit for them and I do think it's worthwhile to save again barring a systemic cascade if you see them getting sicker and sicker then you don't keep trying but I would I fight hard for these and I could tell you over 30 years when I've had these cases bilateral involvement one side horrible I work really hard and maybe the other side I do something simple it works okay whatever and then they come in like I miss them for 10 years and they come in I find that they're missing the leg you know it's usually the other leg the worst leg that I worked on is the one that's good and they lost the other leg because of some gas gangrene something not salvageable so I think you know it's worth it I really it my personal deep deep feeling is it's worth it anything you would have done different yeah just the beads that you mentioned which I am and no I think I like the beaming screws in this indication you could sometimes run the beaming screws even into the tibia but when you did the beaming screws you didn't need to but you know that's another thing I use did you use autographed yes sir both times the first one was from the proximal tibia and the second time was well sorry the first time was from the distal fibula and the second time was from a proximal tibia yeah I love autograph that's great I think that by the way you broke out in the back because you had pinholes where the crack started was one half pin and where it ended was the other half pin so already it was kind of a stress riser so I don't think I don't think you were off with your milling I think that it just was a weekend no I think it's good I think you did a nice job and you know these are tough cases and the patients usually co-participate with you yes and she was very yeah she was very good and she just like you said she she recovered well and she didn't go into any catastrophic multi-system organ failure yeah I think it's important you know if you bond with your patients with these situations you're gonna have a much better result when you're fighting with the patient you will probably lose so this is another indication maybe to push for the amputation a completely non-compliant patient with no system support you know you it may not be worth trying because there's just too many issues but with those cases getting them set up with a prosthetist early it's good but they this one is so big 5 foot 4 with a 54 5 foot 2 with 54 BMI it she may not be a good prosthetic wearer yes and that's what she was told yes yeah I believe that now you can also do with those cases a plastics procedure so you could do a BKA you get a big floppy limb it shrinks down and it becomes even floppier but it's not tight and then you could go in and remove redundant fatty tissue and you can make a better limb so you kind of do like abdominal plastic you know and I've done those and I know some plastic surgeons do them and they're not hard procedure and it could make a not a not not easy to fit leg an easier to fit leg well thank you thank you great great cases we do have a K a question am get you want to go for it yeah so the question is from Sam what do you use for antibiotic coated nail standard nail size and what antibiotics so thank you that's a good question so I use the smallest diameter nail and then I coated with a two millimeter coating because the nail comes in three sizes 10 11 12 so I use the ten millimeter nail and I add the two millimeter coating of antibiotic cement and I use the gentamicin loaded cement and I add per batch one gram of bank and 1.2 grams of Tobra provided that the sensitivities are amiable for these antibiotics you can tailor the antibiotics according to the the bug but actually we all know that you have to add a thermo stable antibiotic so usually it's the same it's the same combination I use for or we use for our total joints so per batch of cement one gram of bank 1.2 grams of Tobra and then it has gentamicin built-in nice I have a question dr. Sean for you and I'm actually it's just came up from dr. NASA fan you mentioned it passing the beam all the way to the tibia doesn't that give them to a two rigid of a foot and predisposes the beam to fail well yes but you could also fail because I've had fusions like this where now you have the only motion segment is a transverse tarsal joint and if that's too unstable you can actually dislocate your hind foot and I have a really horrible case where that happened so you know if it's stable I agree don't bother crossing into the tibia with your screw but I try to get it stable by doing the fusion even if I don't get a fusion I get bone mass there and here I'm worried that you may have you don't have a lot of bone mass and it may be a site where there's future failure it's a judgment call but yeah I think it is going to be rigid but I'd rather have more rigidity than a floppy transverse tarsal joint because then they end up with all their pressure on the calc so you want the foot to participate having motion and having the foot participate in the weight-bearing scrape but once it starts the sublux you will have to fix the hind foot to the tibia yes sir there's a question for you from NASA's any thoughts on advancing the tibia to over the midfoot and fixing it they're reducing the lever arm almost no talus you can't go too far it's too I mean I think you could this is you've gone pretty far here you've moved the tibia to the navicular yes sir so that's that's about as far as you can go in my experience the vessels will I think not tolerate going beyond that and also you're putting the tibia over the navicular which is historically not a good bone and putting it over the cuneiforms also not so good so it's an interesting question but I don't think the vascularity of the foot will will allow that but that may be a good study how much how much can you move the tibia forward onto the foot before you lose some circulation but I think what you've done is is actually quite nice you've gone to the transverse tarsal joint level then there's a question from Jason Rudolph I think we elaborated on it before but you might as well answer it can you discuss your technique and not mine I guess he wants your technique and the type of antibiotic bees which I think you've alluded to before but maybe another reiteration would be good yeah my technique is to to call Southwest Airlines and buy it and send them to my friend Halim and no no it seriously I would I would call you up I would seriously would because you know I think that I haven't coated a nail to be honest so I like what you did with the nail coating I would use the beads so my technique would be very much like this I wouldn't have I probably wouldn't have sunk the calc the the screw into the calcaneus as much I would have left it out a bit more and and then I would have put some more cross screws so I would have gone with some additional screws from the calc to the tibia kind of around the nail and then I would have packed it with the calcium sulfate beads and probably would have done tried to get a screw from the midfoot to the tibia as well but so the biggest difference I would say was I don't coat these rods but the reason I don't is maybe because I didn't have a mentor that taught me how to do it but the other reason is also that the cement beads leach antibiotics for about three weeks and then it might have some prophylactic value but it doesn't leach a high concentration so I think it's you know I'd rather go with the the calcium sulfate beads and get six weeks and maybe even refill it if if I thought we were still having some infection. Thank you there's a question I think it's for me from Robin Fox when I coated the nail how did I prevent the cement from getting into the compression mechanism the question so I I get the nail and I put it into a silicon tube and sometimes if you don't have the silicon French chest tube you can actually roll the antibiotic cement on the nail and before it sets up I get the drill and pass it through all the holes on the nail to make sure that they're vacant so that the cement doesn't set within the holes so as the cement is setting around the nail itself my drill goes through and it opens all the you know the locking holes including the compression mechanism on the screw and that's and then after that the cement sets and you have a nice mantle and then you can bang it in and I really whack hard on those and the cement mantle doesn't come off and if you look at closely at the extra you're gonna see the cement mantle going all the way through you just have to leave to leave it to set quite a quite a time. The technique is a nice JBJS article on antibiotic coating nails it was initially described for fractures of the tibia but then it's applicable to again any nail and I believe it's simple to see if you look it up. Ilyam could you do us a favor someday could you put on this website your step-by-step technique of course of course sir because I think a lot of us don't do that and it's kind of a good trick and and I think it does require skill you got to know what you're doing yeah. Sure I'll be honored I'll take some pictures and maybe do a video that would be a nice idea and post it to Vue Medi or maybe the AOPS website. Yeah that'd be great yeah. Question what's your calcium sulfate antibiotic recipe I believe Dr. Sean answered it it's 240 milligrams of gentamicin and one gram of vancomycin correct sir? Correct the the kit comes with a dilutant so you have the powder the calcium sulfate powder and then it comes with a little dilutant so instead of using the dilutant you use the liquid gent so put aside the dilutant mix the vank with the calcium sulfate powder first get that all mixed up then add your gent mix it up and do not add the dilutant and then you put it in the molds and you let it sit and then you crack them in into the into the cup now delivering the beads in is another thing if you have a wound that is dorsal and you it's easy to just pour them in or dump them in but if you're putting them up the bottom of the heel sometimes it's a bit of a hassle so I've made funnels and made piece of plastic that I put the the beads in and push the beads in holding the foot up I've had fellows come up with very clever mechanisms a couple of my fellows have done some really nice things that they said they were gonna patent one day but it's basically a piece of plastic cut so well that's nifty that's very nice Rabin Fox added a comment he said that one of the nails on the market is easier to prevent with this technique and it's based on an HSS study so thank you for that we'll be looking that nail up for sure and maybe we can do another video and maybe Rabin you can show us the technique yeah that'd be great any other questions on this case okay we had one final question for you by the way that was get the picture oh yeah we'll do it right now so what we will do it we're not going anywhere but there was a question that we we were asked to deliver to you how has your experience been with telemedicine with the COVID-19 situation and are you still doing as much telemedicine now that the restrictions have eased a little bit and what are your thoughts of you know the telemedicine era moving forwards right now yeah well great question and maybe actually that that we just quickly show you something hold on one second so I have been pretty happy with telemedicine because I could the first of all I'm not wearing any pants okay so I like that no I I think telemedicine is okay I don't love it but you know we have to deal with it so you make the best of it so what I do first of all is I have two teams and I use my MA so I have two computers for each team so we have my computer that I'm gonna zoom on and we have the other computer that's doing medical records and either on my computer I have the images and I share the screen with the patient to show them the images and I have a physical exam I do and I tell them how to do it so we've we've been pretty good with most patients that are under 60 I think the success and satisfaction rates pretty high patients over 60 and by the way it's my birthday in three weeks so I will be over 60 so okay that is what it is but you know there are people that are less savvy and so if they're less savvy you could struggle with that so we need to fix it for those people too but basically I have the two computers running I do my interaction at the end I say okay we here's the diagnosis here's the treatment sometimes I'll show them a PowerPoint if I have time or I'll have my PA show them a PowerPoint or we just talk them through it and while we do that I say look my PA my assistant will take you through scheduling and I leave that room that room keeps going when I go to the next room and the fellow or MA has prepped the patient and we keep going that way so you need it you need team so that you could do it efficiently like you're in the office I do think it's not going to go away I wish we could work to reform the laws that will allow HIPAA HIPAA laxity and state laws need to allow us to do telemedicine to adjacent states so I think we should all make an effort for this but it's a it's a great question I I'm interested in continuing the dialogue on telemedicine and I have a few things up my sleeve in this regard oh we'll be looking forward to see what's up your sleeve as always Cesar yeah we do have just one thing we're gonna give you a pee pee break Dr. Sean if you if you if you need to do it but we're gonna go through the website quickly I think it's we think it's very important for us to show around the website for people that don't know it let me just share my screen I nobody should leave because we've got to take the picture yeah nobody leaves okay nobody leaves here we go here we go it's just so when you get to the website is what you see so it's AOFAS connect it's it's really a very cool tool for all the AOFAS members I think it's a very exciting way for you to connect with other surgeons colleagues get opinion of other colleagues post some cases ask any questions doesn't have to be cases you can talk about anything you want here but when you log into connect dot AOFAS dot org that's where you end up okay so you have this kind of a summary of what's going on in a website you do have the upcoming events here so you can miss the ask the expert LuSean MD okay June 2nd 6 p.m. to 9 p.m. very exciting one pretty much everything that AOFAS is organized is gonna be here so you can look to the events and then you can get a glance of the latest discussions or everything that is kind of hot in the website is gonna be here so you can see here or have a question for Dr. LuSean post it below but here is where you really go into the details so you can go to the communities so you can go to if you have your preferred communities or the communities your part you're gonna go to my communities I'm gonna click here into all communities so people can see how it looks like if you haven't if you have never been there right now we have the AOFAS case-based discussion that is the place for you to post cases okay we do have some details of how to post cases following the regulations hyper compliance and everything but that's where you would go and then when you go here again you're gonna have a glance of all the discussions for the case-based discussion you do have the latest shared files on your right side if there's any announcements you would also see it there and you can go specifically to each of the discussions that you go here so you click on discussions and you're gonna like so this is the one we are posting the cases right now have a question for Dr. Sean but there are some cases already posted there you would be it would be very exciting if all the members start giving opinions here giving feedback for the surgeons that need some help or some guidance so we do have hind foot and forefoot deformities telemedicine that we were discussing right now you can just introduce yourself and say hi during this crazy times of coronavirus we do have a something about coronavirus here so you can come here and create a new community you can post a new message you can create a new community all through this a very exciting opportunity for connection and to get some inputs from from colleagues and experts you can just network here you can go to the member directory so you can find any members of AFS here and you can come contact them you can add them to your list of friends and etc and you can when you're posting anything that you want so for example you know AFS case-based discussion let's say I go there and I'm gonna answer to Shelly here so you just you can just reply here and then you can tag people the same way you do in Twitter or LinkedIn so I'm gonna tag Shelly I'm gonna tag Dr. Sean so you can bring people to the discussion if you want a specific opinion so and bring MGAD so you can you can keep adding people here into your discussion you can upload files click in here so you can you can really discuss a case here completely with the details respecting like Dr. Sean mentioned being polite don't put any patient information make sure everything is protected because at the end of the day it's your responsibility because you're posting information here other than that let's go back to home like I mentioned before you can see all the upcoming AFS events here and you can browse through all the posts all the communities using the search button you can go quickly to the participate tag here and you can post a message or share a file or join a specific community anyway I think it's I really love this technology here I think it's it's really good for interaction connection and for getting second third fourth and fifth opinions about difficult cases so I would strongly recommend members to use it and I'm gonna open to Dr. Sean or MGAD or I know Pam Pam Luke is also here and Shelly if you want to add something else about the website go for it Pamela please pitch in unmute yourself the Shelly I'll jump in and I couldn't have done it better myself Cesar you you showed him around and showed them absolutely everything I think the only thing I might add is to go to your profile yep just go to your profile and it's super super easy you can even import right from LinkedIn if you want your information in there but that's a great opportunity for you to kind of share who you are with people that might not know you yeah that's great I also it pops up in your email so if you post something here you'll get a reply from your eating your email Pam you want to say something Pam was there she was gonna say something oh you're muted let me unmute her hold on you should be good there Cesar do you see how many messages you have in there Pam can you oh yeah look at that they're all yours not all can you unmute Pam could someone unmute Pam please I think I'm unmuted myself okay perfect you okay all right yeah no I can't add too much more to Caesar what he said but I think Shelly has been very helpful so if there's other groups that you want to create separately we want to be like all-inclusive that's why we had the case space with the 2,500 members but if there's a certain group that you want to create to you know just among a fellowship alum or you know in a certain area Shelly's been very helpful in generating those so you can the residents have been doing that each each committee within AFS can do the same so yeah we really just want to get online attendance and using this to really keep people connected so it's been a great thing for AO Fest to bring on board for us I would like to add one more thing is that we're using zoom currently because we don't have the live video possibility inside the website but that's a possibility for the future we might have that as an option as well to host discussions and host webinars while we're doing for zoom but that's that's the reason why we wanted to post the cases we wanted the members to post the cases in the website because it's protected we have you have to sign when you're posting a case you have to sign and read the guidelines and acknowledge that you read through it and if you just show here in zoom you're not you're not doing that so for the safety part of it we are also doing through the website so very exciting and we might get even better in the future so we should use it since it's available these are I think it's time for that group photo dr. Sean has been asking for so go ahead and go to all speakers and put us all on the screen yeah now Morali Murthy's driving home in California okay I see him in his car it's great he's got a beautiful elbow and anyway it's great that everybody came and I think I mean this is one nice thing about this the virus is that it did make a little bit more creative and a bit more motivated to use zoom and we should continue to keep it up because I think it is efficient in between all the meetings we should be able to maintain community and I think we will all make the world a better place by sharing more readily more openly and again thank you to everybody all the participants for your cases and all the people listening and not falling asleep I appreciate that so thank you let's do the picture guys okay cameras on as the cameras come on yeah we're gonna close out Shelley let's let's turn the cameras on come on I'd like to thank dr. Sean again with the kids Eric cameras on beautiful pictures we had a great attendance today 63 attendance which I think is a very good show up of heads dr. Sean thank you so much this was a very good session thank you to all the attendees both in the u.s. and abroad it has been a very very robust show up of heads we thank you all I would like to personally thank the office staff the YPC members and the task force led by Cesar of course the chair of our YPC committee dr. Pamela Luke and we'll leave any closing remarks for her I couldn't summarize it better than I think Caesar and I'm God so much and of course dr. shown for making this such a great first inaugural episode hopefully this will be followed by many more and again like both Caesar and I'm good I'd said this is as well as dr. shown this is kind of the future and so hopefully all of us can stay in touch stay safe and take care out there I think all of us are doing the right things and hopefully we just keep up and being a good leader for each of our individual communities so I hope you guys are all safe and wish you the best in this time so thank you thank you everybody love you all looking forward to seeing you in September yes safely over now bye-bye there this is the view we needed Caesar cue the music yeah that's what I had here Eric can are you having your own fellowship yeah I got a fellowship of two right here there's one upstairs I think that's illegal I mean we're just we're a non ACG me certified fellowship okay okay rules are you in the pool house yeah get out of the main house the pigeons are playing ping-pong I got the band rehearsal from the pool next time you should do it from the pool I was going to but my my bathing suit is not miserable make him do things only 530 there's still a lot of a lot of night left give them more coffee yeah all right guys

weight-bearing CT

lapidus procedure

osteochondral defects

rotational alignment

fixation

OCD of the ankle

arthroscopy

bone grafting

medial talus

debridement

allograft

Charcot arthropathy

ankle instability

surgical interventions

patient compliance