We thank him a lot for being with us. I'm going to just go through a couple of housekeeping items that we have every single time. We need to make sure that we are HIPAA compliant in our presentations. We also maintain non-industrial bias, so please refrain from mentioning any industry. As per the other meetings, we'll be alternating the moderation. This is a Zoom meeting. Feel free to unmute yourself and pitch in. We'd like to hear your voice. Each one of the posted cases will be presented by its owner, whoever posted it. So we're going to ask you to unmute yourself. You're not going to be sharing screens. Dr. Cesar Neto is sharing his screen all the time, and he's going to be going through your slides and your images. And without further ado, I'll hand it over to Dr. Cesar Neto. Again, this is hosted by the American Orthopedic Medical Society, Young Physician Committee, and I have to thank all the AOFS staff for helping us with holding this. Dr. Neto. Great. Good evening. My pleasure to introduce this guest. Shetty, you're going to have to let me share my screen here. Here we go. I know I can. Can you all see that? OK. So here we go. So we're very happy to have Dr. Meyerson with us tonight. He doesn't really need introduction, but we're going to do it anyway. So Dr. Meyerson, please come up to the podium. He doesn't really need introduction, but we're going to do it anyway. So Dr. Meyerson, as most of us know, is originally from South Africa. He's currently a professor of orthopedic surgery at University of Colorado. He was in Baltimore for a long time, first MedStar, and then Mercy. He's past president of the Society 2004, 2005. He's currently editor-in-chief for Foot and Ankle Clinics, very strong review journal for Foot and Ankle, and executive director and founder of Steps to Walk. And we're going to go through one more slide about it. Impressive CV, as we would imagine. So let's just check this. 230 publications at PubMed, and impressive amounts of citations. 14,000 citations with an A index of 61. For all of us that know him, he's very sportive guy, very athletic. Here's him riding his bike in one of his thousands of visits in Brazil. This is Dr. Meyerson doing his yoga in between cases. Look at that. I cannot do that. I can tell you that. Like I said, he is a founder and CEO of Steps to Walk. There's a nonprofit organization that takes care of foot and ankle pathologies around the world. And probably the most important thing for Dr. Meyerson, I believe, is the amount of people that he has been able to mentor from all over the world during his time in Baltimore. And even when he was not in Baltimore, but the amount of fellows or people that learned with him at some point. And we were making fun that the Baltimore alumni, that they have a meeting every two years. Him, himself, and Dr. Sean together probably are connected with every single person, foot and ankle person in the world. And that's, I think, is the most impressive thing that he is giving to us, foot and ankle surgeons and orthopedic surgeons. This is just, I don't even know if he remembers this. But when I was planning to come to Baltimore back in 2012, I was fresh out of my fellowship in Brazil. I sent him an email. I wanted to spend some time with him. He answered less than a day later. So that's the way he is. He's just warm and welcome every single person that contacted him. It was very hard on the number of publications that I would have to do. Might be the reason why I was a little bit afraid at that point. But just a nice guy. He's, as in Brazil, one of the meetings, having fun. I wish we can go back to our trips at some point. And for people that spend time in Baltimore, he's a great, great cook. So he is also very good in having people at his place and just cooking things and teaching things and having fun and talking and having a good time. So he's just a great person, just a great mentor. And unfortunately, I didn't have the time to really spend some time with him in the OR, but I consider him one of my mentors as well. And it's a great honor for me. And without further delay, I would like to thank him for being with us tonight and thank him for everything that he did and still do for the society and for all the foot and ankle surgeons in the world. Well, thank you. Thank you, Dr. Meyerson. Yeah, Cesar, that's very, very nice of you. That's a really lovely introduction. I must say, I have this lovely relationship with you. I'm proud of what you've done. And even though I'm only an indirect mentor, it's a wonderful opportunity for us to share ideas. Thank you. Dr. Meyerson, thank you for being with us tonight. Our first case, as Cesar pulls up his screen, is from Dr. Daniel Gus out of Boston. Dr. Gus, thank you for joining us. As Cesar pulls up your presentation, feel free to unmute yourself and start presenting your case. For all others, please unmute yourself at ease. Feel free to ask questions. This is a live interaction session. If you're a little bit hesitant, then type in any questions you might have in the chat box and we'll be moderating for you. Thank you, Dr. Meyerson, for your time. He didn't mention your skiing skills, which have also been legendary. And if I can't yet emulate your surgical skills, I hope to at least emulate your haircut. So I've got that going for me. And so this is a patient I saw recently. She's a 19-year-old female that had a pretty surprisingly low energy injury. She was just getting out of bed in the middle of the night and twisted her foot getting out and suddenly had inability to weight-bear and had significant pain and swelling. She presented to the ER where she initially had non-weight-bearing films, but had a CT scan, so I reversed them. This is when she was referred to our clinic and the initial weight-bearing scans, the contralateral normal left side and the right side. And this is an apioblican lateral of the right side, which is the affected side. And then it's truly, you get an idea of the severity of the injury when you can see it in an x-ray, but you start looking at the CT scan. And as you scroll down, you start seeing that while we traditionally think of Lisfranc's as changes in the relationship of the tarsometatarsal joint, the midfoot is a much more complex structure and Lisfranc's can have many variants. And you can see that there's significant intercuneiform widening and frank dislocation of the navicular and the medial cuneiform with associated fractures. And so truly a Lisfranc variant in which when you look at the CT scan, the actual traditional Lisfranc joint, the relationship between the middle cuneiform and the base of the second actually remains quite well aligned. And so I was curious a few things given that you have authored classification systems that we have used in subsequent research about Lisfranc joints is your own personal algorithm. I'm sure everybody on this call has their own about the fix versus fuse debate, expanding that to then what happens when it's a case like this that isn't necessarily the traditional tarsometatarsal Lisfranc joint. And then thinking of some of the technical aspects as you approach these, I'd love the opportunity to learn from you. Okay. Sure. All right. Do you want me to comment before you show your... Yeah. I wanted to give you a platform because we've literally used your classification and research. I wanted to hear from the expert how you would think about this because I'm sure you'll answer questions that I wasn't smart enough to ask yet. The first thing, Cesar, stop it. You're making me dizzy. He always does that, by the way. Thank you for pointing it out to him. Yeah. Go back to that first AP foot, please. All right. There we go. So the first thing about this is, you correctly pointed out that this is a Lisfranc variant. This is one of the patterns that was in the classification, which I published in 1986. And it was for that reason that probably by the mid nineties, in a subsequent publication on these injuries, I decided to move away from calling this a Lisfranc injury because even though we still commonly use the eponym, I think we need to think of this as a complex. It's a constellation of injuries that involve metatarsal, cuneiform, navicular, and sometimes the cuboid. So I think a more appropriate term would be a tarsometatarsal complex injury. Not indicating the complexity, but we're talking about multiple segments of injury. Now, the first thing that I will point out, and that is that when you have a pattern of injury that exits the navicular cuneiform joint, generally the first metatarsal cuneiform is stable. So that's not likely to be unstable. The second thing that I would comment on is that your indication for surgery here is instability and displacement. It's compounded by the fact that you've got comminution of the base of your medial cuneiform, and there's small fragments at the base of the second metatarsal as well. Now, the goal of treatment is to stabilize the joints and to minimize the subsequent need either for surgery or to decrease the morbidity of this injury. Your approach to this could be percutaneous. If your goal was to avoid open reduction in arthrodesis, then most definitely you could do a percutaneous approach to this quite easily with screw fixation across from the medial cuneiform to the middle cuneiform, screw fixation from the medial cuneiform to the second metatarsal, and then screws into the navicular cuneiform joint also for stabilization purposes. My preference, however, is in arthrodesis. Not because of the pattern of injury. In other words, because this has gone through the navicular cuneiform joint, but because of the comminution. You've got comminution at the base of the cuneiform and the likelihood of arthritis over time is present. Whether this is a high likelihood of arthritis or not is not really the issue. You also have a little bit of comminution at the base of the second metatarsal, so you need to take that into consideration. For those of you who have experience with percutaneous treatment, the only problem treating this percutaneously might be those small fragments at the corner of the base of the second metatarsal, which I can't remember when it was, but I referred to it in one of the publications as a flex sign. So there are a couple of things that I think about. If you do a traditional open reduction and internal fixation, you have to look at what it is that you're fixing and do you need to go back a second time for hardware removal? If your screws are crossing the cuneiforms, there's no real need for you to remove your hardware. If the screw goes from your medial cuneiform to the second metatarsal, there's also probably less need to remove them. But that remains certainly something that you have to consider. One of the things that we've all noticed over the past 10 years is an increased use of bridge plating. Now, bridge plating certainly has a role, but not in this case. I imagine you could have, if you wanted to use a bridge plate from the navicular to the cuneiform, that is possible, but it really isn't necessary here because your first tarsometatarsal joint is quite stable. The reason I say that is that if you use bridge plating, there's a need for a second surgery and possibly a third surgery if arthritis develops subsequently. And my goal with any comminution would be to decrease the morbidity of subsequent surgeries. And the way I look at it is this. If you've got a joint that has minimal range of motion, where you have a high rate of arthrodesis, and I must say that the rate of arthrodesis for primary arthrodesis is very, very high. You've got a hypervascular situation and the rate of arthrodesis is high. So you then have one surgery and you are done. You're done and you're done probably by about three months. My threshold for doing surgery in a laborer or somebody with workers' compensation would be to err on the side of arthrodesis in all of those patients, regardless of the pattern of injury, because I don't want there to be any delayed issues with recovery. I want one operation, one treatment, and return to activities. In low energy injuries, even those in professional athletes, you have the average return to sporting activity amongst elite, let's call them elite athletes, whether they're collegiate or professional, is seven and a half months. So if you think about those in elite athletes who have access to an ideal postoperative recovery, your average patient takes probably between nine and 12 months to recover after a tarsometatarsal complex injury. If you're doing arthrodesis, the recovery is a little bit quicker. If you have comminution, you have a higher rate then of subsequent arthritis and you may need another surgery. So that's my assessment of this. Let's see what you did. Cezanne. So this is a very nice if he's not there. I'll just I'll just comment. Sorry I started I started talking and then realized I'd had muted myself So I wouldn't be one of the offenders who is who is kind of making noise and so we ended up doing a fixation strategy and and Part of it was was given her age part of it was the pattern I'd be curious to hear about your thoughts when you say arthrodesis about arthrodesis of what to what it's often can be very difficult One of the navicular particular case. Yeah, if I would have done an arthrodesis, it would be medial navicular cuneiform joint and the medial and the second toss a metatarsal joint extending down between the medial and middle cuneiform, so it's Just through one incision over that centered over the first interspace first you you want to reduce it and then do your arthrodesis as I've just said and and to your point we actually did a study internally in which we looked at kind of the predictors of whether someone does well with the fusion versus a Repair and it's interesting divergent patterns tend to do better with fusion. And so that's to your to your credit I ended up fixing her this way And then sort of removed these are percutaneous pins that I used to supplement The initial fixation pulled them at about six weeks and now she's a little she's she has started weight-bearing in a boot and is transitioning into a shoe Thankfully, she's doing well right now, but that's where arthrodesis was as I think about this case more and more I think arthrodesis would have been a a very appropriate Very reasonable you've got a great alignment here great alignment go back. This is a great alignment I think you got lucky with the navicular cuneiform joint using K wires there certainly has the potential for further subluxation, but it's possible that by Stabilizing it with your Lisfranc screw and intercuneiform screw that has helped reduce your your navicular cuneiform joint I think only time will tell you know, I think you have to be very careful to use age as the predicate for decision-making Because you could also say looking at it from a different perspective that because she's young She has a higher potential for developing arthritis over time because of her age So I think really you've got a very nice looking foot here and only time is going to tell I would be curious Have you thought of getting a CT scan during the post-operative period To sort of check alignment or to see the no just to look at your joints Particularly that navicular cuneiform joint which was comminuted on CT beforehand. It's not a bad idea No, that would actually be an excellent idea. And what I like is it's funny I love your comment about age because that's a very unique thing that'll apply to every single case we see tonight And the other interesting point you brought up is those wires as far as then affecting your ability to reduce Those wires were intentionally placed after the screws so that the screws could help with the reduction because the wires being Kind of divergent to where I wanted to reduce those were then to just supplement and give initial You know additional initial stability and the immediate post-operative period but you're right I put the screws first to help with the reduction then put the wires to supplement Even that you picked up on I love it Yes, so once you had your screws in did you test for instability or did you already have? Stable articulation at the navicular cuneiform or toss first toss a metatarsal joint and so once I had the screws and we tested because I wanted to see also the first a to your point about the First TMT rarely being destabilized if it comes out through the because that's not the failure point, right? There's often one failure point. And so once we had those two injuries, we tested and it seemed very stable And I supplemented with the two additional wires just to get additional initial stability That's pretty much consistent with the pattern of injury. That's good. Yeah well time will tell get that CT scan for intellectual curiosity one of these days you'll be able to Look at that again and get another CT in one or two years and see what happens. That sounds wonderful Hey, thanks so much for spending your evening with us. Dr. Myerson Myerson I have a question for you if you don't mind When you talked about the navicular cuneiform joint some of us or some some teachings say that the NC joint as an entity Should be fused as a whole like the navicular the navicular Cuneiform the navicular cuneiform with all three cuneiforms while others just like you mentioned look at it as three You know separate entities or three three separate joints. So What are your thoughts regarding this I mean, when will you do an isolated medial navicular form? Yeah, that's a really good question so my the problem with an isolated Medial navicular cuneiform arthrodesis is that it's a little bit more difficult to achieve compression when the space of your middle and lateral Joints are Blocking it from reducing Therefore it's imperative that following your debridement you use intercalary cancellous graft it's terribly important that you are aggressive with your bone grafting and then and I also think that Fixation is important a plate screw construct is probably ideal for that Not to rely just on Screws, so I would be Quite happy with an isolated single joint navicular cuneiform fusion now, of course the the Contrarian point of view is just what I said that it's sometimes in elective surgery Not as easy to obtain an arthrodesis if you do an isolated medial Column navicular cuneiform fusion, however, I do think that that depends a little bit on technique and the method of fixation Dr. Meyers, and this is Samuel Attar. I am a work in the University of Toledo in Ohio Question In patients who have like neglected. I have seen a few of those neglected with frank injuries and they come with osteoarthritis of the first second plus minus 30 MT If you are fusing three those three joints, would you do a double approach or would you go dorsal? Oh So it's in that depends on the pattern Generally, you can do it through one incision centered over the second metatarsal one word of caution for those of you who are familiar with the anatomy if you're trying to reach the third Tarsometatarsal joint be very careful with your incision Because it's terribly easy to reach the first Tarsometatarsal joint from that midline incision But not curiously not so easy to reach the third Tarsometatarsal joint So make sure that it's centered right over that second Tarsometatarsal joint And the reason is simply that if you look at the axis of the second toe You're going to be off don't base it off the second toe base it actually on the midfoot and if you're not sure just Quickly put the foot under fluoro and make sure that you sent it correctly, but I would use a single dorsal incision There really is very rare that you need an accessory medial incision the time that you you do occasionally need that second medial incision is When in a in a chronic case You have large osteophytes that are developing on the plant and medial surface of the foot So the foot starts to pronate It abducts at the Tarsometatarsal joint and you get callosity with sizable osteophytes Now, I think that those need to be removed and you can only remove that through an accessory medial incision however, my fixation is all dorsal Okay, and what's that what your preferred constructs like, uh, if you're fusing one two and three what what construct in terms of hardware? What do you use usually? um, you know That is variable and my preference is for plate screw construct I don't think it really matters what type of plate screw construct you use. There are compression staples that are available You have to be a little bit careful with compression staples That you're fusing I don't know if you can see my hand here i'm just lifting my hand But you know when you put a compression staple in dorsally you compress it they're active But it sometimes will do this so it compresses the dorsally Opens it up and you get a dorsal malunion So you may get a fusion but it pulls the metatarsal up dorsally And that can happen to one or two metatarsals. You have to be very very careful with using compression staples So a plate screw construct is what I would prefer to use. Okay. Thanks. Thanks so much. Sure sam Okay cesar you're moderating the next case Here we go So second case dr myerson comes from philip kaiser uh, 48 female former college admission, uh With a history of gastric bypass and an episode of acute renal failure um hyperthyroid crisis and Cesar sorry I think philip kaiser is with us. Oh, really? I'm, sorry. Thanks cesar. Uh, oh, i'm, sorry, man. Sorry I was I was looking to the least I was just gonna let you run with it. Thanks. No, go for it. I'm, sorry. Sorry. It's your go for it Yeah, thanks for sharing your time and expertise with us. Dr. Myerson. I'm actually a Junior new partner to uh, dr. Gus up in uh, boston Um, but yeah, this patient just just came to us hasn't had any surgery yet. So this is a Prospective evolving case and actually came through our orthopedic, uh tumor people and uh just came to our clinic this week But anyway, yeah 48 year old um some autoimmune disorders in the past, um hypothyroid Uh, three months of atraumatic left ankle pain, uh since this summer she was seen by general orthopedists got initial x-rays the ct and mri She was diagnosed there with a vascular Necrosis of the talus navicular and even possible medial cuneiform and sent to us Um, she'd been in a boot for about a month and using a cane but no real pair of restricted or or non weight-bearing Um, she's pretty painful. It's hard for her to walk And she's quite swollen And then in terms of her risk factor, she was on steroids back in 2017 when she was treated for acute renal failure Um, she's a one pack a day smoker um, no heavy alcohol use So if we can bring up the x-rays, I think they might be a little jumbled the first one from and these were outside Ones were the ankle ones Um, so the lateral the ankle there's a little increased sclerosis there the tailor dome. There's an ap of the ankle somewhere in this photo, um Go in there Yeah, that that was the initial ankle x-ray from back in august Provider got the mri next the mri was from uh, September 29th, which kind of shows the typical changes of avian serpiginous changes of the talus navicular And even on one slice a little bit into the medial cuneiform so these are if you can show, uh There's the uh, sagittal cut of the mri You start to see also some changes some early changes in the tibia with some increased edema in the tibia then ct scan kind of shows Fragmentation, especially the posterior half of the talus tailor body um relative osteopenia of the other Anterior tails and other bones in the foot And then the x-rays that our orthopedic oncology oncology colleagues got Showed further destruction of the tailor body. These are the foot x-rays if we can show those cesare I think there's a lateral and ap foot that they recently obtained Uh, which was actually earlier this week so you can see the body kind of sucking down further some collapse going on through there So she just came to us. She's finally non-weight-bearing put her in a cast Um, and you know, I saw a couple of these kind of cases in fellowship and it's kind of all over You know, she's 48 she has a few medical problems So it's kind of all over the place in terms of what you do and when you do it Okay, my my questions were you know, how long should the initial period of non-weight-bearing kind of be in this acute phase? Any different considerations for that that is one thing I can answer categorically no non-weight-bearing just Just you've got to fix this you've got to do something about it non-weight-bearing the only indication for non-weight-bearing used to be used to be in the historic literature Was when you had a dense sclerotic uh tailored body after Regardless of the etiology, but generally after trauma That where there was no signs of subsidence or um Patchy necrosis People used to think that there was an advantage to non-weight-bearing while it was revascularizing in the hope that it would revascularize That it's been demonstrated uh on in more than one paper that weight-bearing makes absolutely no difference in those uh tali that are not collapsed In other words, we've got hard dense bone So in a case like this where it's already collapsed And you have complete necrosis of the entire body. It's pointless. So I I would not You know, you can keep her immobilized keep her non-weight-bearing Until she's medically stable until she feels that she is ready for surgery The issue here is is a very very interesting one when you think about all the risk factors because This patient really is a high risk for any elective surgery with with that medical history so Let's just cover all of your options just for the moment being a total ankle replacement is out of the question um, what about a total talus? um I probably wouldn't Not do it in a patient like this i'd want to do my definitive treatment and get it over with although um there you could argue that just Scooping out the necrotic talus and putting in um a Total talus is reasonable and you just wait and see what happens um I assume that her contralateral talus is normal Is that right? Yes. Yes it is The reason I ask that is that if a patient has avascular necrosis On one side and you're planning to do a total talus If the planning is taken off the ct Which is mirrored off the other ankle and if there's avn with any change arthritis collapse and so on on the opposite ankle You have a very very difficult time planning your your actual implant Your other option in some patients maybe to put in The tibial component of an ankle replacement and then underneath it put in a total talus That's a consideration Not in a patient like this So we then get to your options for arthrodesis and the approach to arthrodesis So your options here would be a ttc Versus a tibial calcaneal arthrodesis Versus a tibial calcaneal plus tibio navicular You have to decide for yourself what you're comfortable with And then decide on the approach your two approaches that you have available And and I I just want to mention that I would not use an isolated. I would not do an isolated ankle arthrodesis Despite the fact that you've got a vascularized Neck and head of the talus and if you think back historically to the the blair arthrodesis certainly you could consider it but on ct there was already fragmentation going into the Subtalar joint and therefore you really don't want to consider An isolated ankle fusion. So let's go then to the approach you have two options um posterior or lateral Now most of you I am sure are more comfortable with a transfibular lateral approach Scooping out whatever you need to from the body and then deciding what you're going to do the one Caution that I would have for you here is in a patient with all these risk factors Is not to use a bulk allograft I don't think that that's a good idea You may consider a cage but there again I think you want primary bone-to-bone healing and not spacers In somebody who's high risk Come back to your approach then if you're going to do a a tailor body resection and a tibial calcaneal arthrodesis Technically, that's not difficult to do from the lateral side You frequently have to remove the medial malleolus in order to do that So you'll need an accessory incision on the medial side so that the as you're trying to as you're trying to get the your tibia to compress against your your Calcaneus, you don't want your medial malleolus to block you which it frequently will do as you're trying to compress it um as far as Bone graft is concerned. I would be very happy just using cancellous interposition graft And going with a primary tibial calcaneal arthrodesis And then adding The tibia to the neck of the Talus because that's vascularized. You don't want to touch that and it gives you an added point of fixation now What you can do is run your screw from the back of the tibia all the way down through the head Into the navicular or even further if you want to gain further purchase But it's a it's a good idea to try to include include the head and neck in your fixation as to my preferred approach I would go posteriorly here now. Why is that because what what I do is Use an acetabular reamer with the approach. So I cut the achilles. You don't need that. I get that out of the way and then Put an acetabular reamer Grind it down on the back of the tibia and Down onto the calcaneus. So you create a well From the tibia to the calcaneus the patient is line prone you make a small incision on the posterior iliac crest and take your Bone graft from the back of the iliac crest as as well You get copious amounts of cancellous graft You then put a laminar spreader in between the tibia and calcaneus and remove all that necrotic bone You can see it's terribly easy to see what is necrotic and what isn't As you're getting in deeper and deeper Towards the head and surprisingly You can debride the entire undersurface of the tibia and of course all of the calcaneus. It's not very difficult To see the calcaneus from this approach Then once you're done, there's usually only a very very small gap think of it this way If you look at this x-ray, the back of your tibia is already almost in contact with the calcaneus This does not require a structural graft you've already got a little bit of a compression of the body So all you do is you fill that space with some cancellous graft, which you've harvested but most importantly You then put a whole slab of cancellous graft down where you've done your Acetabular reamer from the tibia to the calcaneus. You just lay that down and then use a posterior plate you can use a rod but That would not be my preferred method of fixation and in a case like that You'll find Surprisingly, it's not terribly difficult to do So that would be my preferred approach For many of you I would say a transfibular approach is absolutely fine If that's what you're comfortable with And you could even decide on Cutting the fibula up into pieces rather than harvesting it as I would with an acetabular reamer because I would just grind the fibula up Something that we published. I think I published that with El Malamud from Israel many years ago I could be wrong and I apologize if i'm misrepresenting the co-author But the technique has been published where you just take the acetabular reamer on the fibula And you can get a whole cup full of bone graft If you don't like that technique, then just take a saw and cut segments out of the the fibula for graft That's a well described technique. But again I think in a patient here who's high risk. My preference would be to go for primary bone healing tibia to calcaneus If for some reason from your lateral approach you're noticing that there's more bone Loss or more necrosis of the neck and head of the talus Just take out the whole talus do a talectomy and do a tibial calcaneal arthrodesis And then as you pull the foot up you then do a tibia to navicular arthrodesis, which is quite easy It's something that I have a lot of experience with Okay Thank you so much. That's that's very helpful Any comments Cesar Amgad? Yes, sir question. So When would you include the navicular as opposed to leaving it for if you end up resecting the whole talus? When would you include the navicular versus leave it for you know a pseudo articulation? Great. So that's a great question. I I if you imagine um And Let us take a Charcot deformity, I think that that's a good example And you're dealing with a horrible valgus or horrible varus with body necrosis And the only way you can get to this is with a talectomy or as We have a lot of experience is with talectomy on our humanitarian programs for adult untreated or horribly recurrent club feet where what happens is that You want that little bit of extra stability between your fixation of the tibia to the navicular It's a little bit hard to visualize Here looking at the x-ray, but as your tibia comes down onto the calcaneus um You need to determine the amount of stability that you have That's important in a patient like this you've got full muscle function so you're going to have muscle balance And some active dorsiflexion will be present in some patients either with paralytic deformities or in those who have horrible untreated club foot deformities You're never certain about any muscle function and what you want is to accomplish more stability across the entire articulation So you're thinking more in terms of a of a Pan-taylor fusion. It's not a true pan-taylor fusion, but it's tibia to calcaneus tibia to navicular So that you've got more stability in those cases um At times you may want to do that because of your fixation After doing the tibial calcaneal fixation you find that yeah, it's okay But you need a another point of fixation To add to that to increase your stability in which case A a posterior screw is very very helpful Okay Yes, sir. Thank you. That was very elaborative and I believe I believe uh I hear you have a question. I believe yes Yeah, Mark you said a quick question, um Would you be concerned about uh, the leg length discrepancy, um Just doing a tibial calcaneal fusion. I've just had this with diabetics i've done for charcot Of the talus and and it kind of became a difficult problem For them or they're really unhappy even with a successful fusion, uh, just with their leg length discrepancy Yeah, you know, um There are two ways of looking at that Um Those patients with the charcot deformity can either have an amputation or they can have a leg length discrepancy That's one up, you know, just one way of thinking about it I do prefer in the patients who have these terrible deformities um from club feet It's much easier to make that decision if it's a bilateral deformity, which it is frequently so you're not Going to have as much leg length discrepancy One of the other things to recognize is that in these patients who have chronic deformity And the foot is inverted almost at 70 Degrees or more and they're walking on the dorsal lateral aspect of the foot think about the limb height that they have It's they're actually walking either on the fibula or the dorsal surface of the foot and the foot has de-rotated Now as you straighten the foot and bring the calcaneus underneath the tibia Actually, you gain length now These patients have been accustomed to walking with a leg length discrepancy for a very long time And as you bring the calcaneus underneath the tibia You actually do gain a little length for them compared to what they're accustomed to even though It is Still two and a half centimeters shorter than the opposite limb. So in your case Sudhir That's tough. You know, the patient just has to accept it You know In Charcot patients, you have to make the decision What kind of brace you're going to use? For and for how long? Will you use a double upright brace? Will you put them in an AFO? Would you put them in a cam? Brace or crow walker forever There is some Thought that that may be indicated if you look at the incidence of stress fractures of the distal tibia in the Charcot patient after TC or TTC it's you know, it's Not that rare and some people feel that by putting them in a crow walker It's protective and by when you're in a crow walker you gain height of the limb. So I think that You did the right thing provided you've got an arthrodesis the patient has to accept it Thank you It's nice to see you Sudhir. Yes, of course. Yeah, I think I think Sam has a quick question We're running a little bit behind so we want to go to the other cases, but Sam do you want to turn your Microphone on and ask a question I I mean, I I do have a last question before we move. I know amgad wants to move but dr Marsh, is there any I mean, she's she's a young patient. What I'm gonna do just so that the others know i'm going to um Uh, i'm going to just answer the questions while everybody's talking so that it'll save a little bit of time Is that all right? Yes, sir. Of course. Okay good Yeah, so Since it's a young patient. Is there any any any role for something less invasive initially like for example, uh drilling this and Whatever you want to use as biologics and try to give it a chance. I know it's collapsing, but in a case like this No, sir. Not in a case like this. There's already necrosis with collapse and the problem that I you know, we we have published in the early Um, it was with steven blue felt a a technique for using a small vascularized um Graft Anterior process And a branch of the dorsalis pedis so you make a trefine into the um, through the lateral process of the Talus and you insert this vascularized graft we had moderate success with that um, there's also One only one paper on this in the literature. Uh, it was uh Came from baltimore and lou shone was one of the co-authors on a trefine technique um The the first author actually was a joint surgeon Uh who had a lot of experience with avascular necrosis and this was published so That's that is a possibility my only concern is making multiple perforations into What is a stable? uh solid bone may Potentially lead to avn. So I mean and collapse I don't really have a definite answer for you certainly once you've got necrosis Uh with collapse any collapse and frank or should I say any fragmentation? This is not indicated and single word answer just so we can move forward but Avn talus still equals no total ankle at all or is that going to change? no, that's going to change for sure because Um, you know avn is frequently patchy it frequently involves the dorsal aspect of the body of the talus Um, absolutely that's going to change their implants available where uh, you can cut out a part of the body, uh, almost all of the body and So the answer is it's going to change Excellent Thanks so much. Dr. Meyerson. Uh So let's yeah, we're skipping mine and then moving on to uh, dr. Muhammad Mukhtar from egypt, uh, he's uh up and late with us. We thank him a lot Dr. Mukhtar, uh, feel free to unmute yourself while cesar pulls up your powerpoint One more housekeeping item, please if you're not speaking Make sure you're unmuted so that we don't have a lot of background noise Mukhtar you're on Hello muhammad, it's nice to have you with us Yeah, thank you. Thank you very much. And thank you for precious time. Dr. Meyerson. Oh, it's a pleasure. It's nice to see you Thank you very much And now This case i'd like to present She is a female 34 years old medically free Uh, she suffers from pain during walking and disfigurement in both feet She has very bad bad looking hallux valgus here Like you all see Um She has no hind foot alignment. The hind foot alignment is good. No problem But just pain and disfigurement and here is the weight-bearing x-ray of her Both feet right and left. Okay My concerns here about the x-ray Is that the distal metatarsal articular angle is not normal it's facing facing lateral And the the intermetatarsal angle here in the in this side is is very wide And the first metatarsal is short. Here you can see that there is no significant hindfoot alignment. Go back to the first x-ray please. There is relative shortening of the first ray here. I have the postoperative x-ray of the patient, Dr. Meyerson, but I'd like to know how do you think about this case? I had to think a lot about it before the surgery. I had to do a double osteotomy and the advantage was to make a lateral opening wedge here to gain some length of the metatarsal and then a distal osteotomy to correct the distal metatarsal articular angle. The other option would be lapidus with some plantarization to compensate for the shortening. However, she had no metatarsalgia. The first metatarsal is short, but she had no metatarsalgia. And then to do something for the distal metatarsal articular angle. That was the conventional option that I had. Then I started doing the mini-invasive surgery, so I thought that I can correct both deformities by minimally invasive chevron aching. How would you think about this case, Dr. Meyerson? My approach to this would be to consider either a lapidus plus a distal osteotomy. We have to be very careful how we interpret the distal metatarsal articular angle. Invariably, in these patients, you can see how rotated this first metatarsal is so that you have pronation of this first metatarsal and you can see that as evidenced on the lateral side of the metatarsal head. This has been very nicely demonstrated by Emilio and Pablo Wagner in their publications, how to evaluate the metatarsal head. However, in this patient, this is a congruent metatarsophalangeal joint. And I think that you're not going to get sufficient derotation of the joint just by doing a proximally based procedure. You may. You may be lucky with that. You may be able to derotate this metatarsal completely with a lapidus procedure and you'll still retain range of motion without having to do a distal osteotomy. And that distal osteotomy could be a closing wedge, a chevron or closing wedge, a reverent type procedure. And then you can decide if you want to add an acan to it. The other alternative would be to do a biplanar mica procedure. And I certainly think that that would work very nicely provided you can get plantar translation or what is referred to as plantarization of the metatarsal head. I think it is, what you have said here is really quite interesting in that this patient has no metatarsalgia. And I want to caution everyone that, you know, up until 1998, no, 97, it was so rare for us to even think about doing shortening lesser metatarsal osteotomies. And it just wasn't part of what we did. We corrected the hallux valgus and realigned the first ray without worrying about doing any shortening. And the reason has to do with your hallux and the metatarsophalangeal joint. When the hallux pronates, there's no effective windless mechanism so that your first metatarsal does not plantar flex during the third rocker. So what happens now is once you correct it, and you realign the metatarsal, and you've got adequate dorsiflexion of your hallux, the windless mechanism is reestablished, you reestablish your third rocker, and lesser metatarsalgia, even if it had been present preoperatively, goes away. So I think you have to be very careful about assuming that with a slightly short metatarsal, you're going to end up with metatarsalgia provided you've got a functional realignment of the hallux, you'll have range of motion. So I think that my approach here in this patient would probably be to do a lapidus, derotate the metatarsal. If I couldn't get sufficient derotation of it, I might add a distal first metatarsal osteotomy, as I've said, and then maybe even an acan. The other alternative would be a percutaneous approach, using a microprocedure, and you can easily translate and plantar translate this, as well as derotate the metatarsal with minimally invasive techniques. Okay, another question, Dr. Meyerson, thank you for the nice elaboration. Do you try to do some lengthening during the mica? You can, of course you can, you know, you just change the angle of your cut, but you must bear in mind that as soon as you try to lengthen this, you increase the tension on your intrinsic muscles, and you increase compression, and it makes it a little bit more difficult to regain your range of motion. The one thing that you don't want to do, of course, is to change the angle of your cut and shorten it. So if you're going to do anything, just make sure that your cut is either in neutral or very slightly accentuated, so that you may get a little bit, maybe a millimeter of lengthening, but I would not intentionally lengthen a metatarsal. I know that this is controversial and that proximal opening wedge osteotomies are popular, but I think that biomechanically it does not make any sense. Okay, another question, Dr. Meyerson, this is a question I have no clear answer about it. When do you say that the deformity, not in this case, not in this special case, generally, cannot be corrected by minimally invasive chevron aching? So in, for example, with the scarf you can say above intermetatarsal angle, above 18, above 20, so the corrective power of scarf osteotomy is not enough. So about the mica, what is the limit? So I'm going to answer that only based on my knowledge from my colleagues and not from my own personal experience, and there does not appear to be any limit. And what you have to imagine, I cannot, let's see, this is probably about 22 degrees on that, on the, you've got the label on the right, but it doesn't matter whichever foot it is. The right side's a little bit less than the left, but let's say 20 degrees. And if you just imagine putting the metatarsal head right on top of the sesamoids, you're able to do that. You have 90% translation of your metatarsal head, provided you use the two-screw technique correctly for fixation, you're going to be fine. So I don't think that, you know, you can template that out, and as long as you can cover your sesamoids with the metatarsal head, it makes no difference what the deformity is. One of my fellows, Anthony Pereira, in Wales, has described a technique which I think is very, very important, and that is you want to assess the maximum amount of deformity preoperatively or intraoperatively, so that if you, if let's say you do a distal metatarsal osteotomy, and it fails, one of the reasons for failure is that you have not maximally shifted that first metatarsal into its potentially deforming position. So if you imagine grabbing that first metatarsal and pulling it further medially to deliberately try to increase the deformity or displace it at the tarsal metatarsal joint, and now you pin it, if you put a pin across from the first to the second metatarsal, in that maximally deformed position, the metatarsal can't go anywhere else, so that now if you've got that in the worst position possible, and you correct the metatarsal head where it belongs, there's no potential for failure, because you've already maximally deformed it. So if you're able to do that, you know, Mohamed, in answer to your question, there probably is not that much, you know, I can't give you a number, whether it's 20 degrees, 22 degrees, because it depends on whether or not you're able to shift the metatarsal head over the sesamoid. For example, if you have metatarsus adductus, it changes the whole algorithm completely, because, you know, you have much less space, you may have a severe deformity, but no space to shift your head over the sesamoids. So I think that it's just you can template it out preoperatively. Does that help? Yes, yes. The idea you say about a maximal medial rotation of the first metatarsal, so it's locking of the first tarsometatarsal joint, it's now locked, cannot go in more varus, and this prevents recurrence, that's clear. The problem is, if I go with an angle 25, for example, and then I decide to go mica, and then intraoperatively, I did the mica with 80 to 100% translation, and I'm not happy with the correction, so I haven't faced this. But if it happens, what... I would imagine, then I just go and do a laparus in addition to it. We were on a conference about a month ago, and one of my fellows, Peter Lam, from Australia, he was talking about his experience with mica with over 2,000 cases. And he says that out of all of those patients, it's rare that he needs to choose a laparus procedure. So I think that based on experience like that, there probably are not that many cases in which it will occur. Okay, great. So that's a great question. Now I'll be more, you know, I have the courage to do severe cases with mica. So now I did mica, we can see the post-operative please, Dr. Cesar. So stop there, Cesar. The only... this looks very, very nice, very nice in the AP plane. Your technique is great. The only comment I would make is that you've not translated the metatarsal head very much inferior... plant, excuse me, plant a word. It's not a criticism, it's just a comment, because you've certainly got very nice alignment. And, you know, as I said earlier, if you've got good alignment, good range of motion, shortening probably doesn't make any difference. So you would plantarize more, Dr. Meyerson? A tiny little bit, yes. I would try to plant it, translate it, just ever so slightly. Okay. So I tried the... I was very, very anxious pre-operatively that I will be able to derotate the head or not, but it came easily, surprisingly. Yeah. The other comment is that I failed to take the bicortical screw, so both screws are through the osteotomy, but were stable enough. So that is, you know, some people would say that that's a technical error, and increases the potential for a malunion, because your proximal screw should leave your first metatarsal and enter the disc, the metatarsal head, leaving a gap, so that you need to have bicortical fixation, which you don't have here. But, you know, obviously, there are cases where you don't need it. If you've got solid fixation, it may not matter. But just for a technical, just from a technical perspective, for those of you who are doing mica, and are interested in a bicortical fixation, particularly with that proximal screw, is important. Yes. Now, I do this more and more, but in this case, was one of my early cases of mica. I didn't want to do many, many, many trials, so I accepted this, because she was young, and the screw was stable. This is the post-operative visit, with this alignment, compared to the pre-operative. I think this is a plain x-ray later on, and you can see the correction of the articular angle, so complete correction. This was surprising to me, you know. Yeah, that's very nice. That looks good. Let's see the final x-ray. So, this is a very, if I may make a comment on this, it's a very interesting, there's been a change, there's been an interim change on the AP x-ray between this time and the x-ray taken previously. If you look at your fibular sesamoid, the fibular sesamoid is not centered underneath the first, under the metatarsal head any longer. Now, that indicates that you may end up with a slight recurrence. Now, the helix is in very, very nice position, but if you segment out the metatarsophalangeal joint articulation, it's now in very slight valgus, very slight, and I think that while you've got a very nice result, it looks good, my comment would be, you need to follow this patient carefully because there is the potential for slight recurrence based on the position of the fibular sesamoid and the current position of your metatarsophalangeal joint, not the helix alignment. Is there anything that could be done, could have been done to prevent this? I don't know how to answer that because, you know, on your first x-ray, your post-op x-ray, it looked perfect. The post-op x-ray really, if you look at that, well, you can see there's very slight uncovering of your fibular sesamoid there, but it's more evident in your final x-ray. So, I don't know how to answer that. Did you do a soft tissue release or release your sesamoid ligament? Percutaneous, yes. Okay, all right. So, you know, then I don't have a good answer for you. But Dr. Morrison, if I may interject quickly, while Naomi unmutes herself because she has a question. Yes, I'm unmuted. A lot of the minimally invasive experts would say that they've gone less and less towards a lateral distal soft tissue release. I understand. I wasn't implying that that was something that was wrong. I was just curious. I just wanted to know if it had been included in the procedure. So, Dr. Morrison, this is Naomi Shields. Hello, Naomi. So, looking at the initial APs, there's tailor head uncovering. Yes. And if you look at the lateral, there's some sag. Yes. So, how much of, if quote-unquote recurrence, because I think that last picture, the foot is actually pronated. Yeah. Not the first metatarsal MTP joint. Yeah. Coming from the hind foot. How would you address that? That's a whole different, it's a whole different subject. So, since you brought it up, Naomi, my feeling would be that at the least in a young person, one should consider a calcaneal osteotomy. Not a, I mean, this is about 35% uncovering. So, you could consider either a lateral column lengthening or medial translational osteotomy as part of your procedure. And you are quite correct. Maybe that would have a beneficial impact on the ultimate alignment of the foot. You're quite correct. Because I think if you look at his immediate post-op, it's a non-weight-bearing film and the tail and navicular joint is cut off, but it looks covered. Yeah. Now, if you go to the last film, your tail and navicular joint is now uncovered. So, that may be position of the foot, not position of the foot MTP. I did not pick that up earlier, but you're absolutely right. That could be the reason why the metatarsal is again pronating. Yeah. That's a very relevant point. I think that that's something that I'm going to, and Mohamed and Cesar, you can comment on is what your feeling is about adding a hind foot procedure, a minimally invasive hind foot procedure, such as a MIS calcaneal osteotomy. If that's what you're doing, it's not a terribly invasive procedure. You can translate that calcaneus. What is your opinion on that? I'd like to comment on this. I mean, I would have probably a little bit of a different approach here. I think we discussed that before here and I discussed with Dr. Meyerson for sure. But we have to remember that the subtalar joint and the tail and navicular joint, they move together. So, in this case, in my opinion, it's about the first rate being incompetent. If we think for VAERS, we always think about cable VAERS bringing the first rate up. And if it's forefoot driven, your hind foot will follow. And we never think for the flattening of the arch or like instability of the first rate. So, I think in this case, if she has no symptoms in the hind foot, if you did a lapidus here and bring it down, that coverage would get better because it's the same concept. So, once you bring the first rate down, you're going to move the subtalar joint if the subtalar joint is flexible and you would have more coverage there. So, that's something that we usually don't pay a lot of attention. I have beautiful images, not published, but I have beautiful images with the way my NCT is showing it. And just one more thing is, I mean, hopefully it's going to be submitted soon. It's not published data, but we've been looking into distal metatarsal articular angle. I'm not a believer of distal metatarsal articular angle for adult cases, unless it's something for a pediatric bunny or very young adolescents. We looked into the angulation in the weight-bearing CT for the cartilage, articular cartilage. And in less than 30% of when the x-ray shows the DMAA of more than 10 to 15 degrees, only 25 to 30% of the CT scans show that the cartilage is really displaced. So, most of it is radiographic bias of a two-dimensional imaging. So, just, I mean, not saying I cannot prove it, but I wouldn't pay that much attention. I think it's much less frequent than we think. Yeah. So, I would say, in summary, to Mohamed and Naomi and the rest of you, that intuitively, without even thinking terribly much about all of this, I would have done a lapidus procedure. And that is just my approach to this particular problem. Why? It might have just been instinct that I had seen that something is going on with the tarsometatarsal joint, something's going on in the back of the foot. Obviously, your decision-making is easier when you're examining the patient and you see a persplanus symptomatic or not. So, a lapidus procedure is what I would have done with derotation. I think that this is a good operation that Mohamed did. It's just, there is an answer, at least, as to why that first metatarsal is now pronating. Yeah. And I agree with Dr. Marcin and Cesar. We had this very long debate and it was interestingly one of Mohamed's cases as well with Dr. Luchon on our very first Ask the Experts series. And we kept going back and forth about whether we had to do anything on the Heinfeld or not. And you can all go back on the PRC, the Physician Resource Center of the ALVS to look at this dilemma we had that day. But it's very interesting and intriguing always to hear the different opinions. Naomi, you're on next. So, unmute yourself. And we're happy to present both of your cases. But we're going to try and stay on time, which I think we're doing quite well. Mohamed, it was very nice to see you. Thank you very much. Thank you so much. Always a pleasure to have you from Egypt. Thank you. Okay. So, I really want to tell Shelley, thank you for getting these cases up, because I was too stupid to figure out how to load it up using my phone. So, this is a a woman who came to see me about a week ago. And she tore her Achilles. It looks like probably an insertional rupture. Two years ago, had surgery by a podiatrist and comes in with a two-year history of drainage from her wound. She never healed. She spent a lot of time in wound care. When I asked her about antibiotics, she said she was never put on antibiotics. She does not recall any cultures. She comes in. And can you scroll up, Cesar? She's also a type 1 diabetic with a hemoglobin A1C of 8 and a renal transplant patient from 2005 whose renal function is going down. So, you can see the two draining sinus tracts. You can see the quality of her skin. And she looked at me when I looked at her MRI and said, this is chronic osteo. This needs to be debrided. And you can see all the edema that's in the calcaneus. And this can be stopped anytime by pushing on the stop thing. So, this is more a, what do I do? I mean, her Achilles is thickened. It's horrible. My gut feeling is take out all the implants, all the suture, deep cultures, excise what I need to the calcaneus, culture-based antibiotics, wound vac, and then either put her into an AFO, like a toe-off AFO, and say, you know, you're going to live without an Achilles or try and come back once I know her infection is controlled. Perhaps her hemoglobin A1C is better. But with that skin, plastics, I'm really not quite sure where I go with this one. So, Naomi, my approach here would be a little bit more aggressive. So, I wouldn't hesitate to remove the entire Achilles, the back of the calcaneus, and at the same setting, put on a free flap. I think that if you try to save the skin, even after removing everything with those chronic sinuses and the quality of the skin that you have, you're going to have a really tough time with the skin. And the worst thing I think that one could do here would be to do your debridement and then put a vac on here, because you could potentially still do a percutaneous endoscopic transfer of the FHL. That can be done. But bear in mind that once you use a vac, you're committing yourself to a very difficult procedure, ultimately, to replace your Achilles tendon, other than a terribly simple, either mini incision approach to your FHL or endoscopic harvest of the FHL. So, I think that the more aggressive route is probably the safest one. Well, where would you get your free flap from? Say that again, Naomi. Where would you get your free flap from? From a plastic surgeon. So, I have no relationship with any plastic surgeon in this new community I'm in. So, Naomi, I wasn't being facetious. I let them decide. I mean, you've got many options here for a free flap. So, you would just debride everything, get her infection controlled, free flap it, and then put her in a toe-off AFO for the rest of her life. There's only one other comment that I'd like to make, and that is on the calcaneus. Be careful on assuming the extent of osteo on the calcaneus based on this MRI, because a lot of that may simply be edema, and you may be better off getting a CAT scan to evaluate the calcaneus in conjunction with your MRI to make the decision as to what actually does need to be debrided. Of course, you're going to make that decision intraoperatively anyway, and you just keep on cutting until you've got nice healthy bone, but you'd be helped by CT, not the MRI, which is potentially a little misleading. It overreads. Yeah. How far up the Achilles would you go with your debride? I'd take every little bit of it. I'd go right up to the, just leave a nubbin on there. Look, what are your options? In a patient who does not have diabetes and has a chronic draining sinus, I've done many stage procedures with flaps and gone back and done an allograft. That is one of the advantages of a flap is that you can lift it and put anything underneath there that you want, but in a compromised patient like this, you're never going to be able to do that, and your only option is going to be an AFO with or without an FHL. So there's no point in leaving any of the Achilles behind because you may be able to see intraoperatively what is infected, but what is the point of leaving any of it there? So just get rid of it. Okay. Naomi, if I may add to Dr. Meyerson's point of a CT, I've been, especially in these diabetics, I've been using more and more PET-CT scans. So the positive admission tomography, if you have a facility with a PET-CT scan, it really delineates the extent of the infection very nicely, and you can see the border where you're going to be able to reach a good healthy bone. I have no experience with PET-CT. Does it get scattered from the- It's gamma-based, so it has to be in one of the oncology centers at your place. Okay. Now I just have to make her accept that. We've seen five people, and she said, you're the first person to tell me that this is infected. They just wanted to put a skin graft on it. Any more comments? Daniel, you're too quiet. No, I agree with Dr. Meyerson. We're blessed, our institution, with a skilled plastic surgeon who has no interest in cosmetic surgery, and so we end up doing a lot of exactly what he said, control the infection, get a free flap. I can get her a flight to Boston. If that's what she needs, we'll take care of her. And the other part is you kind of want to do it while her kidney's still working. No dialysis machine can compete with mom's home cooking, and I think once she's on dialysis, her chances of healing become even worse. Yeah, so she's on anti-rejection things. Her diabetes isn't well-controlled, which may be because of the infection as well. Hey, you want to move on to your second case, Naomi? Sure, because my second case is the answer to what Mohamed was showing. This was my first MIS chevron. I plantar flexed his head. She has severe sesamoid pain. She has sprung wider through her IM angle. Is that the only picture that came up? I'm trying to move it here still. So, I know there's a learning curve for Micah. Her complaints are her deformity has returned to some extent. She feels like something is moving every time she steps. She has significant pain under the sesamoid, which is very painful for her. And on the lateral, it looks like her sesamoid joint first metatarsal is almost bone-on-bone. I'll have to reload the page here just to see if it's gonna allow us to do it. Give me one second here, Naomi. Okay. Sorry about that. So, I guess some of my questions are, I feel like I've been burned by Micah. So, she's one year out. And I will tell you that her IM angle is wider than it was on the initial post-op films. Her sesamoid is more uncovered. And the real problem, I guess, is that she's not able to move her head. She's not able to move her head. She's not able to move her head. So, she's not able to move her head. She's not able to move her head. So, she's not able to move her head. She's not able to move her head. Her sesamoid is more uncovered. And the real problem for her pain is if we look at the sesamoid first metatarsal head. So, I plantar flexed her, which you were suggesting to Mohamed that he should do. So, now how do you decide when you do that? But Naomi, there's a difference between plantar flexion and plantar translation. And I can't tell from here whether you tilted the metatarsal slightly or whether it's just shifted and translated. You know, the main issue here on this for me is that you've got metatarsus adductus. And you have instability at the first tarsal metatarsal joint. That worries me. So, if I were to come back to what we had been discussing earlier with Mohamed, in a case like this, go back one please to the AP. In a case like this, I'd be even more determined to do a lapidus and worry a little bit about, I would worry a little about how much correction I'm able to obtain because of the position of the second metatarsal blocking me. In a case like this, you clearly have not, while you have derotated the distal metatarsal head, and you can see that quite easily. You've got a square shape to your head. Your sesamoid is subluxated, which indicates to me that proximal to the head, something is going on to pronate that metatarsal, and that's probably coming through the tarsometatarsal joint. So, I don't think it's a failure of the technique here, because you've got a nice alignment of the hallux. Hallux is in fact very well aligned. I think you have to go a little bit further and say, well, what is the problem? Is it the undersurface of the articulation of the metatarsal and sesamoid? Could that be a problem? Could it have something to do with pronation and instability at the tarsometatarsal joint? And if it were that problem, how could you approach that, and what could you have done differently? So, I come back to what I said earlier about maximally displacing the proximal first metatarsal, particularly in a case like this. So, where you have potential for instability because of that metatarsus adductus, I think it's rather important if you're going to do a mica procedure. But that wouldn't have been my first choice here. I would have done a laparus, and if I were worried about my intraoperative correction before I actually fix the tarsometatarsal joint, I would consider a percutaneous osteotomy of the second, third, and fourth. Just a little oblique osteotomy. It does not have to be fixed. You can do it percutaneously and minimally invasively, and then just strap the forefoot along with your laparus. So, I went back to my original note when I saw her, which was in March last year, and I said her left first TMT has greater motion than the right, but stabilizes with reduction of the IM angle. And so, I think I missed her instability. So, my question now is, how do I salvage this? Well, you may have to do an arthrodesis of the metatarsophalangeal joint. You have two problems. You have an arthritis problem. I don't think that that has anything to do with your procedure. I really don't believe that that's a a problem caused by your procedure at all. I really don't think so. I think that that was probably pre-existing. I cannot see that you could have caused it based on the position of the metatarsal head. It's a little bit difficult to see here. A CT scan would be helpful. A weight-bearing CT scan even more. There are no weight-bearing CT scans in San Antonio. So, all right. So, a CT scan may be of some help, because if you've got an erosive change there, you don't have terribly much choice but to choose something that's predictable, which would be an arthrodesis of the MP joint, or to consider a sesamoidectomy along with a lapidus procedure. But then you still have, if you choose the lapidus procedure, you've still got that issue of correction and how much correction you're actually going to get because of the metatarsus adductus. Those are the things that I would be thinking of now as I'm planning the next step. My thought would be, if the patient would accept it, an MP fusion would be great. An MT with a TMT, with a lapidus. Yeah. Dr. Meyerson, Panos here is asking a question. In such a case, would you include the base of the second metatarsal or the middle cuneiform in your fixation of the lapidus? No, it's absolutely not necessary. If you move... So, what Panos is talking about... Panos, are you still there? Yes, he is. He's just muted. Everybody in his household is asleep. No, no, no, because Panos said he's asleep and he's leaving. So, I've been watching the chat. Panos also said goodbye. He said everyone's asleep. Anyway, Panos, thank you for your question. Panos is a good friend and he's one of our international surgeon volunteers on our humanitarian programs. So, Panos, I don't think that you need to include that as a formal lapidus procedure. I would do a modified lapidus and then just do an osteotomy to realign the base of that second, third, and fourth, as I said. You know, why increase the morbidity when there isn't any terrible evidence of arthritis? Sometimes with these patients with metatarsal seductors, you have awful arthritis at the base of the second and third. And in those patients, yeah, an arthrodesis is helpful. I can't remember when we published that. I think Tabs Iyer was a co-author on a couple of papers that we wrote on metatarsal seductors. And in one of them, we did show some cases which necessitated an arthrodesis of the second and third, but those had arthritis. I can't tell here. I don't think there's any arthritis present. Dr. Myerson, a question, if you don't mind. It seems coming out of the AOFAS virtual MIS course that was just a few weeks ago, speaking of the MICAs, it didn't seem that there was a lot of emphasis of, you know, TMT instability. And a lot of the advocates were still moving towards a MICA in the face of TMT hypermobility. Well, this seems a little bit of a rebuttal of what was going on a few weeks ago. So, you know, that's an interesting point. You know, as I said earlier, not based on my personal experience, but only on what I understand from others, including Peter Lamb, who's done thousands of these, he said it's very rare that he needs to do a Lapidus. While he does them and considers them, it's rare. So, I think that that supports the MICA proponents that it's not necessary. However, you've got a problem here and I can't tell, let's ignore the sesamoid arthritis for the moment. Let's just ignore that. I can't tell whether or not the problem is because of instability of the tarsal metatarsal joint, or if it's because of metatarsal seductus. I don't know. I think Mohamed, you had a question as well. Yes, that thing you came through now. When do you decide to do an original Lapidus or a modified Lapidus? So, I base that intraoperatively. You cannot make that decision preoperatively. Once I've done my realignment and my stabilization of the first ray, I'll do a push-pull test. So, you can either use your finger and just clamp between the, you know, in the first interspace and pull on it. And if the first ray is stable, you don't need to do or consider a true Lapidus. Or you can try to get a simulated weight-bearing fluoroscopy view by loading the foot and seeing if the first metatarsal moves. That would be also an indication. Some people just put a towel clip on the metatarsal head and under fluoro pull on it to see what's happening. Sometimes it's obvious actually. You know, you do your fixation and you've got maximum realignment of your metatarsal. So, your intermetatarsal angle is actually zero. And provided, of course, that you've supinated your metatarsal during the procedure. Under those circumstances, there's nothing more to do. But it's what I've called a squeeze test. I don't know if you can see my hand, but what I do is I just squeeze between the first and second metatarsal and watch what's happening here. Because if this is happening there, then I'll go to a true Lapidus. Okay, thank you very much. So, Dr. Meyerson, when she came in to see me about two weeks ago, she said she felt like something was moving every time she stepped down. Her first TMT joint had increased motion and a click which reproduced the feeling she gets when she steps down. So, I think she has true TMT instability. Yeah, you know, Naomi, first of all, thank you for sharing this with us. As everybody knows, you know, it's hard to show your outcomes. And I'm not so sure that it's hard to say whether or not you even made a mistake here because your hallux is still well aligned and her problem may indeed just be from the pain coming from the sesamoid. In retrospect, should you have, I don't think it's a matter of should you have done a Lapidus. I would have, but I don't know that that is just my preference. Yeah, I'm curious how the Myka people who've done thousands don't do Lapidus because I go to Lapidus a lot more than I ever used to. Yeah. Yeah. Thank you for reviewing this for me and giving me suggestions. You're very welcome. Naomi, thank you again. I echo everybody's words. Very, very insightful from you to present these. We all learn from definitely our mistakes. I don't know whether we have our two next presenters, but if not, if they are here, Dr. Chang Patel, or the next one is Utwedeker, is he here? I don't think we have any of those. So if you don't mind, I'd like to present my case, Dr. Meyerson. Oh, I'm glad it's a pleasure. Now I've got to tell you that there are a lot of people who came on after our initial discussion about squash and Egyptian squash in particular. Now I'm going to hold you to that because unlike many of the people who are on this call, only you know who Mohamed Elshorbagy is and Rami Mashour and Karim Darwishi. Okay, Darwish. So you and I know. So you're going to take me to a squash game sometime. I will. I'll take you to the world champion Egyptian open underneath the pyramids just right here. Okay. All right. Let's see your case. So this is a, when I first saw her, it was back in 2016, a 13-year-old girl. She was diagnosed with juvenile or idiopathic, quote unquote, traumatoid arthritis. She had been complaining of right ankle pain for a while. And as we scroll down, the x-rays got mumbled up, but these are from 2020. Can you go back to 2016? There's another plain x-ray titled 2016. There we go. This is how she presented to me. There's a medial osteochondral lesion with some collapse. There's an MRI. So Cesar, if you... I'm good. Before you even show the MRI, I just want to point out something which you've already shown, which is so interesting and presents a terrible treatment dilemma. Don't look at the AP, look at the lateral view. On the lateral, here you see a reasonably symmetric joint. Now, if you go to the follow-up lateral that was in that other image, look at that now. Now you've got anterior compartment arthritis. And this makes this case so much more challenging in the decision-making as to what you do. Regardless of MR and CT, this is going to be... This patient is now how old? Still an adolescent? 16 going on to 17. So her feces are closed. Wow. But she's young. Yeah. So if we scroll... So what I did back then in 2016 is I did an all arthroscopic oats. And these were her initial MRIs she presented with me. So it was very big actually. But what I ended up doing is I minced her... I took osteochondral plugs from her knee, three. I minced the bone down, put it in through the scope portal, laid it down. And then I went ahead and put the chondral plugs with a very thin one millimeter rim of bone. And I put it in a mosaic pattern and fixed it with fibrin glue. We subsequently published that report as a surgical technique tip. And I'm currently using it in healthier patients, of course. But okay. Needless to say, she did well for a while and then continued to collapse. And this was her last follow-up MRI. And Cesar, if you go back to the x-rays under 2020, these are just like you said, Dr. Marston, her last x-ray. So pretty much everything collapsed and failed. Now she's 16, very reasonable range of motion. Her recent MRIs, as we also have seen it, has good remaining talus apart from that medial one-third. So I have three questions. Number one, would you fuse or salvage? If you'd salvage, what are your options trying to do that? Would it be an autograft or an allograft? And if we end up doing an allograft, do we do it through a medial malleolar osteotomy or through an anterior plathontoplasty of the tibia? I think all of us recognize that this is an extraordinarily difficult problem to begin with, regardless of what your treatment plan is going to be. My preference would be to use a large, fresh osteochondral graft. And the only question, and of course I cannot tell on here, but based on the appearance on the lateral x-ray, I wonder if there's not bipolar disease. On the scan, it appeared that there was some erosion of the tibia. If you go through the AP view there. No, that's an old CT. We have a new one, but yeah, there were some changes on the tibia. There are changes on the tibia. So the question then is, will you do a bipolar? You can see it there even. There's anterior beaking and lipping of the distal tibia. You can see that on the tibia, the articular surface is not healthy. So I think that you'd probably be better off with a bipolar graft. And so a fresh matched talus and tibia probably is the way to go. Cut out as much of it. You've got nothing to lose. Cut out as much as you want of the talus, a small corner of the anterior and medial tibia, and put in a bipolar graft. I think that that can be done through an anterior approach. I don't think it necessitates a medial malleolar osteotomy. In fact, I would avoid doing a malleolar osteotomy so that I've got a reasonable backdress for my tibial graft. And yeah, that would be my approach. I'm good. It's such a difficult case though. And I don't know that what I've suggested is going to be the solution, but it's what I would do. And then of course, you can add some biologics to your graft as you choose. So I booked it already for a bulk allograft. We're in the process of getting it matched. I don't know. We might be a little bit out of luck in getting a bipolar one, but I requested one. But we're just waiting to see if we can get a match on a bipolar one. Yeah. Thank you though. Yeah, of course. Okay. Cesar, any comments? Yeah. I mean, tough one. I have one to Dr. Meyerson. Slightly different case, but similar concept. So I'm 20 years old. I had a pelan fracture. I had better tritis. You've tried everything that you could with me in conservative. I used all the braces I can. I can't see any images, Cesar. No, no. I'm just creating something here. It's a hypothetical scenario. It's a hypothetical scenario. Then I have to concentrate on what you're saying. Yeah. Young age like this one, 20 year old, had a bad pelan fracture. Had surgery, a hardware removal, better tritis, tried conservative treatment, all the braces available, all the injections possible. Debridement, arthroscopic debridement, crazy pain. No, there's no other way. You either do something or I'm going to amputate my foot. What is the best answer in your opinion? Should we fuse it and do a good fusion thinking that you can do a takedown fusion down the road when the patient has abdominal joint arthritis or we do a total angle now and let with the limitations that the patient would have. And then we deal with complications down the road. What is your? So 100% of the time I would do an arthrodesis. Look, we're in an age of emerging skill and emerging interest in joint replacement. I want you all to understand though, that for the first 20 years of my practice, I did ankle arthrodesis. And of course, I've continued to do that. And I have many patients who are athletically active with an ankle arthrodesis who've had their arthrodesis for 15 to 20 years. So, and these are individuals who are playing racquetball, squash, skiing, tennis. So I don't think that an arthrodesis precludes an active lifestyle. Of course, many patients develop radiographic evidence of arthritis in the peritalar joints. And a percentage of those are symptomatic. But why would anyone want to consider a joint replacement in a young patient knowing that you can go back and do a joint replacement 20 years later? Take down your fusion if you need to. At least give the patient pain relief. The outcome, remember this, just it's a terribly simple way to look at it. There are no complications. If you think about ankle fusion, ankle fusion doesn't fail. Yes, there are potential complications. But total ankles fail. And I'm telling you this as a designer of ankle prostheses, more than one prosthesis, ankle replacements fail. So I would never consider it in a 20-year-old. I probably wouldn't even consider it in a 30-year-old. I have done them in patients who have bilateral disease, bilateral rheumatologic disorders, in younger but very, very limited activity individuals. Otherwise not. And what about, what are your results with the takedown fusions in ankle arthritis? Sorry, takedown fusion and potentially subtalar joint fusion or no fusion? So my results are modest. There seems to be a lot more interest, success, and enthusiasm over the past six years than my experience which was based on the 15 years prior to that. And I had modest results. I would not say, wow, they are great. You get about 15 degrees of motion. I've had complications with subsidence of the implant, complications of stiffness, heterotopic bone formation. Look, I think that this remains to be seen still in the next decade as to what we're able to do with takedowns. There's a lot of enthusiasm for it, but I'm not sure what its role is and whether or not converting to a TTC or a Pantaylor would be preferable in a younger individual. Amgen, Naomi, thanks Dr. Meyerson. I've been asking this question for every single person I talk about ankle arthritis. It's just kind of a pull. But I would like to know, Amgen, Naomi, Mohamed, Daniel, if we can just quickly say here, would you consider total ankle in a 30-year-old or 20-something or 30-something, yes or no, for bad post-traumatic arthritis? And if you do take down fusions, what are the results for it? Amgen? I'll start by saying no and no. So no ankle replacement before the age of 40 for me. Then 40 is actually me lowering the cutoff much, much way more than it used to. And then just like Dr. Meyerson said, no for fusion takedowns. Where we trained, they've moved more and more away from them just because of the exact same reasons Dr. Meyerson echoed. Naomi? I would not do an ankle replacement in somebody at least 40 or more. I will echo Dr. Meyerson's statement that people who have early ankle fusions can do quite well. When I was in the Air Force, I actually helped a gentleman who was in the special forces who had had an ankle fusion when he was 10. He could outrun everybody in his unit. He wanted to become part of the super-duper special stupid Green Berets who jumped behind enemy lines to make roads and do all kinds of stuff. He went all the way to the Air Force Surgeon General, but he could outperform everybody in his unit and he got it. I've also been beaten by somebody who had a fused ankle playing doubles tennis and it was three times we played before I learned he had an ankle fusion. So people can be very functional. It's a very good operation. I'm not doing any takedowns because in addition to the difficulty of doing them, if your ankle hasn't moved, what kind of muscle do you have? It's all fibro-fatty infiltrated. I just don't see how it can work. I'm waiting on science. Mohamed? I agree with all. I don't do an ankle arthroplasty in a 20-year-old patient and I have no experience about takedown fusion. So I have one quick question. You said you tried all braces. Have you tried the IDL or what the Center for the Intrepid developed for their returning warriors to offload the ankle? No, I haven't. That was a hypothetical situation. No, I have not tried in any of my patients. Since I'm in San Antonio now, I'm getting some of them. A couple of them have IDOs and they just love them. Does the insurance reimburse for them, Naomi? I don't know. I can tell you they don't necessarily reimburse for your full allograft osteochondrographs. That's true. Daniel, anything to add? Yeah, I would echo the sentiments that I'm not the 20-30-year-old replacement I worry about. I think the other variable that isn't taken into account is the age of the surgeon. I think the closer you get to retirement, the more you're happy to replace ankles in young patients. Not only am I not retired, you are invoking a clause that's going to get you into trouble. No, just because we have Andres here. Andres, anything to add? Like any ankle replacement below 40 years old and take down fusions and ankle replacement. So no, I would not do it. I have many patients. I take care of a lot of trauma patients in our Level 2 Trauma Center and a couple of 20-30-year-olds. I've talked about other surgeons and some of them have bad infections and post-traumatic arthritis. I think I wouldn't do an ankle replacement because if you do a 20-year-old, you're going to have at least two or three revisions throughout its lifetime, right? So I just would try to avoid a replacement on a person that has 30 or 40 years left of life at least because then it's going to be a failure at some point. You can't revise them so many times, right? So I think a fusion is a great way of solving their problems and giving them an active life with less chance of having a reoperation than an ankle replacement. And I'm never going to take them. I just want to add something to that, which it just, it's a bit of history for you all. In 19, I think we published it in 1990. It was a paper with John Papa on TTC arthrodesis, post-traumatic TTC arthrodesis. And it wasn't a large group of patients. There were 22, 23 patients included in the study, but of those 17 were laborers. And of that group, not only did they all go back to work, but the long-term outcome of the TTC arthrodesis in these active individuals was fairly good. So just bear that in mind as you are thinking, and that's TTC, that's not isolated ankle. Just bear that in mind as you're making your decisions for patient care. So can we pick on Duke for a minute? I'll tell you a funny story. So I had this post-traumatic guy who was like 30, 31, bad tibial pylon, missing some anterior bone, talus wasn't entirely there. And he comes in and he tells me, well, I want you to do my ankle. I want an ankle replacement. And I said, whoa, I've not done enough of these. Your deformity, you have no bone. He says, but I want an ankle replacement. I said, well, why don't you go? Cause I was in Wichita. I said, go up to KU and see Greg Horton. He's been part of the star. Oh, I've already seen him. He said, what did he say? He said, well, he said he wouldn't do an ankle on me, but I want you to do an ankle on me. And I say, okay. I said, who else have you seen? Well, I've been to Baltimore and seen Dr. Meyerson. And he said, he wouldn't do a total ankle on me. And he saw you were your partner. He couldn't, you know, I said, okay, so this goes on. He keeps coming in. And I said, no, I'm not doing a total ankle replacement on you. And then I said, well, if there's one place in the country that'll do a total ankle on you, it's probably Duke. They're doing 200 a year. So I packed up his CD, his CT, his x-ray shipped it off total letter. He gets a letter back from them saying, oh, he is a great candidate for a total ankle. And I thought, oh my God, they really will do a total ankle on anything. So he flies up there, he gets there. And I think that's when they finally looked at his images and he comes back to see me. He says, I want you to do my ankle. And I was like, what part of, no, he says, no, do my fusion. They will not do it. So I did an arthroscopic fusion on him. Two months later, he goes, this is great. I don't hurt. I should have done this years ago. So, but I just had to laugh because I get this letter from DeOrio going, yes, he's a great candidate. And I'm like, oh my God. So that's my story to contribute to humor for tonight. Well, before I hand it over to Cesar for closing remarks, we're close to the two hour mark. I would like to thank every single one of the attendees. This has been a very rich discussion, just because of your cases and your participation. I'd like to thank the LFS staff, young physician committee members, my co-pilot Cesar, and finally our star of the night, Dr. Myerson. This has been a tremendous learning experience for all of us. And as we get ready with the snapshots, Cesar usually takes snapshots. So everybody turn on their camera. Yeah. Come on. Camera's on. We're going to shout out names here. Come on. Let me see the names here. Sue, Chris Miller, Chris Miller, turn your camera on. Come on. I'm trying, but all I can see is how to unmute. I want to see myself. Let me see myself on the screen. Turn your camera on. Come on. Okay, Cesar, I'm trying, but I only see- Lorena, Lorena, we're not going to take the picture without you. Come on. Here comes Sue Ann. Here comes Lorena. Who else? Do we have anyone that's trying to hide from the- No, there you go. Yeah, I think we have Panas. Panas, can you- Is Panas there? Panas is there. Okay. So we have pretty much everyone here. So let's do the pictures. Dr. Morrison. Hello. Excellent. Come on. Wait for Kenneth. Kenneth is coming. Come on. Let's do it. That's great. We have at least a medium picture. So I'll share with all of you by- Oh, here comes Nasimi late with the hair completely crazy. That's good. That's good. One more with Nasimi. Great. Well, so this was great. Dr. Morrison, we can't thank you enough for taking the time. We know you're super busy and people are fighting to have you on webinars. So we were very happy and honored for you to take the time. I think it was great. And thanks for teaching us for all over these years and for sharing your knowledge for this very tough cases. I thank every single one of you for the challenging cases. There's some great supporters like Daniel and Elomi that are always sending challenging cases. And the guys from Egypt staying up late. Oh yeah. Muhammad, you're always there. Thanks for everything, guys. And Dr. Morrison, you close it. You start it and you close it. Oh no. There's no need for me to close it. Goodbye. Peace. Stay healthy. Be happy. Enjoy your life. Good. Bye. Bye-bye. Y'all have a great evening. Thank you all. Thank you. Bye-bye.

orthopedic surgeon

hallux valgus deformity

treatment options

double osteotomy

lapidus procedure

minimally invasive chevron achings

preoperative X-rays

postoperative X-rays

deformity correction

Dr. Meyerson

modified Lapidus procedure

MICA

ankle fusion

osteochondral autograft

osteochondral allograft