On behalf of AOFAS, I'd like to welcome you to the AOFAS Advanced Foot and Ankle Virtual Course Revisions, Complications, and Complex Cases. Thank you to our course chair, Dr. Christopher Miller, and the course co-chairs, Dr. Jacob Seid and Dr. Elizabeth Cody, for putting together a fantastic course. You can find their disclosures, as well as the disclosures of the faculty, on the course webpage on the AOFAS website. All faculty will also share their disclosures in their individual presentations. I'd like to run through a few housekeeping items before we kick off the course. For technical difficulties, please try closing your browser and logging back in the same way you did the first time. This course offers 11.75 hours of AMA, PRA, Category 1 credits. You'll receive an email following the conclusion of the course on Saturday with a link to claim your CME. This course is being recorded, and the recorded presentations will be available to view on the On Demand Education Center in approximately 24 hours after the broadcast each day. We encourage you to ask questions during the presentations. To send your question to the faculty, click on the Q&A tab at the bottom of your navigation bar. If we cannot get to your question during the broadcast, the faculty will reach out to you following the broadcast to answer your question. We also want to give a special thanks to Medline Unite Foot and Ankle for supporting Symposium Managing Complications of Forefoot Surgery with an educational grant. Funding for the course is also provided by the Orthopedic Foot and Ankle Foundation to support the education programs like this, please donate to the foundation on our website or by giving AOFAS a text at 41444. Finally, we hope to see you at our future AOFAS education events, including next week's foot and ankle focus webinar on 3D printing and foot and ankle surgery, and also our 2025 winter meeting in Lake Louise, Canada. Thank you for taking the time to attend this course, and I will now turn the program over to Dr. Miller to begin. Hi, good evening, thanks for joining, so this is day two of the advanced course for 2024, and we had a great session last night on pediatric foot issues as well as dealing with the athlete, so I hope you guys can take a look at that if you were not on live. Today we have some really great talks I'm looking forward to, and as a reminder, if you do have questions, please, from the audience, please put them in the Q&A tabs and we'll get to them. But with that, I'm going to turn this over to my co-chair, Dr. Liz Cody, who will be starting off the first session, so thank you, Liz. Thanks, Chris, I'm Liz Cody, so I'll be moderating this session on complications of forefoot surgery, one of the most rewarding and also frustrating parts of foot and ankle surgery, so we'll be starting things off with Dr. Scott Ellis, my colleague, who will be talking about bunion recurrence. Thank you, Liz and Chris, and for the words, Julie, it's an honor for me to be here. I'm going to share my expertise in an area of the lapidus, and I realize it's not the only way to fix a bunion, but it's what I've used over a long period of time. Let me get my screen up here, but as I understand and want to convey to you, every surgery is not without complications, and I'm going to share my experience about how this one can have complications and how you might deal with them. Liz, can you see my presentation? Is it? Yes, you're all set. And it's full. Okay, so I'm going to talk to you about preventing complications, particularly going to focus on preventing recurrence with the lapidus and what that really means, and then I'm going to at the end talk about some other complications as well, because recurrence isn't the only complication. And again, these complications are not specific to just a lapidus procedure. I gave a version of this talk at the winter meeting in Montana, and the title of that talk was very similar, but in that one I titled it, How Bunion Surgery is Like Playing Golf, and so it's almost like Liz's comments were. It's kind of fun to... Sometimes it goes well, and sometimes it doesn't, and you're sitting there scratching your head like, what on earth did I do differently? And the key is just to figure out those patterns and ways that you can predictably make this go as well as possible. I know Becky will be on too, a lot of people are doing MIS now, and each is going to have their own version of these complications, so just keep that in mind. Just a few disclosures, I'm a paid consultant for Stryker, I'm on the international weight-bearing CAT scan board. You're going to see weight-bearing CAT scans here, a plate from Stryker, but I'm not advocating one versus the other. I don't get royalties. I think the concepts are all the same, no matter what plate or screw you use. I have videos, I just don't have time to show you them about technique. I used to use just a cross-screw technique, which Matt Conte helped me video and publish on the Foot & Ankle International website. There's a lot of good videos, by the way, in the library on that website. And then I also have one published with a screw-and-plate contract I'm going to show you on YouTube, but again, there's many different ways to do and fix a lapidus. What I'm going to talk about is recurrence and the moderate bunion, and what that means. What does a moderate bunion mean, and what does recurrence mean? Moderate may depend on how you define or what x-ray parameters you use, but in general, for me, it's an IM angle of between 12 and 16 degrees, rather, and an HV angle probably between 20 to 40. For me, even with a moderate bunion, lapidus is still a great procedure because it corrects deformity often where the apex of the deformity is, and it's particularly helpful in cases where you have arthritis of the first TMT and stability of the first TMT or gapping that you might depict on a weight-bearing CAT scan or x-ray. Liz, can you still hear me? Yes, I can. Yeah, I just got a little error message saying my internet is unstable. I think we're okay. So why do we talk about moderate bunion in general? Mild deformities often in my practice, I counsel patients and tell them they're probably going to need a bunion surgery, but if it's not painful, particularly if it's mild, we wait. Although I always say that it's easier to correct the deformity if it gets really severe, particularly when the second toe starts becoming a problem because the results of second toe deformity are so much more unpredictable. And I also think that a lapidus is good for severe deformity because it's very powerful, but even in those severe cases, it's harder to get them just right. So moderate is kind of the sweet spot. What is a recurrence? Well, it depends how you define it and it depends on the literature, but in my research, I've defined it as an increase in hallux valgus angle more than five degrees of what you finished immediately postoperatively. So it's a recurrence based on what you get at the time of surgery, but you could also say a recurrence is an IM angle that increases more than what's normal or a hallux valgus angle that recurs more than what's normal. We know that sesamoid position is very predictive of a successful bunion results of sesamoid subluxation can be a predictor as well of recurrence, but these are all the parameters you're trying to correct and have them not come back. And we, Konstantin, one of my colleagues is now a spine surgeon, Chevy Iyer, and I published a study looking at recurrence after an opening wedge technique that I used to use a long time ago. And this was the definition that we used. Okay. So why does a bunion recur? It's not just a lapidus where this can happen, but it's when you probably don't correct it from the beginning. I think a lot of them is that you just never got it right. We like to think or tell our patients that we got it perfect and then it came back, but probably often it's, you didn't get it right. So oftentimes it's, you didn't get the IM angle corrected completely. There's this concept of pronation we've talked so much about recently, but maybe you didn't get the pronation corrected or maybe you didn't get the sesamoids completely reduced. There's this concept of inner cuneiform instability, which will come up also with the MIS docs, but maybe you get a great correction even through the TMT fusion, but there's instability, which allows some gapping at the inner cuneiform joint, and that can lead to recurrence and also delayed union. So there'll be cases where I see where the bone just doesn't quite heal at the TMT joint in a perfectly well corrected bunion, it looks like it just drifts over time. Here's an example. Liz asked me to use cases that were enough followup out that I can say it really truly was a complication. And this is probably a followup about a year in each of these scenarios, but on the upper upper panels, you see a bunion, which looks pretty well corrected. Maybe the sesamoids aren't exactly corrected in the middle, but you can see how it drifted over time. It probably rotated and the sesamoids came back at a position and on the bottom, whatever I did, I got it just right where the sesamoids were perfectly reduced, the IM angle perfectly reduced and the thing never came back. And that probably was just the way I got it done at the time of surgery. Lou Schoen one time had a talk and I remember this vividly at one of our foot and ankle meetings and it was titled, why does my bunion cheat on me? And this is how I so often feel about this. And it's why fixing a bunion is like playing golf because there's so many moving parts. One affects the other. Sometimes the more you play in the more bunions you do, all of a sudden you get one wrong. You're like, what on earth? How's it? I'm not getting better. And every single patient is different. I played a little bit of golf growing up and my brother, who's not a great golfer, I must admit he had two theories on the golf shot. One was one, don't think about your shot and two, hit it as hard as you can. This is me in a picture and I was in high school with a few times I did play golf, but that is not the right advice. So you have to think about your bunion and don't just go for broke. When we see recurrence, it's usually from about six weeks to six months. Oftentimes I feel like it stabilizes at six months and it doesn't increase too much afterwards. This is why I still feel like it's not really so much a recurrence, but just a failure of my original correction. This is that same study that we showed. I was using an opening wedge technique at the time and you can see what looks like a very good correction at six weeks and that middle panel just went on to drift over time. Maybe that's coming in that case through the TMT joint, something we can talk about, but that is what a recurrence is. I think you have to choose your patient, like you choose your course carefully. You have to have somebody with reasonable expectations, motivated, they're going to stay off it to the extent that you need. It's the analogous to playing an easier course with par three, perhaps. Set those expectations really early. The workhorse of this procedure is the TMT fusion. That's why I call it the driver, the three wood. It has some important components, including the approach, how you make your cuts and how you correct all the planes of the deformity, including the metatarsus varus, the pronation and the elevation. I generally go dorsal medial. I go between the EHL and EHB, watch the neurovascular bundle, and I make an electrocautery mark as I open the capsule so that I know where my rotation is. I dial in, I can't say exactly the right amount that you need based on preoperative imaging, but essentially, I think more or less what I think I need. I take out the cartilage first and then make my saw cuts. Again, I'm not going to go into details of the technique, but I usually make a flat cut on the metatarsal and a small lateral wedge on the cuneiform. In general, I don't use guides because I worry that the guides will force me to take a little bit more bone than I want. You have to get that IM angle corrected, and I go for almost one or zero degrees. You have to correct that pronation based on research, two to eight degrees, and really avoid elevating that metatarsal because if you take too much dorsal bone, you will elevate it. This is a video that Jim Holmes sent us. So many of us have seen iterations on this theme, but the rotation is so important because even if you just stick a K wire in the metatarsal and rotate, you can see what it does to the overall appearance of the bunion and the sesamoid, so I think pronation is key. Here's an example of a patient who is a 16-year-old diver that I had preoperative, and you might say, well, that's pretty young for a lapis, but it's not. I've had good results with a pretty severe bunion. I get a weight-bearing CAT scan on all my patients preop. You can see how the sesamoids are subluxed out of position. I get the IM angle corrected and the sesamoids corrected, so pretty good result. Getting those two joints opposed is so key. Oftentimes I'll take a little bone off the first metatarsal base laterally and the tissue out of the second so that I can bring the ray over also, but you've got to be really careful in the vascular bundle. Now the analogous to the modified big bride, which I don't always do now, by the way, depending on the tightness and severity of the bunion, is the three iron. Sometimes you don't need this club, but just be careful when you're making that dissection. You want to over-release it because these are cases that can lead to other complications, so if you really over-release it and correct the IM angle for broke, you're going to get varus. I almost always will do a medial eminence resection, so this is analogous to the nine iron, the sand wedge. It's a small component, but yet important. I do a longitudinal capsulotomy. Watch out for dorsal branches of the medial nerve because you can injure that and patients get numbness or pain, and I just take a very small sliver of bone off the side. This also helps the capsule stick down to good bone and helps you get your sesamoids over when you tighten the capsule. I generally tighten the capsule with a tube of fiber wire. Sometimes with a bite growth, I feel like I don't need as much, and I will take a little bit of the capsule out to really bring it over. I'm going to skip joint prep because I've already talked about the flat cut. Sesamoid position is paramount to prevent recurrence, and this is true whether or not you do a McBride or not, and whether you do soft tissue excision or not. Generally though, you want to get those sesamoids over so that they're reduced, and that's what I've found leads to the least recurrences. This is a study by Kim out of South Korea, basically showing in four panels there that the amount of pronation that you have is not always hand-in-hand with the sesamoid subluxation. You can have the sesamoids that go out without the pronation, they can go together, but they're not always together. Then I use calcaneo bone graft because I feel like if I put a wedge of bone graft, it's called stress strain relief, invented by the group at Harborview in Seattle, that it helps my healing. I hold the joint with two pins, and then I put a plate and screw construct. Again, the most important in this talk is not the construct, but I will say that I have a cross screw, and I'm going to show you in a picture in a second, that comes across the base of the first metatarsal to the middle cuneiform, and I think that really helps me hold that first metatarsal over and prevents intercuneiform gapping. I'm trying to prove that in some research studies, and here's an example of it, but I can't really for sure say it yet. The dorsal medial plate allows for good compression in early weight-bearing, and here's what it looks like. The achin is the final step, you've got to be careful not to overdo this. It's easy to make a good bunion go bad with the achin where you destabilize it or make it go too far over. Do not use this to compensate for a failure of your overall correction. I generally fix with a small staple. The recovery in general, when I used to do cross screws, I didn't let the patients put weight on for six weeks. Now, in general, for younger patients, less than 40, I'm going two, and for those more than 50, I'm going a little bit longer. I'm going to skip because I want to stay on time and be respectful for everybody else, but I just want to tell everybody that we have shown that you can correct pronation well with the lapidus. I think you can correct it with other techniques as well, and the amount that you correct the pronation, it correlates with the clinical outcomes. In general, just choose your course wisely like you choose a bunion. There's many factors that go into correction. One affects the other, and just choose wisely. I'm just going to close briefly with some of the other downsides of a lapidus. We talked briefly, but you can have a non-union. If you choose the patient correctly and have good joint prep and fixation, that's less common, but it still happens. Adjacent joint arthritis can happen, particularly the medial cuneiform, endovagal cuneiform. In general, it's asymptomatic in my experience. These require subsequent surgeries. You can have wound issues, minimally invasive. Lapidus probably obviates some of these. You can have nerve injuries. The dorsal bundle is really right near that EHB, which you see in the picture. I've even had patients with RSD, so just watch out for that because that can be a long road for those patients. You can under-correct it or over-correct it, so avoid over-shortening, and I mentioned avoid dorsiflexing it too much. You can also under-correct it, and you lose loss of correction. Here are just a few examples that I've had where I sent it into too much varus. Patients generally aren't horrible. I end up having to fuse some of those first metatarsophalangeal joints, but here's one with a cross screw on the right side, here's one on the left. Here's one where I shortened it too much, and I let it transfer metatarsalgia and end up having it go in a non-union where I shortened it, put a graft in, so just ways to make it go wrong. Here's one where I actually brought it too far down, and you can see the arch almost looks exacerbated. This was in the setting granted of a flat foot reconstruction. The biggest one is just the fusion doesn't take, and that is a big deal because after six months, if it hasn't healed, I'm talking about going back, and it's just an ordeal for the patient, so just be meticulous about your joint prep and keep the patient off. Here's an example of a non-union. Okay, and I mentioned joint arthritis. Last one is these patients, it's an emotional roller coaster, especially when something goes wrong, if you have recurrence or not, so you just educate the patients early and set expectations, tell the patient you're there for them, and they'll stay with you. So long story short, LAP is a great procedure. I talked about how you can have recurrence and then mentioned briefly some other complications, so happy to take questions, and I think this will be similar to some of the other talks. Thank you. Thanks, Scott. So I think we're going to save questions for the end of all the talks. We'll have a good discussion session after all the talks. Next we have Bobbi and Du talking about Hallux Varus. All right, can you hear me? Yep, all good. All right. And I believe I'm sharing my screen. And can you see that? All right. Yes. So, hey everybody. So today I'm going to talk briefly about Halox virus. And I'd like to really thank Scott there for that nice little segue. He was not a plant folks that actually just really worked out nicely. So Halox virus and the question of how to address it when it shows up, fix it versus fuse it. So my disclosures for a moment. All right, quick outline of what we're going to talk about today. So we're going to talk about Halox virus and where it occurs from. Then the decision points about making your choice as to how you want to address it. Then some on non-operative management and then going into operative management on the reconstruction of tendon transfer options versus infusions. Actually, I lied to you. We are not going to discuss non-operative management. This is a surgical conversation. So let's keep it to that, right? So in terms of this, I was asked to mind the pictures that I use for copyright issues since this is being recorded. So what you're going to see here today are all my drawings. So this is just me drawing it out so that we avoid any of that stuff. So what is Halox virus? So it is a medial deviation of the Halox at the MTP joint which occurs for a multitude of reasons. It can be congenital. I mean, it's something that the patient is born with. It can be the result of a traumatic issue but a lateral collateral ligament rupture as pictured here by your great artiste. And then it can also be the result of inflammatory arthropathy which has weakened the soft tissues around the joint leading to laxity and then drifting off in either direction whether valgus or varus. But the most common reason for it is that it is iatrogenic. And it is usually the result of Halox valgus overcorrection or aggressive medial eminence resection as you can see pictured here. So here is a normal medial eminence. And then when you over resect it an ice cream cone falls off. Over placation of the medial capsule in terms of your correction. So being aggressive with how you're suturing that together or it can even be something so simple as an aggressive dressing, right? Causing stretch or overcorrection of the lateral complex again within the dressing in the first one to two weeks. And then the classic also association with this is the sesamoid ectomy. So the bunion that is fixed and at the same time sesamoid is excised in particular the fibular sesamoid to then lead to this Halox varus. And for our younger learners on this just as a quick test taking point. So when we talk about the sesamoid ectomy, the way I think about this, the toe always goes the opposite way, right? So you'd take the fibular sesamoid that would go into varus, you'd take the fibular sesamoid that would go into valgus, you'd take both sesamoids of a cocca. Just a quick teaching point. All right, so you now have this patient that is standing in front of you with Halox varus and what are you going to do? Well, the first thing you need to do is start figuring out your decision points about this deformity. And the first decision point is, is this a fixed or flexible deformity? Meaning that is this something that you can correct in clinic while you're pushing on them or is it not? If it is not a flexible deformity, then you are by definition going to have to do some bony work to achieve correction. And that is a simple rule, again, for all of our young learners that may watch this in the future. If it's a fixed deformity, some bony work must be done. If it's flexible, you may be able to get away with just soft tissue. So your first decision point is it's a fixed or flexible deformity. A second point to that is going to be, when we talk about taking out the sesamoids, the metatarsal head can buttonhole through the defect that's left behind, leading to a cock-up deformity of the toe as it buttonholes through that plantar plate. As you can see here, pictured on this excellent sagittal view of it pushing down through the plantar plate, leading to a flexion contracture then a cock-up deformity of the toe itself. Once that starts to happen, you're going to be leaning again more towards doing your bony work infusion rather than just soft tissue reconstruction. And we'll show some pictures of that later on. Second decision point around this is going to be the articular surface and the integrity of the articular surface, right? Has there been an aggressive medial eminent intersection as we talked about before, such that there's not enough of a metatarsal head for you to land on in terms of doing a soft tissue reconstruction? Also, is there arthrosis or arthritis in the joint? Because bear in mind now, that typically by the time these folks are seeing you, especially if they're coming from another surgeon, they've been in a malposition spot for quite some time. So that means affected joint biomechanics. And then what is the condition of the cartilage within the joint? If it's starting to break down, then once again, you're going to be thinking more fusion than reconstruction. So reconstructive options, if you're catching this early, meaning that this is something you see in the first couple of weeks and you've taken the first dressings off, then I would consider doing things like doing your release of the medial placation of the capsule and then tightening laterally. It works as an early solution, but it's definitely not always successful, but it's sort of your simplest answer for the iatrogenic Hallux virus situation. Then you get into your tendon transfers. Now the tendon transfer is more of a dynamic correction and can work longer term than just doing the simple lateral placation. And there are multiple options for the tendon transfer. Hopefully you all can understand my drawings here. The classic one is to do an EHL transfer, where you would basically detach the EHL from its attachment at the distal phalanx and then bring it up and weave it through the base of the proximal phalanx to act as a newly reconstructed lateral collateral ligament. Problem when you do that though, especially if you take the whole tendon is now you have a floppy IP joint. So you will have to put a screw or fusion of the IP joint if you're going to harvest the entire EHL tendon to do the transfer. So then came around the idea of doing a partial EHL tendon transfer, which you can see pictured here, basically harvesting a distal longitudinal split of the tendon, passing it underneath the intermetatarsal ligament to make sure that you're removing the dorsiflexion force, right? That it would create at the phalanx. And the idea here is that when you do transfer these tendons or any of these things we're going to talk about on the sagittal view, you want to be perfectly midline. If you're too dorsal, you'll end up cocking up the toe. If you're too plantar, you'll end up plantar flexing the toe. The idea being that you take the EHL as a dorsal structure and pass it underneath the metatarsal ligament to ensure that you basically counter that dorsal pull as it will be then correcting your position of your proximal phalanx. Then alternatively, another option is to then proceed with the EHL transfer from proximal, right? Now this one, to me, seems a little bit less trustworthy and I like it the other way around, but I'm going to show you all your options. Same thing again, I'm going underneath the intermetatarsal ligament. There you go. And you can see it passing through, but now you're weaving this into the metatarsal head slash neck area to, again, reconstruct that lateral collateral ligament. Now for these though, you will need to have pretty large incisions. So you're going to be doing a pretty big whack and a pretty big dissection on these patients who are likely often a revision surgery because remember I said, the most common reason for this is iatrogenic following how it's about this correction. So you have to be cognizant of your soft tissues and where you're placing your incisions and the type of dissection you're going to need to do these large tendon transfers. In terms of the fixation, as I mentioned, you're going to be fairly precise in particular on that sagittal view. You want to be in the midline as close as possible to make sure you're not creating more of a dorsiflexion or plantar flexion moment across that MTP joint as you're correcting the position. Now using augments as we do other things beyond just a tendon transfer, you can use a tight rope or soft tissue reconstruction augments and to do those, it's the same exact concept though. And you see here where you recreate that lateral collateral ligament with your suture button on the medial side of the phalanx and the medial side of the metatarsal neck. And that's coming through both reconstructing that LCL, excuse me. But again, you have to be perfectly midline on your sagittal view. And if you're using one of these, you want to make sure that you have that button straight down on bone. There's no soft tissue between it because over time, if there is soft tissue, you will have some drift of your correction as the button erodes through the tissue to eventually seat itself and stabilize on the bone. So you want to get it down on bone as quickly as possible during the initial procedure. Then for the other issues, so if there's been aggressive medial eminence resection, if it's a fixed deformity, significant arthritic changes. Another point to mention, kind of caveating off of Scott's talk there, if there's non-union of your bunion correction, you have a lapidus with a non-union, you have a metatarsal osteotomy with a non-union, you don't want to have another floppy area. So then the idea being you would fuse the MTP joint to provide at least some medial column stability to the foot as you progress through angulation. If there's significant arthropathy, such as RA or psoriatic arthritis, then you're going to be worried about those soft tissues and your soft tissue reconstruction may or may not last. Hence again, the idea of going forward with the fusion. Neuropathy, they're not going to be able to protect this following instructions as well, in terms of staying off and allowing soft tissues to heal. So then I'm a big fan of going forth with the arthrodesis. Now, this is my shameless plug for MIS arthrodesis, as you can see here, to be able to do something like this. Like remember I said, this usually is a patient who's already had an incision, how to do atlas correction, you're worried about your soft tissue envelope and what you can do with it. So to be able to take them, and instead of doing a big whack, do an MIS MTP fusion through incisions that look like this, right? So there's my mouse. This is actually one of the scars, and then the other scar is down here. And then the joint prep was done through here for this patient, where you can see we were able to achieve full union by doing this in a minimally invasive fashion with great respect for the soft tissues. So quickly running you through a case that I have done. This was a 61 year old female who was referred to me by a colleague, who actually is the patient's brother. She had a laparoscopic done six months prior by another surgeon and had some concerns because to her, the foot just quote, didn't look right. And so this is how she came to me. Sorry for the poor quality on the films there. This is a picture of my computer screen, just because I don't usually take pictures for stuff that I'm just working. And you can see her here with the deviation and subluxation that way. And so also, if you look on her axial view here, you can see that her fibular sesamoid was resected, and you can see that she is buttonholed exactly as we talked about. And she actually started to develop a cock-up deformity of the toe, precisely as we were talking about happening with these. Now, I violated everything I just taught you though, because she really did not want a fusion. So we ended up for her doing a augmented reconstruction using a tight rope and helping to bring her over. So you can see here the intraoperative thoroscopy shots, bringing that in and weaving it through from the metatarsal up through the phalanx and then tightening it down. And interestingly enough, this was her correction immediately post-op. She's in her dressings there, and then this is her by the time she gets to three months. You can see we lose a little bit of that correction, and she has drifted a little. Now, that may be because I didn't have my buttons fully down on bone, the fiber tape stretched out. There's a couple of possibilities here. I did come back later on. I don't have the x-ray in this talk, and I did end up fusing her IP joint because she continued to have a bit of a contracture through the IP joint where the toe wasn't cocked up, but she was flexed through the IP, and that was causing her some pain. But so here we have it in terms of doing that. Then another one coming up. This is a 63-year-old gentleman who I've done an MIS triple on his contralateral left side. On his exam, he has a positive grind test, and he has this idiopathic appearance and how it's various. He's always had these, as he calls them, hobbit feet, and I'm actually doing his case on Monday with an MTP fusion because he has the positive grind test and breakdown in arthrosis within the joint already. He does not have a cock-up deformity on his lateral because he has still both sesamoids and has not button-holed through that plantar plate as of yet. So someday when I give an update to this talk, I'll show you his x-rays. Thank you, great talk. I especially enjoyed your illustrations. Thanks, that was an entire night of my life. It shows, yeah, they're very impressive. All right, so we're gonna be moving on to complications of MIS surgery with Becky Serrato. Can you guys hear me okay? Yes. Got you. Okay, can you see everything okay? Yes. All right, hold on one second. All right, I think I'm frozen now. Nope, I think I'm good. So I guess good afternoon, evening, wherever you guys are located, Liz, thank you very much. Chris, thank you very much. And Jacob, I think is listening. Thank you very much for the invitation to speak on the virtual seminar and webinar, I should say. I got asked to speak on MIS complications in the forefoot since this is a forefoot symposium. And I just wanna say, everybody is all on board with MIS, which I'm very happy about, but again, it's not all nirvana. So here I am. And so here are my disclosures. I wanna highlight, I am a consultant for Stryker and specifically their pro-step MIS line, but I will hopefully be able to keep this without bias. And then specifically, my other disclosure is not all of these complications I'm about to show you are mine, only most of them. So, complications in percutaneous surgery, I think it's a little easier for me to give this lecture now than it was five to six years ago, where everybody would look at x-rays, particularly an x-ray like this, and you'd look at it, you'd see that, who didn't put hardware across these metatarsals, and you just say, this is really bad surgery. And so it's really easy to show some pretty frightening x-rays on MIS surgery, but I would challenge all of us, and we probably see it as new patients almost every day in our clinic, somebody who comes in here and has multiple incisions, this is an open surgery. So both of them can have complications, but what I wanna focus on with this lecture is specifically complications that can be unique to percutaneous procedures and how to avoid them with proper technique. And I also wanna talk about some that are not what we consider true complications, but actually the natural healing process of percutaneous surgery. So these are the ones, I'm not gonna list them right now, because I'm gonna actually go through a lot of these, but these are some of the avoidable complications we see in forefoot MIS surgery. And I think with good technique and good practice, you can avoid a lot of these. And so when we talk about skin burn, there's two ways you can get this. Number one, you have an inappropriate approach can cause skin damage. So the rule of thumb is, there is one incision for every working osteotomy or technique that you're doing at that time. You can make multiple little incisions with your beaver blade. Beaver blade. And so to try to extend this incision to do other things is where you oftentimes can run into problems. And then the other time that I think is probably the more common reason that you see skin burn is the use of the burr. So if you have excessive rotation and or translation of your burr at the time that you're making this cut, I think that that's where you put the skin at the biggest risk. And when we train people in MIS, you can see that without them even realizing what they're doing, they're sweeping their hand excessively and causing this trauma to the skin. And again, with proper technique, again, one of the biggest advantages of percutaneous techniques is the decreased risk of wound infection, which has been documented. So this is just highlighting, this is a hand doing the chevron osteotomy, the dorsal cut with it. And you can see it's not just a supination or rotation of the hand, but it's also a translation. So that at the skin incision, which is the fulcrum, there's really very little translation or motion or torque or pressure happening at the skin. And so here's an example of a patient who, if you look on the left-hand side, the medial eminence was burred down and excessively burned down, creating heat, not aware of this. And you can see that the wound complication that happened with it. And this is a patient that actually had to come back. I would argue, if you see any issue that you're concerned about, even at the time of surgery, the best thing to do is to probably ellipse that really traumatized skin, if you can, to get a closure, because you can potentially avoid some of these. And on the right-hand side, you can see the trauma that happened to the skin with placement of the screw. And although this didn't lead to any kind of deep wound infection, it can oftentimes lead to a really ugly and hypertrophic scar. Skin and bone burns are avoidable, particularly with the power. So again, we've talked about this, and if any of you guys have been in any kind of training things, you must have the right power. And that means it has to have a strong couple, meaning high torque, that allows the burr to initiate a cut at a low speed, reduces heat production during the bone cut and at the skin to avoid these disasters that I'm highlighting right here. But it's more than just that. You wanna try to reduce the heat that's generated from the burr, even if you're using the right power system. So no tourniquet, that can be debated, but many of us feel like it's really not necessary, and if anything, it may aid in the reduction of heat production. Copious, copious irrigation with bulb syringe. Use chilled and refrigerated saline. Be cautious with your young adults and adolescents. They have really good strong bone. Calcaneal osteotomies go really slow with it. I pause frequently. I often take my burr out and clean my flutes to make sure they stay nice and sharp and constantly irrigated to minimize this heat generation. Tendon injury. Tendon injury is, again, unique to the burr as opposed to open forefoot surgery. But again, if done well, this is extremely rare in MIS techniques. The main thing is, kind of similar to a cast-off, avoid tension on any soft tissue structures, particularly tendons, as the burr exits the bone. And so with proper technique in making your osteotomy, you can avoid this. A cutting or Shannon burr is less likely to injure a tendon than a wedge burr. So particularly, you have to be careful when you're doing the percutaneous chylectomy techniques. You want to dorsiflex the hallux during the bone resection. And I put this, even though the toe is slightly dorsiflexed, if you notice somebody's thumb is here, putting pressure down on that, probably to feel things. But the other thing that you're putting pressure down on is that patient's EHL. So there's subtle techniques that you can do to help mitigate and minimize the risk of these things, such as tendon injury. Uncontrolled osteotomies. I mean, I think that this can happen in the beginning if people are not careful. And so this is an example of a patient with a wet corn. And we all know that we've learned that you do usually a medial partial condylectomy to resect some of that at the fifth toe. And if you look, there's been this excessive destruction at this patient's IP joint on the baby toe, essentially because this was not well-performed. And I would argue, particularly in the beginning, when you're doing these osteotomies, DMMOs, lesser toes particularly, the C-arm, the mini C-arm, hopefully, is your friend. This is your eyes. And so you want to make sure that you're using this so that you are starting your osteotomies at the proper location, you're directing them in the proper location, and you get what you believe you're getting when you're making these cuts. Here's an example of a DMMO that was performed too proximal. And so what can that happen if the DMMOs are performed too proximal? The second through fourth metatarsal head elevation, the second and third toes are elevated, and you can see the calluses because of the transfer load under the M1 and M5 heads. What else is avoidable? Well, M1 shortening. When you're doing a bunion correction, a mica correction, mica, pica, whatever you want to call it, one of the original conversations with this technique was that it was inevitable to shorten. And that's not true. The surgeon is in control of where this head goes. Again, it's a two millimeter burr when you perform this osteotomy. So the surgeon has to adjust the hand to avoid shortening, lengthening, or whatever way you want to go. And for most bunion corrections, I want to maintain the length. Occasionally, I may want to shorten a little bit. That's not common. Sometimes I want to lengthen. You also want to avoid with this over-lengthening potentially over-tensioning the first ray. So it's very helpful to use your second metatarsal as a guide to help you translate this over. And so, again, this is something that I think the surgeons need to practice to be able to have a predictable position where they're putting that first metatarsal head. What about the avoidable complication of fractures when you do these MIS bunion surgeries? So this is a very early, early practice MIS bunion. And you can see the screws are distal if you're looking at that. And when you look at the two-week post-op visit, okay, head's translated over. And when the patient came back at six weeks, the head is right back where it was before. The screws are sort of rotated and clearly fixation was lost. And the problem with this was, if we look at the original X-ray on the left-hand side, that screw was placed too close, if not right at the osteotomy. So the key to fixation, if you're doing percutaneous distal metatarsal osteotomy surgery to correct bunions, is you need that lateral bicortical screw. And that screw needs to exit at least a good centimeter out before it engages the head in order to have that strong stability that we were just talking about. So you can see that there. Another avoidable malunion dressing. So most of us here in North America, when we do Aiken osteotomies, we fix our Aikens with a screw, but elsewhere, many times they actually treat their Aiken osteotomies or hold their Aiken osteotomies just like they do their lesser-chosen DMMOs with dressings. And poor dressing technique, in this case, shows you develop this dorsiflexion malunion at this Aiken osteotomy. And on the right-hand side, this is showing you a series of two through four DMMOs that were performed. And if you look, they're angled to allow the heads to translate lateral. And as these metatarsal heads heal in that lateral position, that's how patients who do not have bunions develop bunions, and or if they had a bunion correction will likely develop a recurrence. So again, these are all malunions that are usually with technique or proper dressing avoidable. And so this is just a little nice sawbone explanation with the DMMO, how to avoid these, whether it's the right foot or the left foot. Most times, unless we're specifically trying to translate the head lateral, most times we're trying to avoid this. So you're either trying to have a perpendicular osteotomy and or even angling it such depending upon which foot you're doing to help minimize that lateral translation when you're doing this. Again, as I mentioned, bad use of dressings, unless it is rigidly fixed that we typically do with our bunions. So for our DMMOs, our bunionettes, our lesser toes, we are using our dressings in the first two to six weeks to help us hold the position we have. And so again, bad use of dressings will result in these bad complications. Painful hardware. I think that this was a bigger conversation a couple of years ago than it is now. If we look at the early MIS publications, they noticed the highest complication rate of anything was the need to remove these prominent screws. So again, current hardware design minimize that occurrence, especially if you're doing the technique of the distal metatarsal osteotomy, there are screws developed to be able to accommodate this extreme longitudinal position with the beveled head. Nerve injury. Nerve injury is most avoidable if you use correct technique. So again, this is looking at a lateral soft tissue release. The beaver blade is being introduced, and studies have shown how close we are to those nerves in between in the web space. And yet, as long as this beaver blade stays parallel to the tendon in this position and only rotates once this is in the joint, then the risk of injuring that neurovascular bundle on that side is almost unreportable. So again, beaver blade and its position and how you use it is also very important to avoid these complications. Early hallux valgus recurrence, which I guess you could argue is not unique to MIS, but I think when you first start using the MIS techniques, you have to make sure that, you know, same with TRU with OPEN, bad technique will result in bad results. So again, as I mentioned, inadequate lateral bridge, this will fracture, the head translates back over. Oftentimes that doesn't recur, but that patient will heal very short, and many times you have problems with transfer metatarsalgia. Inadequate reduction, maybe unrecognized underestimated arthritis or an unreducible MTP joint. Poor patient selection, maybe you picked the wrong surgery, MIS or not. Compliance issues, probably poor protoplasma. I think one of the biggest thing is bone density and bone health. So when I, you know, patients ask me who, or, you know, surgeons and my fellows ask me, who do you not do mycosis on? Bone quality is one of the big ones. If they have pretty significant, they come in and it's not an age thing, it's a health thing, it's x-rays. If they come in and if you look here, that lateral cortex is super thin. I hesitate because here's a patient that I did earlier that I placed my screws, I placed it a good centimeter before the osteotomy, I was all proud of myself. But if you're looking at that, you can kind of already see a little bit of a fragment there as if it fractured. And so here's this patient that came back, you can see where she broke through where I placed that screw, you can see even the proximal screw here rotated. The other one that I think, you know, I would challenge, particularly when you're early in the MIS techniques for doing this, is a more rigid arthritic deformity. They can be really difficult to reduce. And I think until you get really proficient with the percutaneous lateral release, you know, this is potentially somebody that you may want to be doing a more extensive open procedure. So now I want to finish with what we consider not true complications, but I think a lot of people knock them as complications when it comes to MIS surgery at the forefoot. Number one, a hematoma. Many times, a lot of surgeons, especially when we do our lesser toe corrections, we don't put sutures in these, we don't use tourniquet. We often put dressings, our gauze dressings that are wet. And so they'll absorb that blood, spread it out like a wick and dry. So don't be afraid when they come back for their post-op dressing that looks like this. In fact, this kind of gets a little stiff and acts almost like a little bit of a mini cast to the toes. And here's the kind of post-op dressing that way. The other one I want to talk about is a DMR, a delayed union. When you have non or unfixed osteotomies, this is going to translate into swelling. We know that. And so if patients have lesser toe corrections, DMMOs particularly are known for that. These patients have to be prepared, and other clinicians have to be prepared for the amount of swelling these patients are going to experience. And the other thing is the idea of a delayed union. You need to prepare your eyes, your radiologist, your colleague's eyes for the idea that DMMOs and lesser toe osteotomies are going to take a lot longer to look like they've healed, and they're going to have all of that bone callus that you don't typically see with rigid fixation. It's not unusual for a DMMO to show significant bone healing in about three months. And if we look at this retrospective comparative study, again, DMMO healing was greater than four months. They had greater edema, but similar outcomes and better range of motion. So here's, real quick, a patient of mine that I saw had a TTC fusion, four-foot pain, chronic ulceration. Here's my DMMOs of two through five. If you're looking at these, they look kind of fragmented, scary. He had a lot of swelling for the first three months. And then when he came back, this is about five months out from surgery. This is what he looked like before I did those DMMOs, and this is what he looked like afterwards. So be patient with these. They can develop non-unions, but you cannot call them non-unions before three months. Speaking of delayed unions, this is an example following out to six-month-lives. This is an example of a MECA that I did. This is actually an early one of mine. I saw her at pre-op. Here's her two-week post-op. Here's her at six weeks. She comes back to see me. Everything's looking good. She comes back at six months for her follow-up. I don't like what that looks like. Denies pain, though. She's doing things like belly dancing, biking. She had swelling around the first ray, but had no pain. So is it time for me to worry? And what I've learned with a lot of these MIS bunion corrections with screws, if you look, the screws are solid. They're not rotated. They're not backing out. Her head is in the same position. And more importantly, she doesn't have pain. And so she came back at 12 months, and you can see all of that bridging. All of her swelling resolved, and she had no other issues. So again, with MIS techniques, when it comes to the forefoot, there is a learning curve. We've all learned this. Cataveric training, repetition, start with easier procedures first to avoid some of the things I just talked about. Proper, proper technique. So appropriate skin incisions, plan the steps for the MIS osteotomies. And we talk about this. Performing the osteotomy is that step. How you displace it is important, and how you hold it is important, whether it's with screws or with dressings. And again, like anything else, proper indication. So don't worry. Be happy. Thanks, Becky. That was a great talk. I definitely have had some of those delayed unions, and they can be harrowing at the time. And definitely trying to talk the patient out of worrying, and it's lots of hand-holding in the office. All right. So now I've got my talk. Let me share my screen. I'm talking about the lesser toes. All right. So this is my talk. I'm talking about lesser toes, particularly the issues of stiffness, floating, and recurrence. These are my disclosures. So the lesser toes can be deceptively tricky. They're very small bones. It's really best to get it right on the first try, because if you don't, then it can be really hard to address. I'm a big proponent of minimally invasive procedures, which can be your friend, especially when trying to avoid stiffness. But there are definitely limitations. So we all know that forefoot surgery has a high rate of complications. Can you share the screen as a presenter mode? Oh, yeah. Right. There we go. Better? Good. Okay. So we all know that forefoot surgery has a high rate of complications. So PIP fusion in several studies has been reported to have up to a 13% complication rate and only 84% satisfaction. An original study by Coughlin showed a 19% rate of nonunion, and he cited malalignment and numbness as the major factors in unsuccessful outcomes. So malalignment we can control, numbness to some degree, but sometimes not. Flexor to extensor tendon transfer, there's one good study on this, only 13 patients, however, again, highlighting how little there is in the literature on these procedures. In this one study, there was a 38% rate of mild residual pain and 92% satisfaction, and stiffness was the major factor in unsuccessful outcomes. Another reason to favor minimally invasive surgery is because you generally tend to get less stiffness. In a study on the wild osteotomy, they found a 36% rate of floating toe, 15% rate of persistent metatarsalgia, and 7% rate of transfer metatarsalgia. And again, these are relatively few studies with few patients, we really don't have a ton in the literature, but I think what we can say from both the literature as well as surgeons' individual experience is that there are a lot of complications with these surgeries. So percutaneous surgery seems like the answer for a lot of things to help avoid a lot of those complications. I do love percutaneous proximal phalanx osteotomies, I think these are really great for angular malalignment. There's one good study on this that I could find that had 40 cases where they did a percutaneous osteotomy of the proximal phalanx to address residual valgus at the second MTP joint after bunion correction, and in this study there was greater than 90% satisfaction, zero non-unions, zero infections, and about 5% recurrent deformity, which seems acceptable for all the other benefits. Distal metatarsal minimally invasive osteotomies, or DMMOs, which Becky talked a lot about, these have great results in the literature, but I found them very hard to control and they take a long time to heal, and I feel like every time I've done these I've been a little disappointed, so I generally steer clear of those myself from now. Intramedullary implants, these have some attractive features, so the use of intramedullary implants for PIP fusion have been associated with increased patient satisfaction as well as higher fusion rates, however they can be complicated or difficult to remove, especially the ones that aren't just like a screw, so if I'm using an intramedullary implant it'll usually be a cannulated screw. Situations in which I like an IM screw, if I'm trying to shorten the toe it can be harder to get it to heal in that scenario, so that's a case where I'll favor a screw. If you're doing a revision for non-union, sometimes a patient will have strong preference for an intramedullary implant, and if you're using an IM implant there really has to be no need for reduction at the MTP joint because it's very hard to get a wire alongside the screw, and you could use the wire that comes in the screw, but then it's a very small wire at high risk for breakage. You can see this case I had on the right where there was a non-union, a symptomatic non-union at the PIP joint. I really struggled to take out the screw and in the end could not get the whole screw out without breaking the toe, but I was able to get it out just enough that I could redo the PIP fusion. In lesser toe surgery I've found that post-operative self-directed PT is critical, so I always spend a lot of time talking to patients about this stuff in the office. Two weeks post-op I'll have patients start independent intrinsic strengthening. The way I have them do this is just while they're standing in their post-op shoe they'll try to plantar flex their toes while keeping them straight at the DIP and PIP joints. And this is a really simple exercise, you know, you just kind of push down and hold for 10 seconds, but I think that's helpful. And then six weeks post-operatively I'll have them start gentle stretching and plantar flexion at the MTP joints, no dorsiflexion. So this is usually the point at which I have them transitioning into sneakers. So, you know, I always tell them that they'll naturally get dorsiflexion from walking, but there's no natural way to get plantar flexion and it's essential to get that plantar flexion motion back so you don't get a floating toe. And then at 12 weeks post-op I really have them be more aggressive about this stretching. I emphasize the importance of doing the stretch multiple times per day, holding for 20 seconds at a time, and they really have to stretch to the point of discomfort to get an effective stretch. And I've really found that the patients who are better about this stretching overall tend to do a lot better. So to go into some cases, so windswept toes, this is a relatively common thing that you can see either primarily or after a surgery. So this is a patient who had a bunionectomy done elsewhere and had this complication of her toes drifting over and getting the second crossover toe, which is quite painful. So I did a first MTP fusion, I did second and third metatarsal shortenings, I do a macera osteotomy where you slightly dorsiflex the metatarsal head in addition to shortening it, and percutaneous second through fifth toe osteotomies. So for those lesser toes with that big windswept deformity, all I did was the percutaneous osteotomies. There was that big crossover toe, but once I shortened the second metatarsal, that toe really came down a lot, and I was able to get the rest with the percutaneous osteotomy. So all of those individual toes, you can imagine doing open procedures for all of those, which would be a total nightmare. But this ended up being a relatively fast, easy procedure. You can see the postoperative dressing here holding the toes very snugly in place. And then these are the postoperative x-rays. So you can see the really good deformity correction that we got at six weeks, and there's a little bit of recurrence by three months. You can see the osteotomy sites are healed, and on the clinical photo you can see there has been a little bit of recurrence of deformity, which I think happens relatively often, but I haven't really seen them progress much further than something like this. This is another case of these kind of windswept toes. You can see pre-op to six months post-op, and again this is a case where that second toe was really elevated, and I was able to get it down with basically just that osteotomy and the second metatarsal shortening. This is another case, 73-year-old female who had a new bothersome toe flexion deformity after a hammer toe correction eight years ago. You can see those toes curled, and she's also got arthritis at the second MTP joint. And she really wasn't having any pain at the first MTP joint, so I just did a really big ache in. You can see I actually ended up breaking the lateral cortex, but I got a pretty relatively big correction from that ache in. I did a second metatarsal shortening, I revised the PIP fusion, and did a flexor to extensor tendon transfer to bring the toe down. And you can see pre-op to post-op the improvement in the flexion of the toes from this, and even though she still has quite a bit of arthritis at the second MTP joint, she's very happy with no pain. This is another woman who had a malunited second PIP fusion. This is why it's really important when you're doing PIP fusions to get the toe in just the right position the first time. It's very easy to dorsiflex through the PIP joint or even translate the middle phalanx dorsally so that the proximal phalanx is very prominent plantarly, which can cause a lot of pain. You can see in her x-rays here how that second toe is really dorsiflexed at the PIP joint, which was the main source of her complaints, in addition to the recurrent bunion. So I planned to do a little plantar wedge resection osteotomy. I did this through a dorsal approach. You can see here were her initial post-operative x-rays after the MTP fusion. I also shortened the second metatarsal. And you can see the improvement here from pre-op to post-op and how that toe is now sitting in a much better gently flexed position. And she was very happy. So this is a woman who came in. She'd had a failed first MTP arthroplasty, and she had this really painful second toe with the other toes crossing over immediately. And it was really the painful rubbing of the toes that was causing her the most pain. I did a first MTP fusion with allograft interposition, and then I was able to get away with percutaneous osteotomies of the other toes for a deformity correction. So even with that big deformity of the second toe, again I was able to basically correct all of that deformity with just one percutaneous osteotomy of that toe. And you can see the nice correction from pre-op to post-op. Of course, her foot looks great, but then she was continuing to have some pain, and she had a nonunion at the first MTP joint. So I still have to deal with this. This is another one. 81-year-old with multiple surgeries presented with great toe pain and painful lesser toe deformities. And this is one of those cases where you just look at the foot and you're like, oh my God, what do I fix? So I think in these cases, it's really important to focus in on what's really bothering the patient. What do you have to fix, and what can you leave alone? So I really spent a lot of time drilling down on where most of her pain and symptoms were coming from. So of course, you have to fix the recurrent helix valgus to address the toes, and then I just addressed the other things that were bothering her. She was having a lot of metatarsalgia, so I ended up resecting the second and third metatarsal head so they would match with the short fourth and fifth metatarsals. I took out the arthroplasty at the fourth MTP joint, and I redid the PIP fusions at the second and third toes. And six months postoperatively, she was doing very well with no pain and happy. This is a really challenging case I dealt with recently. This is a 41-year-old, very nice, normal person who had a lot of bad things happen to her. She originally went to surgery somewhere else for lesser hammer toes. Six months postoperatively, she just mentioned vaguely that she developed nerve pain and underwent further surgery after that which resulted in a wound dehiscence and infection, and this infection was quite hard to treat. She was in the IV antibiotics for a while and then presented to me once the infection had been cleared, complaining of metatarsalgia, pain at her lesser MTP joints, and very limited in her activities. And she does have autoimmune disease and on immunosuppressants. So these were her initial x-rays. You can see pretty severe arthritis which kind of looks erosive at the second and third MTP joints, and she was extremely stiff at those joints. And so the question was how to both relieve her pain and restore better function. And so in this really young, active person, I was really hesitant to do metatarsal head resections, which I felt like was probably the most reliable option, but I really didn't want to do that for this young, active patient, and she wanted to try something else as well. So what I did is I opened and debrided both the second and third MTP joints. I did a third metatarsal osteotomy. You know, both metatarsals, they were already kind of elevated, so I didn't want to further shorten them. And then I ended up putting umbilical tissue graft over both metatarsal heads. And then I did fourth and fifth percutaneous proximal phalanx osteotomies for realignment of those toes to get them out of the way. And you can see here are her six-month post-op x-rays. You can see the fourth and fifth toes are out of the way. I think the second MTP joint looks a little bit better. Third, not so much. But she was overall better than pre-op, still stiff, still having some pain, but more active than she was before. Unfortunately, nine months post-op, this is just a few days ago, she comes back having worsening pain for two months, pain at the second and third MTP joints, and really unable to be active at all due to severe pain. And so unfortunately, she is now scheduled for lesser metatarsal heterosections. So just kind of illustrates how humbling these surgeries can be. So in summary, for the lesser toes, it's really best to get it right the first time. You really want to be as meticulous as possible with these surgeries. I love percutaneous osteotomies for angular realignment and mild elevation. These patients have a lot less stiffness than with open procedures, and you're much less likely to have those thorny nerve issues compared to open procedures. You always have to make sure first MTP deformity is addressed. Post-op stretching at those lesser MTP joints and plantar flexion is critical. So I think this is something that's a big contributor to success. And finally, adjusting patient expectations is also critical. These patients with these mangled lesser toes have to know that the goal is pain relief, not perfection. And I think if you're good about adjusting those expectations, you're more likely to have more successful outcomes. All right. Thank you. So I guess we can go into some questions. Let's see. I think we had some questions that were already answered in the forum. Let's see. So Scott Ellis answered most of them. Should we go over the ones, Chris, that were already answered? I mean, I think if there's one that you want that's interesting, go for it. I was going to ask Becky, do you do the cooling, like the cold fluid when you do the burr? Yeah. So most of us use a burr attached to a pencil driver that already has some irrigation on it. The irrigation setting I have on that is actually pretty low because if you put it at 100%, that thing is shooting up on the ceiling and contaminating your sterile field. But in addition to that, yes, I do. The saline that I have on the pencil driver is in the fridge. Then I have just routine saline in big 30C syringes. I take 16-gauge angiocaths and have them cut off so that they're kind of blunted. And they're just constantly irrigating. And they know to irrigate, like when I stop the burr because the pencil driver stops irrigating, you just keep irrigating. And so with my FORPA MIS cases, I have one of those cystoscopy drapes that they clamp onto the thing to literally just collect all of the fluid, both saline and blood at the time, because I probably have just as much fluid on the ground as I would have with a scope. I think it, I believe it. I think it makes a big difference. It's not going to get deep. So if you think that all of that irrigation is gonna help you, if you're not, you know, stopping intermittently and taking your fluid out for the bone temperature, but I do think it makes a big difference, superficial. Yeah. And Scott, I was, I know you might have to jump off quickly, but if you had a sensor there, you know, you showed some of the cases with you having some varus after a, after a lapidus. What, how are, I mean, we had a great talk by Bobby. He had to jump off or lost connection or something, but what are you doing to address those? What's sort of your algorithm? Because, you know, the fusion of the TMT and the MTP is sometimes a little controversial. Yeah. Okay. Good question. So the question came up also, can you fuse the MTP after a TMT and get away with it, if you will? And I have, I've fused it and really not seen too many problems. I think the first TMT is a non-essential joint. And so fusing the TMT, the MTP distally, sequentially is not been a problem. I've seen some colleagues even present cases where they do a concomitant TMT and MTP and it hasn't been too much a problem. I mean, I think in general, we should try to avoid it, but I haven't not seen a huge problem. There are ligamentous reconstructors that you can do. If it's flexible, the most predictable by far is to fuse the big toe joint. And I will tell everybody, and I tell all my patients, my mom had the same thing. She had an overcorrected bunion. I didn't do it. MTP fusion. And she's like incredible. And so if it's good enough for my mom, it's good enough for anybody. Now, one other thing, and Becky, curious to hear your thoughts. There are cases also where I feel like I've almost overcorrected the lapidus and I'll have Holly help me. And maybe Liz, you can comment too, where you do a MYS to actually reverse the metatarsal head the other way a little bit. And that, because one of the causes is overcorrection that I'm angle. So take the metatarsal head back the other way and maybe do a soft tissue reconstruction at the same time. And that has salvaged a few of my overcorrections. Agree. I've done that. And I've also done occasionally lapiduses that maybe I didn't, I thought I did, but the IMA wasn't well reduced and they'd gotten a recurrence. And I've done the MYS distal osteotomy to kind of get the further correction. So I've done it both ways. So Scott is kind of your go-to for a recurrent lapidus to just fuse the first MTP joint. Yeah. You know, our colleague Matt Roberts says patients will allow you to operate them on them twice, but not three times. And the MTP, and I think people probably heard me say this, they actually function do quite well. And it depends on the age of the patient, but I just feel like they do well, regardless. You have to, women with it have to accept that they probably won't wear a high heel, but it's such a predictable way to fix the varus. And it's just, the problem is done and they generally heal very well. So I've been really happy with it. Yeah, I totally agree. And the link in the reconstruction are hit or miss. Go ahead, sorry. Yeah, I totally agree with first MTP fusion, just a very reliable surgery, especially for older patients. I'll even try to encourage them to do that. I don't know if Bobby is still there, but you know, one of the other panels can answer as well. For hallux varus, you know, I feel like the reconstructive options are a little unreliable. How much are you kind of going straight to first MTP fusion? And what are your, I mean, I feel like I have very strict criteria if I'm going to do a reconstruction. They have to be very flexible, you know, no arthritis, like perfect motion. How do you guys think about it? Even if they have all of those things, I tried talking them into a fusion. But no, I mean, all kidding aside, you're going to run into patients that are not going to be down with fusion and they've got the motion. So you take that risk with it. I've had some successes and I've had even ones that look great fail afterwards. But same for you. I mean, you have a very small incidence of non-union at your MTP fusions. So if they fuse and they're in the position you have, it's just a much more predictable surgery. So you can also, you know, discuss that with your patients as well, but you're going to have plenty of patients in your practice that are just not going to accept the fusion. Yes, that is the case. And as far as like reconstruction material, like a tight rope, do you like those EHL things he was talking about? I mean, it seems very complicated to me and like a very involved procedure. What's your preferred technique? I have done the last two I've done. And the key for me is, is I have a very low threshold to correcting a bony deformity as well. So we always talk about that with bunions, you know, you don't just rely on soft tissue correcting you, you have to correct a bony alignment issue. So I have a very low threshold, whether it's to widen the IMA a little bit, or reverse Aiken. But then I've been using the internal brace as my sort of collateral ligament reconstruction. Good. I just think you need something biologic too, Becky. Maybe it's that there's scar tissue that heals in around it. Yeah. But when I first started practice, I read in the Roger Mann textbooks, you could take the EHB and use that to reconstruct. I tried that a few times, it was okay. Or you could take a slip of the EHL, but I just feel like something biologic would help too. There are all these new biologic materials that you can use for ligament reconstructions. I don't know if I'm supposed to mention them by name, but there are several out there, but they all resorb over a period of time, whether it's like one to three years or something. And I always worry about what happens when they do resorb. Are you actually going to have good, viable ligamentous tissue there, or is it going to kind of fall apart at that point? No. I guess that's something we'll have to wait and see. I did have another question. Becky, I wanted to know your tips for MIS bunionectomy when I feel like I've had several of these cases, especially in men who tend to be a little stiffer, not arthritic yet, just big, stiff guys, where it's really hard to shift that head over and get a good correction. So what are your kind of technique tips for dealing with that situation? I think one of them, the more rigid, even if they don't have arthritis, the more rigid the deformity, don't aim, I accept a little bit of loss of length because if I sit here and try to get my length exactly where it was, they're just as rigid and stiff as they were. So they tend to be a little more flexible in their correction. And so if I just lose a little bit of the length, and when I say a little bit, like maybe a millimeter or so, and then it's a soft tissue release. You got to get comfortable with, once you've done your lateral collateral, once you've done your Chevron and you've fixed it, get comfortable with doing a little bit more of aggressive percutaneous lateral soft tissue release. And that takes practice just like any of these other ones to make sure that you are not just releasing the lateral border of the FHB and the adductor, but potentially the sesamoid, suspensory ligament and stuff like that. And even with all of that, I still, with some of them, it is hard, but you know what? That was hard to correct with the scarf and stuff like that for me. Some of these with, they're not arthritic, but they're rigid and big bunion deformities. But the beautiful thing about most of my guys is, you know, the correction I give them, they love. Yes, I have noticed too, that even if, you know, cases where I've been unhappy with the correction and there's a little bit of recurrent bunion, you know, they still tend to be happy. Exactly. Exactly, yeah. That was good. We have a few questions from the audience as well. I think the first one here is for you about when doing your PERC osteotomies for lesser toes, can you describe a little bit of your technique? Where do you do your incision? How do you decide the angle of your osteotomy is medial to lateral, dorsal or plantar? Yeah, so really where you put the incision totally depends on what kind of osteotomy you're doing. So if it's purely for angular correction, you know, if the toe is in valgus, then I'll make a straight medial incision and then I'll do a medial wedge resection to correct that. I know some people come from the opposite direction, do a complete osteotomy, so it'll kind of slide down medially, but I like doing the closing wedge osteotomy. So an oblique medial wedge osteotomy and then complete it manually. And usually it completely completes and then you can kind of put the toe wherever you want it. And then the toe should be, after you complete it, the toe should be sitting kind of in the position that you want it to be. So you put the toe in the position you want it and then you put the dressings on to hold it in that position. If you're doing, if the toe is slightly elevated, then I'll cheat the incision more plantarly and I'll do like a plantar medial wedge resection. So it's really totally based on the deformity, but I like to do an oblique osteotomy. It's kind of right at that metaphyseal part of the proximal phalanx angled so that you get more surface area for healing and then close it down manually. And then I think the other one was for you as well, but in the 41-year-old with RA and SLE, would you have, in retrospect, tried met head resections on the first time for the surgery? Or would you have, looking back, would you have changed your thoughts on that case? Honestly, I think if she presented to me the same way a second time, I probably would have done the same thing again just because of how she was. I could tell that she was not going to be happy with the metatarsal head resections. And I think now she will be because we did try to save the joints at first, but she was just like too active and too high expectations. So we were really trying to go for the home run. It was definitely the less reliable option. Of course, knowing in retrospect, or knowing now what happened, I probably would have just done the metatarsal head resections, but you can't tell the future. And I did think there was a chance for success with that route. There's a question for MIS techniques. Do you have any experience with more than 100% translation of the metatarsal head? This is probably a better question for Becky. No, I mean, I probably, I have plenty with like literally touch the corner to the corner, so 100%, but I don't typically, I've not done more than 100%. Honestly, if I need to do that, that patient's getting a lapidus in my hands versus that of a disalimented tarsal osteotomy, but I have done them up to 100%, but I want the corners to the corners to touch. Yeah, I sort of agree with that. I did have a case recently where I think there was unrecognized first TMT instability. I thought she felt stable preoperatively. There was no indication of instability on the x-rays. And then when I took her in, the head just shifted an unbelievable amount. It was more than 100%. And I sort of freaked out because I wanted to have the bone contact. So I did sort of that corner to corner contact that you're talking about. But then of course I asked my colleague, Holly Johnson about it later. And she told me that she'd had multiple cases where she did translate it more than 100% that have healed. So I think you can do it, but yes, I agree that if it's going that far, then I feel like probably that that's a case that should have gotten a lapidus. I think a part of that reason too is it takes much longer to see that healing happen. And even if they heal, that's great. But if it takes, if you're looking at somebody and they still have some swelling and you're restricting some of the activities, six months, seven months, eight months out, that's really where I, I haven't had failures with my 100% greater than when I used to do just 60% early on and stuff. But it's the length of time it takes for it to heal. Yeah, and that's sort of been my concern with the GMMOs too. I know that I can get the Y alarmisera osteotomy to heal predictably pretty quickly. And I put it exactly where I want. And I just really worry about those DMMOs. You know, you're watching them look like they're not healing for a long time. It's just stressful. Yes. Liz, one question is what, any tips or tricks for doing both MTP and TMT fusion on the medial column? So if you're doing a lapidus and combining it with a first MTP fusion, any thoughts on that? I don't know if you've done a whole lot of that or not. Yeah, I've never done both at the same time, but I have fused the first MTP after the first TMT has been fused. Yeah, I think you can do it both at the same time, but I don't think there are that many cases where you really need to. I don't know if either of the other panelists want to comment on it. I've done it a couple of times, a handful of times, and it's always been for like somebody who has arthritis and that's very symptomatic in both. And for me, they've been very happy doing it and they haven't noticed overly stiff medial column. That being said, I think it's just, you have to be even more careful with your joint position because you're not gonna have any sort of wiggle room. It's not gonna take a joke at all. And so those cases take me much longer than when I'm doing it separately because I really want focusing on getting the lapidus perfect so I can get the MTP perfect. I just don't think there's a lot of room for error there. And that's the only sort of tip I have is start proximal and go distal. So Chris, do you find that maybe in the sagittal plane, you fuse it just ever so slightly more elevated since they don't have that TMT wiggle room? At the MTP joint? Yes. I probably, yeah. So I usually, with the like flat plate test, I'll try and get the toe to rest on it. And when I have done this, I've brought it up just a little bit so it kind of a little bit rolls off the front of the foot more. Same here. Yeah, I just feel like it's so critical to get that first MTP joint in the right position. I think I love first MTP fusions. I think they're super successful surgeries, but it's just so important to get that toe in just the right position, because you get it wrong and people will be unhappy. I agree. I like the fat pad just kind of gently resting on the flat plate and so that you can still dorsiflex it a little bit. And actually I sort of do the same thing if they've had a previous first TMT fusion, but yeah. All right. What other questions? Comment here was sort of from Dr. Shah. In India, we see lots of Halox virus. We see more Halox virus than Halox valgus and we tend to salvage joints more commonly than the Western world. And that he will use an abductor hallucis for the correction of the virus. And it's been very satisfactory in his unpublished study. So I will answer that. I think that's very interesting. I don't have a lot of experience with it and I would encourage you to put that together and publish it and teach us more about it. I would welcome learning more about what you're doing there. And if there's more Halox virus that you're seeing than Halox valgus, understanding what the demographics and sort of etiology of that is in your population, I think would be really important to understanding how best to fix it. We're obviously giving a very American centric view of the foot pathology that we're seeing, but perhaps you're seeing something different. And if you have other thoughts or comments, Liz, I'd welcome them. I just think, I mean, there's so many interesting procedures you can do in foot and ankle. And I feel like we do relatively few of them or hear about relatively few of them, but there are obviously lots of different ways to do things. I think it sounds cool. I did one of those with Dr. Meyerson as a fellow and it worked actually very well. It's a lot of surgery to transfer that abductor around underneath and attached to the proximal phalanx, but it worked. One thing that I think is always interesting is what you see in the literature doesn't always correspond with your personal experiences. And one area that I feel like that's true, and I'd like to get your comments is with plant or plate repair. I feel like every plant or plate repair I've done has not worked out well. And for that reason, if I need to bring a toe down, I'll use the Flexor Nu Extensor Tendon Transfer, but you read everything in the literature about these amazing results or pretty good results with plant or plate repair. What are your guys' thoughts on those? I would say the same thing about plant or plate repairs. I mean, it's no different than all of our collective experience with CARTIVA, right? We just didn't get, and you have to be honest with what you're getting from your results as well, just like you said. So I have very, very strict indications of the patient I may do a plant or plate repair on now because I just, I didn't get the outcomes that I was reading. Yeah, agreed. I think plant or plate is still my least favorite surgery that I've done for those reasons. I think they're footsie and some people have the secret sauce for that and maybe I don't have the secret sauce for it. Yes. Maybe you had a question about bunion correction surgery. What is the preferred order of steps, bony work and then soft tissues or in what order do you sort of think about it? I think it almost depends if it's open or MIS, so I'll throw that to you guys and see what you think. Becky, you want to talk about MIS? Sure, and I think Chris alluded to that. So when I'm doing an open, for instance, scarf osteotomy and I'm trying to shift the head over through the intracapsular in the joint, then the lateral soft tissue release is done first because a component of it is just simply whether you do an intra in the joint or from a separate incision in the web space, you need that in order to be able to translate your head. Very different from the MIS correction like the MICA because this is outside the capsule, this is extracapsular. And in fact, if you release all of that, you have less control of your head when you're shifting it over. So the principle of extracapsular percutaneous correction is the lateral soft tissue release procedure is done after your bony work, your metatarsal osteotomy. Some people will talk about doing the medial eminence resection before. If you know you need to do a percmedial eminence resection before, it's probably easier to do it before you shift your head just because of the hand position. I mean, if you shift your head over 100%, it's very hard to lay that bird down on the head almost tangential if it's over 100%. It can be sometimes difficult to predict that in some people with smaller things because when you shift the head over 80 to 100%, what seemed like a very prominent medial eminence is no longer prominent. And so, just takes a little bit of experience with that. But I think as Chris mentioned, open oftentimes a lot of the soft tissue procedures around the bunion correction is done first before the bony work. But particular with the percutaneous MIS, you wanna make sure that you leave the lateral soft tissue structures inherent intact, don't touch that lateral collateral ligament when you shift that extracapsular osteotomy over. I do get nervous doing MIS, doing the lateral release after the fixation is in because I worry I'm going to displace it or cause a problem. But I have not, I think I am very, I probably don't do as much as I probably could for that reason. Yeah, I do very few with MIS. But usually if I'm doing a lapidus, I'll still do all the distal stuff MIS. So if I'm doing a lapidus, for instance, I'll do the medial eminence resection first, and then I'll do my lapidus and then I'll do the Aiken later. Yes. So it's nice to combine different techniques. And I think even if I'm doing an MIS lapidus, I'll do the lateral release first because I think that then lets the toe move out of the way. So I just think it's sort of different philosophies and different ways of doing things depending on what technique you're going to use. And in my fellowship, some of my mentors would rarely do any bony work. They would do everything through the soft tissue release and medial invocation, and then they would put a tight rope from the medial to the second, from the first to the second to hold that in place. And I have to say that, although I don't do that anymore because I'm so much more into the MIS side, I do think forcing yourself to learn how to do it that way and rely on those soft tissue restraints made me a better bunion surgeon. So I think you can get very nice corrections through multiple different techniques here. I, yeah, that's an interesting point. I have done several MCL reconstructions in patients, like young patients who injured them, like doing sports or whatever. And I wonder, should we be doing that more for people with bunions, regular bunions? Yeah. Interesting. Another question, have had recurrent talus valgus after doing MICA and DMMOs at the same time. Any thoughts? Becky? Where are those metatarsal heads? Because I, like I mentioned, I think it is not difficult for those metatarsal heads to shift lateral unless you're careful with your osteotomies. And if they're shifted over even slightly lateral, once you've done your hallux valgus correction, you will get a recurrence of your hallux valgus deformity. Do you ever do isolated DMMOs or are you always doing at least two through four? If I do DMMOs, it's two, three, four. I have played with the distal interdicmo, they call it. So it's inside the joint, which is far less shortening. It's more for just transfer metatarsalgia, but then you can, because you're not getting that excessive shortening and it's more controlled as far as its position, you can be isolated. But the majority of the ones that I do are DMMMOs or they're variations and there's usually multiple ones. The only time I do an isolated DMMO is if it's for a bunionette. Great surgery. Yes. If there's one surgery that somebody should just adopt right away. I used to hate when patients came in complaining of bunionettes and now it's like, sure, sign up. My OR staff gets mad at me because these cases are so fast. I'm done. The dressing's on. They haven't even started logging the case in yet. Yes. The only problem I've had with that case is I had one patient who was profoundly unhappy. She wasn't having any pain, but she was profoundly unhappy because her fifth toe ended up elevated. What happened to the head? Was it that? Did the head go someplace different? I mean, the head looked okay to me. That's the beauty of follow-up. Yes. Well, let's take this moment to say thank you to these excellent panelists and Becky is the last man standing here. Thank you. You are welcome. And amazing talks as always. So thank you. But we will move on to the next panel. And so I will welcome some of my Boston friends here. So our next panel will be talking about malunions and malalignments. And we're going to be talking a lot of trauma today and tomorrow in these next sessions. So I'm really looking forward to this because these are some of the people I look up to and ask for help when I need it. And that's why I asked them to join us for this. So talking about calcaneal malunions is my close friend, Dr. John Kwan from MGH. And I will flip this over to you. Thank you very much for joining. Hey, thanks, Chris. Thanks for having me. Let me go ahead and share my screen here. Not my email. Can you see my screen? Looks great. All right, great. Well, Chris, I want to thank you and the co-chairs for inviting me to give a talk. Chris has been my on and off again practice partner for many years. And he is one of the most innovative people that I've had the pleasure of getting to know. And Chris has taught me a lot. So thank you, guys. So I'm going to talk about calcaneal malunions. These are my disclosures. My senior partner, Christy Giovanni and Dr. Richardson gave me a couple of the slides for this. But there are only a few etiologies for calcaneal malunions. And I think you could argue that improper correction via calcaneal osteotomy is technically a malunion. But really, most of these are secondary to intraarticular calcaneus fractures. And we know that malalignment of the calcaneus leads to significant problems with gait and function. And while we talk about conservative treatments in the form of bracing or orthotics or posting the foot or things like that, there really is limited options for that. And so when we think about surgery, I think we really have to think about 3D anatomy, thinking about intra and extraarticular pathology. And we certainly can't forget about the soft tissues when we're dealing with these type of injuries. Now, you know, arguably, the best way to avoid a calcaneal malunion is to get it right the first time. And, you know, I have a strong clinical and research interest in lower extremity trauma, but I do think that nearly every calcaneus fracture, you can justify some type of operative treatment as long as you're mitigating risk. And so I think we're familiar with this study by Sanders, but basically he wanted to look at what happens to patients who require a subtalar arthrodesis if they have initial operative treatment or they're left with a malunion. And, you know, when he was able to correct the varus, poster facet height, axial alignment and whatnot, they did better after their subtalar fusion with higher AOFS score. So you can make an argument to, you know, try to avoid a calcaneal malunion in the first place. But of course, you know, these don't always go well, and even well-intentioned surgical treatments can lead to advanced subtalar arthritis and problems. And, you know, one of the common things that you see when you look at all these images is depression of the posterior facet, early subtalar arthritis and anterior ankle impingement. And you know, Tyler Gonzalez, when he was a resident with us, did a study some time ago, and we wanted to look at settling, whether it was operative or non-operative calcaneus fractures, and we found they settled about six to eight degrees on the Bowler's angle, and there were certain risk factors. So, you know, I think, and this isn't a talk on calcaneus fractures, but I think anything that we can do, you know, whether it's filling the void under the posterior facet, different types of fixation to prevent posterior facet settling will save us some problems in the future. I'm not really going to go into the anatomy of the calcaneus, but, you know, I think we do have to recognize how difficult intra-articular calcaneus fractures are, right? They're different from other articular fractures because we have multiple facets and joints, right? We got the anterior middle posterior facet, we got the CC joint, and all these joints are tangential to the long axis of the calcaneus. And unlike other articular fractures, whether it's the elbow or a pilon fracture, the long axis of the calcaneus is always involved where those other articular fractures, the long axis of the bone, is rarely involved, right? So this is what makes this thing really difficult. And the other thing that we know with malunion is that varus malalignment is really a problem, right? These patients are walking on the lateral side of their foot. You know, we know the lateral column of the foot is flexible, but the base of the fifth isn't, right? And so that's why they get stress fractures. They're walking on locked transverse tarsal joints, or they're walking on a rigid supinated foot. And we know that, you know, if you would choose between hindfoot valgus or varus, I certainly would take valgus any day of the week. So you know, I'm not going to talk much about imaging, but the truth is, is that weight-bearing CT scan has really opened my eyes to things that I wasn't seeing before, right? We know we have to get our standard x-rays of the foot and ankle. We could get, you know, Saltzman hindfoot alignment views. But this is a patient, a 35-year-old who had this intra-articular calcaneus fracture. And we went ahead and pinned him and fixed him and was having a lot of pain in the sinus tarsae area, right? So he's about six months out having a lot of pain. We all have these patients, right? And you know, I would say, well, yeah, you injured your posterior facet, you have cartilage damage, you hurt, right? But when you get weight-bearing CT scans on a lot of these patients, you see a lot of subfibular impingement that you simply can't see on other imaging studies, right? But the weight-bearing CT reveals this. This is another patient who had a bad calcaneus fracture, and I did a primary subtalar fusion. And he hurts in the sinus tarsae area, and he's six months out, he's walking on it, right? So where does that mind go? Does he have a nonunion, right? Is it the peroneal tendons? But we don't really think about subfibular impingement a lot, and I really think we need to be looking at this. You know, there's a handful of studies looking at the sinus tarsae versus the extensolateral approach and our ability to correct calcaneal width. And most of these studies say that there's no difference, but you know, in my opinion, I think width is challenging when you do the sinus tarsae approach. You know, the more weight-bearing CT scans I'm getting, the more I'm realizing that I got to do a better job with that. So you know, impingement from a wide calcaneus is one of the malunions that you're most commonly going to address. And I think the other common deformity is varus, and of course, loss of talar declination, and now you have anterior impingement. There's several classifications for this. Stevens and Sanders had talked about a type 1, a type 2, and a type 3, and it depends on the lateral wall axostosis, whether there's varus malalignment, and how much in subtalar arthritis. And you know, Ramalton and Zwipp, they included not just coronal malalignment, but sagittal malalignment. And you know, I, truth be told, do not know these classification systems very well, and I think that's because, you know, when I see a deformity, I don't necessarily think in terms of this classification. I think about the 3D anatomy of the calcaneus, right? And this is what we all do, right? Is it in varus? Okay, then how do I correct that varus? Do I have posterior facet loss of height? So how do I, you know, improve the talar declination, these sort of things? But I do think they give you a bit of a framework, and so I really try to simplify these. Do I have an extra articular deformity or an intraarticular problem, or both? Do I have loss of talar declination and anterior impingement? And do I have a patient who has anterior pain? Okay, you'll have a lot of patients who radiographically look like they should have a lot of anterior pain and they don't. You know, not sure entirely why that is. I think, you know, one of the things could be that these patients get stiff, right? So they get a tight Achilles, and so maybe they don't have all the functional dorsiflexion that you think they would need. But they have to be symptomatic in the anterior ankle if you're going to, you know, really dive into doing some certain procedures. And then, of course, always think about the soft tissue problems that come with calcaneal malunion or calcaneal fractures. And so, you know, if I have an extraarticular problem and I have normal talar declination and no varus, then I do a lateral wall exostectomy. Now again, this is probably the most common procedure that you're going to do. If you have a varus, then you have to correct the varus, right? So you have to address the impingement and the varus. And if you have arthritis, then you have to address the joint, right? So I don't think we need a classification system to kind of tell us these basic concepts in foot and ankle. You know, one thing to keep in mind is when you're doing a lateral wall exostectomy, it is way easier to remove a significant portion of that lateral wall to an extensile lateral approach. But some of these patients that we're doing this on, they can't tolerate that. So understand you can do this to a sinus tarsi or some other kind of extensile lateral approach, but it is much harder to really clear that large lateral wall blowout through a sinus tarsi approach. And then, you know, so if we have loss of talar declination and they're actually having anterior ankle pain, then we know to do a bone block subtalar orthodesis. I really think that if you're going to get a meaningful correction, you have to have a vertical incision. You know, I've talked to some surgeons that say, well, I do this through a sinus tarsi approach. And, you know, I think that's great. But then the question is, is how much correction did they get or how much correction did they need? Right. It's really easy to put these patients in VAERS when you're putting whatever material bone graft or what you're going to use. So that's really the challenge to prevent VAERS malalignment. And you know, there's all sorts of different graft materials. And you know, I think that I had a patient who had a three-time subtalar nonunion. And so, you know, I went right up to the crest, right, with the morbidity that can come from that. But I think you have to tailor what type of graft material you use to the patient. You know, one thing to keep in mind if you're going to use trabecular metal grafts, you know, very often it becomes a little bit more technically challenging because you either have to shoot through it or shoot around it, unlike some type of bone graft. So you know, this is kind of a typical case. You can see that I'm putting my elevator in just to kind of mark that I'm in the right spot. Then osteotomizing laminar spreader goes in. And one thing I like to do once I have my height, I'll put a heavy K-wire in just to hold it. And then I'll take my laminar spreader out. And I usually try to put that K-wire lateral so then I can go ahead and put my graft or if I'm using, you know, pre-cut wedges, I can put my popsicles in. But otherwise, you know, it can be hard to keep that open with a hinterman or things like that. You know, and then finally, you know, we have to think about the soft tissues as well. So it can be a little bit unclear sometimes whether it's the joint or the perineals or whatnot. So, you know, just keep in mind, just with like calcaneus fractures, patients can have perineal tendinopathy, they can have tears, they can have tendon dislocation. And the other thing too is, you know, after ORIF, be very cognizant of the patient who has medial pain, right, instead of the typical lateral pain. So this is an interesting case where there was multiple screws put in too long. I tried to take them out from the lateral side and they were all cold-welded so I had to go medial and you can see I had to burr off the tips of those screws and do a tendon repair. So, you know, pay careful attention to the soft tissues. And of course, you know, think about Achilles contracture, which many of these patients get after trauma. You know, whether they have injury to the tibial nerve or the calcaneal nerve branches and whether they have post-traumatic fat pad atrophy. So, you know, we know these malunions are really tough. There's really limited conservative treatments. Think in three dimensions, kind of simplify the process in terms of intra and extra-articular pathology and don't forget the soft tissues. Thank you. John, awesome talk. I always learn more about calc fractures from you than if I ever need one, I'm calling you for it to have it fixed. Next up, we have Dr. Mikulski from LA and Cedars and he will be talking about revision ankle ORAF. Thanks for joining. All right. Can you guys hear me? We're good. All right. So yeah, as Chris said, well, first of all, thank you guys for inviting me, Chris, Liz and Jacob. I'm talking about revision ankle ORAF. And so here are my disclosures. I have to admit one of my disclosures is a ankle fracture system, but I'm going to discuss a variety of implants and I won't really be mentioning anybody's name. Another disclosure is that I've been brainwashed by John and Chris. So I'm one of their, you know, they trained me a lot on this. All right. So it's not an all-inclusive talk about failed ankle ORAF, including fusion infections that would take hours, but I'm going to go through my process and then hopefully get through a couple of cases. I didn't realize how many I see, but these are just a couple I've seen in the last two months that I'm currently dealing with. So it is nice to have an algorithm, but I blurred mine that I kind of go through intentionally to start here. Patients don't present me off saying, hi, I'm here for my, you know, revision of my ankles, aseptic malunion. They come in, you know, hurting with some swelling after surgery and a part and part is to figure out how do you get to your different branches? So my office patients come in, they, you know, they've completed the intake form and either come with a disc or get films. I opened this chart, you know, they had a trimal ankle fracture six months ago and I opened up the images and this is the disc I see. So now I haven't seen them yet, but I've reviewed the ankle intake form and the imaging and my decision tree kind of starts like this. I want to know first off, what does a joint look like? Is this joint stays preserved? I'm thinking revision or is it eroding or I'm headed towards reconstruction. There's also a caveat in that comorbidities or age can push me over to the reconstructive side even with minimal joint damage. And this may be a diabetic on dialysis or 80 year old who frankly can't tolerate non-weight bearing. So that will also put me over there. And then the next question I want to know is, is it infected or not? And this is kind of really where the investigation begins because you can be tricked by this. So anytime you're seeing these patients for a revision surgery, you kind of have to, or poor outcome, you got to put on your detective hat. It's eyeopening really to find out how little these patients understand what their injuries and what their treatment was. In this situation, I often want to know, do they have an open fracture? Patients rarely know what that means. They might tell you it was a compound fracture, which they may think means comminuted or open or both. And you're not sure. I just simply ask, were you bleeding when you broke your ankle? It's pretty straightforward when most of them remember that or more drastically, did the bone stick out of your skin? Next again, did you have an infection? It seems pretty simple. Most people may interpret this as, are you currently infected or not? So I just ask, how many surgeries did you have? Did you get antibiotics? Which also for some reasons, I'm not sure, but it's confusing. And I'll say, did you have an IV in your arm getting medication? Because that's what narrowed it down for a couple of patients that didn't know, but they, oh yeah, I had this IV for six weeks. And then I want to know how did it happen, which gives me an idea about bone health, but can, you know, open up a Pandora's box about a minute by minute recount of the previous year. You know, it's fun working with trainees. I had one come in, closed fracture, malunion, no infection. I go in the room, I see kind of an S on the medial malleolus. And that's weird. So I asked simplified questions. Was it bleeding? Did you have an IV? Yes, yes. Oh, yeah. OK. Now I got the outside records. Eventually, yeah, it was an open fracture and they got an infection. Next, how do you, you know, I want patient specific factors. Did you have any falls while you were recovering? Is there a reason this happened outside of technical issues? Another one is, do they have diabetes and they may deny it because they're on medicine, therefore, you know, they don't have it. Instead, I ask, I look at a medication list and just ask, does your foot feel numb or asleep? And then almost always I perform monofilament testing. I just keep one of those in my pocket. And then I want to know about their bone quality. Have you been told you have soft bones? Do you take many medications or you've had a DEXA scan? And then thankfully, I don't see many smokers, but depends on where you are. And that may be a big issue here or for us, more so drug status. So I have these questions built into my new patient intake form, so I unfortunately seek quite a few revision type procedures and I find them helpful. What kind of support do you have at home? Are you housed? Do you have any help? Can you be non-weight bearing? And this is they have a variety drop down choice of yes, without any issues. Yeah, I can for simple tasks or no, I can't use crutches or a walker. And if I say I can't use them. Can your home be arranged to use a wheelchair? So if they can, if they say no to both of these, my options are pretty limited to anything that they need to be non-weight bearing for. And then final two questions are, you know, do they need surgical wound complications and diabetes or neuropathy? I move on to the exam and this is not all encompassing the exam, but more of the focal points. And I think the inspection is where you need to stop to look the most. Scars and incisions tell you so much and really raise red flags and something out of the ordinary. That's not a typical incision for ankle ORF. Next up again, inspection and part three inspection. Anytime you see transverse or S shaped incisions. Take a pause, look at it, think about it, because there's more to the story than what you think. Next, tenderness, you know, I don't assume that all the pain is from the fracture. This patient came in and I can see they have a nonunion and yeah, there's some pain, but most of the pain was at the tip of the fibula. And so when I did this, I opted to open up that nail site and actually fully open it. And I see, yeah, there's this tear on the underside of the brevis that I had to repair. Another patient, pain was much more severe than what I would have expected on the medial side, the screws seem like they were pretty well seated, but again, you can see in this tunnel, the arrow is, it went right through the tunnel of the post-tendon on the bottom side, there's some fraying. So you really want to know more than just the fracture site, don't get fooled by that. There's more going on if they have pain. Next, look at the range of motion, oftentimes they're stiff, but I also check for instability. Rarely are they unstable, but I want to know deltoid or elsewise. And then neurologic deficits, look at the main things, you know, where the incisions are, do they have SPN, is it out, is the SERL out, those are the common ones you'll see. And you don't want to, you know, be kicking yourself, did I get that or was that there beforehand. I always love adding pictures to the chart, I find it useful. I typically have no clue what I'm going to do when I first meet them and I'm looking at all this complex, broken hardware. I just take pictures, I put them right in the chart, and I can always reference it when I'm trying to plan my surgery later. Sometimes I'll even mark out my plan approach and add them to my note, and I'll, you know, CC my plastics colleague like this person who had a flap. All right, so on to the imaging, I get three views of the ankle weight bearing if they can tolerate it. Some will advocate for weight bearing and non weight bearing views, because there may be some subtle instability or malalignment. It's always a little easier to look at this patient and say, oh yeah, that failed, but it's really important to look at the details. Look at anything that's atypical. You know, I wasn't there, but I imagine this person had some difficulty in that medial malleolus. I don't usually see three screws in that small little fragment. If the fibula is left short, that medial mal is not going to bail you out and bring it back over, and that's really kind of where you get stuck. Also, I want to know, you know, the broken screws and do I recognize the implants. This wasn't an ankle ORIF, but I think it's a useful trick in planning. This was an extruded talus patient I was managing, transverse laceration laterally, and I didn't know what access I was going to get if I went back through that incision. Add some fiducial, you know, metallic markers of that scar and take some new x-rays. Now I know exactly where I can get to based on this previous incision or laceration and can guide where I want to go. And that's kind of where you get, as far as for me, on the first time when you meet them, unless they come with a lot of records. So it's time for further workup. I tell my patients, I have homework for you and that I need you to complete if you want to get better. I asked him to get a disc made and I asked for all the images, in particular, injury films, interops, if possible, and then those first post-ops to tell you what really happened. And I want to see the operative report and I want to know what I need to take out and also read it for any pertinent details. You know, if they mentioned anything that was atypical. I often get advanced imaging in the form of a CT. Those patients that you saw with the soft tissue kind of pain, I had an MRI, some, both, but it depends on the patient. Sometimes I'll just get the MRI instead. And then labs. So I have a couple of order panels built into my Epic because I see a fair amount. So for malunion, I get CBC, A1C, ESR, and CRP. I don't want to be surprised by an infection. And then nonunion, this patient had or early failure of the fracture. They haven't proven to me yet that they can heal a bone. So I'm adding on vitamin D, prealbumin, TSH, and PTH. So almost always getting a CT scan. This case on the left, I thought was malunion on x-ray, but turned out to be nonunion. In the middle, I was thinking initially that this was something I could revise, but ended up having a lot of joint degeneration. And also I really want to look at that posterior mal. Is that something that wasn't addressed? And then I think I can get enough fixation to add stability. On the right there, this is one that was well reduced, and I was wondering what was going on. I got the CT scan, and it was an open fracture. There was a big void of missing central plafond. I know some people, I know John's written about this, about getting bilateral CT scans. And for me, it oftentimes caused headaches with insurance approval, delayed images. So I don't routinely get them. This is one that I did get that. And if you look at the nonoperative side, it looks like there's a synismatic malreduction. So now when I'm going to plan, I don't know if I'm going to shoot for that or if I'm going to shoot for what I think looks best intraoperatively. So I typically just get the single CT. All right, we're going to get back to the algorithm here. We determine the joint status, hopefully whether or not it's infected. The aim isn't to discuss, you know, infection management fusions. We're looking at nonunion and early failure or malunions. And then I want to know, break it down to expected or unexpected. So what do I mean by that? It's kind of as a technical issue or a patient issue. On the left here, I see that they came in with introps and I see the final introp and the leg shrew and backed out already and was lost. So this has a nonunion or malunion. I'm not surprised by that necessarily. So it might be a little easier to get to because I expected that outcome versus on the right here. I have this patient who is known noncompliant, previous Liz Frank of mine. I over fixed her, trimal, I'm patting myself on the back. She doesn't hear her fibula, doesn't hear her medial mal. I get that workup and turns out she was, you know, obese, but protein and vitamin D malnourished. So in something I didn't expect it on, I'm getting more information. Okay. Next is the operative planning. I like to break down to approach techniques and kind of instruments. So previous slides, I always capture clinical images, incisions. Okay. So I'm doing revision. I want to know where I can get and where I need to go. And that'll dictate my position. Techniques, regardless of being malunion or nonunion, I always seem to be fighting for fibular length. And do I need an osteotomy? If I need to lengthen it, how am I going to achieve bony contact or what graft do I need? And finally, you know, what drivers do I need? What extraction tools? And with regards to construct, I am always trying to add stability almost always. And so I like to do a lot of dual plates. Nice to have other things in your toolbox, like tension band, in the case of the medial mal, and other forms of supplemental fixation, which could be X-Fix or even just Steinman pins. So I like this coat when it comes to revisions, because, you know, if you don't know where you're going, you probably end up someplace else. And that's usually with regard to length. So contour line images are really important. And I usually start there. Many techniques described for it. But I try to recreate that position on the nonop foot, on the bone foam, try to get the same angle, because the angle of the beam can make you look shorter or longer. I like to look at the width and the symmetry of that lateral gutter, as well as you kind of outline the peroneal fossa. And immediately there's also that double density you can gauge to see if you're getting the same image on both sides. On the lateral, I'm most interested in looking at, you know, where the fibula cross the posterior malleolus. This is a nice paper about the radiologic findings that you can go read. So pertaining to length, I think John wrote up a great technique on this. So how do you get the length back? And you can put a, instead of doing the push-pull screw, putting this screw across the tibia from just in front of the fibula, and then another one in the fibula. And you can really distract right there at the fracture site without being pushing from so far away like you are with a push-pull screw, and you're not married to a plate. So, you know, this isn't a revision, but, you know, I've slightly modified this technique. I put a Steinmann pin across because it's just one single shot and I'm done, and I'm not burning screws, and it's pretty quick. So I'll use that with a laminar spreader just like John wrote up. And so that's the lateral medial K wire, and then a P to A to P. And I'll click it out to length and look at that, and I'll compare my contralateral view, and I think I'm pretty good. So then I'll add my plate, and I haven't bought anything yet. All right. So try to get through quickly through a case or two here. Sorry, Chris, I'm running a little late. So case one, 75-year-old healthy female. You saw these images before. Four-week x-ray in cast. So, you know, she was a healthy-appearing woman without diabetes, but I'm questioning her foot's always asleep. I discovered she has neuropathy from chemotherapy and pretty unhealthy-appearing bones. So I know I'm going to need to strengthen this construct and basically treat her like a diabetic. Got a CT, look at that joint space. Looked okay. I didn't think there was enough posteriorly to get me to go through a whole new approach to get that. So I get my contralateral images. Her bone's soft, so I opt to open immediately first and remove that, de-breed that gutter. You know, it's really critical to do the de-breedment, because otherwise you're fighting an uphill battle at reduction. I put that plate on to clamp and kind of give myself more strength, and I was ready to do Kwan's distraction technique, but I had it where I wanted it. And then I put a K-wire in just to hold that from the fibula down in the tibia. I haven't had success replacing legs with new legs, so I oftentimes put one plate so I can anti-glide, and then a second plate as a neutralization. So here you go, and a little fast forward. You know, she was neuropathic and bad bone. I decided to put some Steinman pins in, you know, through there. You can put them extra articulately, which I saw one of John's calcs he did. But for her, her joints didn't matter as much, and I put these bicortical. If it broke, I can get them out. And last, I went medial, and there wasn't a lot of bone left. So it's nice to know how to do a tension band construct. If you have the wire or not, or you can use some sort of fiber wire, and one of my partners will do, it's just nice to have in your toolbox because you can't always get a screw in there, and hook plates don't always fit that well. So I see her back every two weeks, check those pins, room at sixweeks.msu, and I used an incisional vac for her. Second insult in four weeks, so I just wanted to be safe. And now here she is at one year. You know, there's some joint space narrowing. She does complain of some stiffness, but she healed everything, and I don't think removing the distal stenosis mushroom may help, but I'm not in any hurry to operate on her again. So, Chris, do we have time for – I'm going to move on. No, Max, why don't you just do this – these are great. Do one more case, and then we'll move to Ongud. Okay, so this is case two, my usual workup. We saw this image before. It's a nonunion, and I got the intraoperative images, but here was the pain. So I said the fibula he had there before was a brevis tear. It hurt really bad right there. And also at the nonunion sump. So I got the – I got the upper port. I look at it, and the reduction was pretty well lined up, and then when the nail went in, it malreduced it, and it held it out to length with this gap. So I'm thinking, all right, this was kind of an expected outcome, and now I know all the instruments I need to get it out. So I start – I remove all the hardware and, you know, address that previous brevis tear, and the saphenous was laying right over the tightrope there, so I took that out as well. His alignment was pretty well lined up with his contralateral film, so I said I don't need much for length but just a little bit, and I'll get some bone graft, which I was expecting based on my, you know, the gap preoperatively. You know, not always is this the case where it's lined up well like this, and I stole this from John's paper. You know, putting a laminar spreader in there and debrising like crazy is really important, especially in a malunion versus a nonunion. So as I kind of explained before, I almost always dual-plate the fibula. I'll put one to keep the reduction, and another one as a neutralization-type plate of that. Here he is at one year post-op. He had a kid at three months post-op. Didn't really get any therapy, but I know he's doing well because his scores have all gone back to normalized, whereas preoperatively a year before, he had them all moderate to mild dysfunction and depressed. So he's pretty happy with that. I don't always like to say, you know, people talk and they go, yep, and he did really well. It's nice to have an outcome score to say, yeah, he did well. So in conclusion, simplify your questions. Take the time and get the outside records. Planning is key. I really think 90% of this case should be done before you start, knowing your incisions, what fixation you want and have it in the room, what graft you need, and intraoperatively. Contralateral films, which I'd love to hear any of you guys' feedback on getting the prone ones, because I never seem to get a good prone contralateral film, and debridement length and rotation. Finally, alternative supplementation, like those K-wires I used, and other times I'll put an X-fix on. Thank you. Max, that was tremendous. Thanks so much. I've got us a tough act to follow, but I think you got this one. Looking forward to hearing what you can share about neuropathic trauma. Thanks a lot, Chris, and thank you to all co-chairs. You're going to have to forgive me. My voice is a little muffled. I was a little bit under the weather. I'll try and make it as clear as possible. I was given the task of talking about neuropathic complex ankle and hind foot trauma. These are my disclosures. I'm going to skip the introduction. Neuropathic fractures are a very common part of our practices, and we're going to inevitably see them. Even if you do not want to treat them, they will see you, and they're going to fall in your lap. I think we all have to have an algorithm to manage these. Just like Max Mikalski said a minute ago, detecting the neuropathic state of denial is what I always say. This is a very nice paper that came out of the importance of recognizing neuropathy in these patients. Just like Max, I always carry my 5.07 monofilament with me, and it's my gift to all the fellows and trauma residents on my rotation, and Chris knows that. So I always check for neuropathy and the density of the neuropathy, and it's pretty much 40 to 95% diagnostic. The preexisting neuropathic patient with a complex ankle fracture is not going to present to you straight away. He's going to be most likely that chronic patient who has been walking on it, felt a minor trauma or a twisting injury, had a painless pop because of his neuropathy with minimal pain and swelling that gradually progressed over time to sometimes even these horrendous forms of ulcers and gross malalignments. So the outline of my talk is going to focus on the client foot, mainly ankle, talus, calcaneus, and if we have time, we're going to go to the navicular. Fractures and diabetics, if they're non-neuropathic, well-controlled, then this is where the standard of treatment goes in with standard ORF. We know that in these patients, double the time, double the fixation is the standard. However, in the neuropathic, it becomes a little bit of a spaghetti or a macaroni bowl that we don't have a clear algorithm for, and my hope with the literature that I'm going to provide that we come to a consensus at the end. This is the chicken or the egg. Did these patients break because they were neuropathic, or did they become neuropathic because of the fracture? Believe it or not, there was this study that showed that ankle and foot fractures in the diabetics can be a provoking factor for neuropathic joint changes. This is what I just mentioned about double the fixation with double the non-weight-bearing time, which has been standard in the treatment. The glycemic status has become of utmost importance. Some of us are looking at fractosamine right now, but I think hemoglobin A1C still guides our management and has been published on extensively. If you look at the ankle fracture literature, it was previously at 8% cutoff with A1C. Then there was this paper that came out and mentioned an elective full foot surgery at cutoff of less than 7.5 was desired. But this paper just came out of FAI in 2024 and found that patients with an A1C of greater than seven within three months of surgery were more likely to have wound infection and more likely to undergo a secondary procedure after surgical treatment for torsional ankle fractures. With that being said, should we do things differently with internal fixation? This is another paper that showed that uncontrolled diabetics has a potential risk in tibial-talo-calcineal fusions using nails. So TTC nails should be used judiciously in patients with uncontrolled diabetes as the risk of failure increases. Should we do things differently? Yes, I think this question is pressing. I do not think we should shy away from using external or hybrid fixation constructs. A study showed that while the use of ring external fixators had seven times the likelihood of complications, yet most of these were adverse events, what we call minor complications in the form of pin tract infections. So when we come to ankle fracture, I think this was the beginning of some studies that looked at primary fusions in the densely neuropathic patients. And the fusion indications of patients with dorsiflexion weakness, foot drop, then sensory loss, comminution, and in my book, a patient with a contralateral bologna amputation should be considered for a primary fusion. So this is a case that represents that. He was a 78-year-old male, diabetic, densely neuropathic with an uncontrolled diabetes presented with this fracture dislocation. He was treated by my trauma partners back in 2021 in my previous institution and seemed like they did a decent job. However, he continued to pass out, got an infection. They tried revising him, took out the hardware, washed him up multiple times, and he was left with this. And as the time progressed, not only did he continue to break and the osteomyelitic changes progress, but also the hardware continued to fail to a point where this patient literally became septicemic and was in septic shock in the ICU. ID and internal medicine were pressing for a bologna amputation. But we went in, did an aggressive debridement, took out all the infected bone, did a tibial-telocalconeal fusion with a spanning ring axonal fixator, and that is, in my hands, the best choice of treatment with antibiotic beads. And then we kept the frame on for a good four and a half months, close to five, and then removed the fixator and backed it up with an antibiotic-coated nail. This was in 2021. This patient continued to follow up with me four years post-op and was doing great and maintained his foot. This is another one that came with an ankle fracture but had a history of a right or a contralateral bologna amputation. So history of multiple falls, dense neuropathy. kept her non-weight bearing, but she comes in on her first post-op visit like this and I asked her what happened. She says, well, I wake up in the middle of the night, I have to run to the bathroom. I don't have my prosthetic on me, so I walk on my leg. So we went ahead and did an antibiotic-coated nail, but unfortunately she did not get an infection, but she went into a non-unit. And that's when I say, well, if one method of fixation fails, definitely go to another, and you have to diversify your armory to be able to do something else. So we went in, did another extensive debridement, ring external fixator, antibiotic-coated beads, and she healed it. This is a third one who came in with an ankle fracture, but a history with dense bilateral peripheral neuropathy and a drop foot with dorsiflexion weakness. So instead of fixing her, I went ahead and gave her an ankle fusion to give her a plenty great foot, and she did well. This guy, not only did he have an ankle fracture and he was a kidney transplant patient with neuropathy and diabetes, but he also had peritalis subluxation with a flat foot deformity. So with this talus being an aquinas with a fracture, with a drop foot, we went ahead and did a TTC nail, corrected his talar aquinas, as you can see, from here to there, and he ended up healing walking without the brace, and I had him up to three years follow-up. So this is a nice study that came out in FAI in 2019 with outcomes of primary TTC fusions with nails and complicated diabetic ankle fractures with a high limb salvage rate of almost 96%. Relatively early weight bearing, although this remains controversial, I still don't walk my patients before at least eight to 10 weeks. Maintained ambulatory or other unacceptable complications rate within 18.5% with no incidences of malunions or symptomatic nonunions. Now, this is a phrase we always play on in the diabetic neuropathic work, symptomatic nonunions. If you get a patient to heal, but with a fibrous nonunion that is asymptomatic, well, is that a win? I don't know. They will remain asymptomatic because they're neuropathic. So should we be reporting these as symptomatic nonunions, or sorry, asymptomatic nonunions? I beg to differ. I think this is a failure and this is a doom to collapse, especially with long-term follow-up. Taylor fractures. This is a paper that showed post-operative outcomes of Taylor fractures ORAF in patients with and without diabetes. And it was a systemic review with almost 5,000 patients. And when you look at the breakdown, significant numbers. So with complicated diabetes, 223, uncomplicated 418 patients, and no diabetes, 4,000, close to 4,000 plus. The reoperation rate increased among diabetics compared to non-diabetics. There was more likelihood of sepsis and wound disruption. There was higher incidence of Taylor nonunion in patients with complicated diabetes. So in conclusion, complicated diabetes is associated with significantly higher risk of multiple adverse event following a Taylor's fracture repair. Now, this is the simple Taylor fracture. How about Taylor fracture dislocations or extensive Taylor fractures? This was a very nice study that was done by one of our partners at Boston, when he looked at Taylor fractures with proximal extension. And by proximal extension, we mean extension into the body beyond the line extending from the anterior Taylor body to the lateral process. And they found that if a fracture extends proximally, there is a very high rate of AVN and a rate of collapse. Now, this was done in the healthy patient population. Now, can you imagine what it would look like in a diabetic neuropathic patient who presents with this? I think this definitely, with a Taylor fracture dislocation, most likely will mean that this talus is avascular. And that's where, really, when I look at this and I see this patient at my clinic, I try to get an MRI and assess that talus. And if I'm not getting an MRI or a CT, I would consent that patient for a possible partial or complete talectomy, because I know this talus is now avascular. Anish Kadakia and his colleagues published a small case series on seven neuropathic patients with almost or total loss of the talus, where they reconstructed it with a TCT fusion using either iliac crest bone graft or distal fibula bone graft with no non-unions and good salvage. In my hands, I showed you this patient who was a patient of mine, and in my hands, I do not try and go for a tailor, sorry, an iliac crest graft or a distal fibula. I really want to get bony opposition. And in my textbook, there's nothing wrong with a tibio-calcaneal fusion with a total tailectomy. We're going to argue that the patients become shorter. I tell you, they are low demand patients that need a leg rather than an amputation. I have had them be, do totally fine with a shoe lift. I never shy away from doing a complete tailectomy with the talus as a vascular to get bony opposition and get native bone to heal. And that's what I did in this patient, took her talus out, did a tibio-calcaneal fusion. This is her CT at six months, and I'll go through it quickly. But she ended up with a plantigrade stable foot with a two centimeter shoe lift. She was a teacher and worked fine and refused the lengthening procedure. And that's what I have in my armory. I tell them, look, if you don't like your limb length, discrepancy, we'll go in and later on lengthen you. A lot of us have partners who do limb lengthening. I do it as part of my practice with a proximal lengthening nail or a frame. And I would tell you, and I'll do honestly throughout 10 or 10 plus years of practice, more than 80% of the patients are gonna refuse subsequent lengthening because they're satisfied with their shoe lift. Calcaneal fractures. This is a paper that showed the outcomes of ORF and calcaneal fractures in patients, again, like the talus paper, with and without diabetes. So they have the three same groups, patients without diabetes, uncomplicated diabetes, and complicated diabetes with a significant number of participants, as we can see, 10,000, 1,800. Non-union, sepsis, surgical site infection, wound disruption was higher in patients with the complicated diabetes as the ones we are mentioning in our talk. So I think it makes perfect sense to go in and do an intra-articular reduction of the calcaneus, get it up to length, restore as much as possible, and then do a primary fusion with bone graft. Another concept that's coming into the surface right now is distraction, osteogenesis, or sorry, distraction with a ring external fixation across the fracture site, getting it out to length with a ring external fixation, and then coming in through minimal approaches, minimal incision, and doing a primary fusion within two to three weeks. So this is a very atypical calcaneal fracture case. A patient, not a patient in line, but could have been a patient in line who had a TC fusion and then was walking, felt a crack, and then pain in her calcaneus, and excruciating pain, and she came with a backed up nail. The nail had totally come out of her leg, her calcaneus had cracked, and she had an obvious calcaneal neuropathic fracture. Now, this is a very, very difficult situation because of the lack of the bone stock. And this is where really the CT shows us what we can and what we cannot do. So in her, I think an oil wire frame made perfect sense to me because I can gauge the wires to hold on that tuber fragment. I went in, took everything out, injected calcium sulfate into the canal, did extensive bone grafting of this calcaneus, and held everything with a ring external fixator with smooth wires only in the calcaneus, waiting on her to build up bone stock. Six months, I usually get CT at three months. If they're not healed, I get it at six months. So this was her CT, and you can see that she's building up her bone stock in the calcaneus. And that's when I went in and did another nail, and that was in 2021, three years post-op. Her foot was holding, you can see she had some bone stock in her. Again, that tuber fragment was docked into the tibia with significant shorting. She was still wearing a shoelace and happy. In the sake of time, and I'll be very quick, navicular fractures, they're part of the hind foot. Management of the neuropathic navicular is also severely devastating because this is another hypovascular bone. This paper by Blumen and Morrison was very, very nice, and it showed that the acute and an acceptable aligned navicular fracture, immobilization, protective weight bearing, and just don't trouble, trouble, let it be. But if you can have a significant dislocation or subluxation like this with eminent ulceration, again, the golden answer becomes effusion. So this was a patient of mine that went into my board cases, actually, that presented to me with an eminent ulcer with a deformity after a pop and a snap walking on her foot, nothing crazy, a split in the navicular. We went ahead and tried to restore the navicular, so I did an ORF of the navicular and fusion with a bridging plate because of the common usion. But as we know, she went into, again, failure, hardware started backing up, non-union three months into it, and that's when I took everything out, did an extensive bone grafting, and did fusion with beams, but at least I had some relative bone stock in there. I followed her up for two years until I left, and she had fully healed and was walking on it pain-free, and you can see the difference in the bone stock right there compared to the pre-op. Tips and pearls, if you're fusing, use the kitchen sink. I'm not gonna talk about it, but biologics, bone graft, antibiotic-loaded calcium sulfate beads, post-op, start them on calcium and vitamin D straight away. Tell your colleagues, your PAs, your fellows, the calcium sulfate beads, if you use them, they're gonna absorb, and as they absorb, they sometimes cause yellowish discharge. So in conclusion, I think neuropathic fractures are difficult and challenging. It seems that primary fusion in the literature seems to be the treatment of choice in patients with and without deformities to achieve the primary goal of a planty-grade, showable, unaltered free foot. Despite the lack of high-evidence study, relatively high rates of complications of failure have been reported with internal fixation, especially in the uncontrolled diabetic. So consider ring external fixation. It has the added benefit of spanning the fracture site, indefinite compression to achieve bony opposition, early weight-bearing, as I walk my patients with frames in two months. Consider subsequent antibiotic-coated nailing. This has been part of my practice as an internal splint. I'm read to remove any of these nails due to infection. Yes, they can fail, but they fail mechanically or for non-unions, but they do not fail for infection. The best chances of healing are with autologous bone grafts, with a iliac crest or fibula. Acute shortening is not a no-no. Please consider it. Alectomy is not the end of the world. These patients will function well. So I think instead of this, we have come to the conclusion that primary fusion, whether with internal or external fixation, remains the illness choice. Do not repeat your fixation method if it has previously failed, as this genius man has once said, insanity is doing the same thing over and over again, expecting different results. Thank you. I'm glad that was tremendous, and I'm glad there are people like you taking care of those really complicated problems. So now it's my turn, and I definitely do not have as exciting cases to show, but I'll tell you, I learned a lot to putting this together, and as I'm thinking about this one, we put all these talks together, and then I volunteered for this one, and I sort of, I learned a lot, but it was challenging to find, because there's not a ton written on it, and that's why I sort of retitled this The Forgotten Injury, and you teed me up very nicely, Omgad, talking about neuropathic navicular fracture. So I'm gonna go through this. These are my disclosures here. So this is the case I wanted to share. This is a 24-year-old healthy carpenter. He's just motocross, and he's in a motorcycle accident, so he's 30 miles an hour, and just slammed his foot into the ground. And this is what we had. He had this fracture dislocation of his navicular. I think it was a CT scan. You can see the comminution. You can see the injury to the cuboid as well. Many of these midfoot injuries are not just one or the other. It's often a combination of problems here. I'm just gonna keep a little timer to keep me honest here. Okay, so you can see the amount of comminution he had, especially in the sort of lateral part of his navicular. So this is where we had him. Comminuted midfoot. And the surgical plan, this was something I did fairly early in practice, and it wasn't necessarily immediately obvious what to do. And I wanted to get it. Obviously, I want to get him out to length. I want to get the joints restored. Do I do a fusion? He was healthy. He was not neuropathic. I wasn't really trying to do that. Is there something I can do to get him out with a distraction X-Fix and try to tease these things back in? I think there are a number of different options of how to fix this. And, you know, I'm gonna come back to it at the end. When it comes full circle, I'll talk about the case. But in sort of thinking about this, I took a step back and I was like, why should we, why do we care? You know, the calcaneus, the talus, they get all the glory in the hindfoot and the navicular. It's just like one of those bones that we don't like to think about as we head off to the Lisfranc and talk about fixation versus fusion and all the other options. But, you know, it is a really critical part of the complex here. And, you know, we talk about keystones, but like here it is. And it's also very articular. Any injury to this is gonna be intraarticular. And because so much of it is covered by cartilage, there's very limited blood supply. So I'm glad I was already talking about how it's a relatively dysvascular bone, but really critical for the function of the foot and the hindfoot. And we know we've seen these before, but, you know, if you are stuck in varus or you have a malunion, if you have any disruption of the Chopard complex, you can get a very stiff foot. And if you end up in varus, you have these, you know, cross planes of motion, whereas, and so you get a locked stiff midfoot, which is good for propulsion, but not great for regular everyday. You don't wanna stay there. Whereas if you have too much valgus, more flexibility. So, you know, this is the thing that's gonna, needs to move so that we get into the right position. You can see, as we know, 90% lost supination and midfoot motion if this is fused. So what's the vascular anatomy look like? This is from seraphins. And again, we know it's limited because a lot of it is covered in cartilage, but so all of it comes from either the dorsal portion, and you can see these are the dorsal pedis arteries. And then they have these mid-tarsal arteries that come out and feed the navicular, and they come in through the top. And then we have the plantar supply that comes from the medial plantar arteries with some perforators that come up underneath. So those are two areas that we're gonna get our blood supply. And then oftentimes there's this central watershed area. As we age, we get less blood supply and blood vessels into the area as well, which may make our older patients or sicker patients more vulnerable. And then as we think about this, if we're gonna fix this, the first thing we're gonna do is we're gonna strip off most of the blood supply that comes from the top. So this puts us at potentially higher risk of non-unions or AVN post-op as well, because now we're really relying on that plantar artery. Okay, so a bunch of different types of fractures and classifications. We have the standard avulsion, the tuberosity, the body fractures. I'm not gonna talk about stress fractures here because I'm gonna run out of time. So we're gonna focus on mostly the body fractures as we get into it, but very briefly, avulsion fractures. These are the things that we see all the time in ankle sprains. Unless it's really large, I basically ignore it. I talk about, this is like the paint. If you put tape on a wall and you pull it off fast, this is the paint that comes off. And so I treat them like an ankle sprain. I think they take a little longer to get better, but larger fragments, I may keep them off of it or immobilize them longer, but I've rarely fixed them. I have taken a couple out that had a malunion and were painful. This is a great video dissection showing, this is from Dr. Pastor in the University of Barcelona, but you can see the ligament and the ligaments as attachments at the TN joint there. And so as it comes into inversion, sort of the ankle sprain position, you can see how that gets tight and will avulse some of your ligaments there. So next step, we have the tuberosity fracture. So this is where there's a forced eversion, the eccentric load on a posterior tib. You're gonna pull off the medial pole. And then this is something that's now gonna destabilize the hind foot potentially. So for these, if it's truly non-displaced, I will cast them. I'll protect it a little inversion, you know, a little varus to the heel to protect it. I keep them off of it and then slowly progress in the boot. And I don't let them evert the foot or go up on a single heel rise for two to three months. If it's displaced, however, I do think that this is worthwhile fixing. We're gonna restore the anatomy. We're gonna fix the posterior tib back to its insertion. And I think that'll lead to better functions long-term for the patient and avoid the potential long-term flat foot progression. And then if it's a chronic non-union, I treat these much more like a kidney procedure and I'll advance the tendon back up. So this is, I think, the thing that is more rare but more severe injuries as well. And thankfully, there's not a lot of them. But, you know, we know these come from typically fairly high impact activities. So most of my patients have either been like this gentleman here who has a motocross injury or a fall from a height, often with a sort of axial load up the foot along the axis of the metatarsals. And then there's this twisting. And frequently you'll see the talus head off laterally and impact into that area. And of course, look for other associated injuries. This patient here had the cuboid injury as well and commonly go together. So these come in three varieties. This was defined, I think, by Dr. Sam Georgian in the early nineties. And so the type one is this transverse split. And I think you saw one of these, which was a more neuropathic example that Omgad showed. But this is where the dorsal portion will elevate up. One important difference here is that typically the length of the medial column will stay intact. So it's rare that you're gonna have loss of length of the foot with that one, but may still need to get fixed to restore the joint. Type two, probably the most common that I saw in the literature and that I've seen in my practice. This is a sagittal plane split, but without significant, without comminution. And then finally type three, similar sagittal split, but you have more of a comminution of the lateral portion. So the patient I showed up front is more of this comminuted type three patient. So we know high energy, significant swelling. Don't forget your standard trauma principles. So, you know, you can X-fix these. You can let the soft tissue rest before going in as long as you can get it adequately reduced, closed. But I think with sort of modern techniques, I don't think there's a lot of role for nonoperative care in these patients. Okay. So what have we seen in terms of fixation? There've been a number of studies that have reported on outcomes. They're typically fairly small series, you know, between the high teens and low fifties in numbers. And they, in general, for noncomminuted, not significantly displaced conditions, show favorable outcomes with ORAF. So this was isolated navicular fractures. You can see it improved in AOFAS scores. More significant displaced cases had worse outcomes. Not surprising. The non-displaced ones did excellent. And then this was the San Georgian article that came up with those classifications. Two here. So this is Schmidt in 2016. So he showed, or they showed that the degree of comminution and injury impact outcomes. So not surprising. We see that across the board. But, you know, the more severe have worse outcomes, particularly if there's dislocation. And then this is an article from JOT showing that bridge plating for these comminution, comminuted fractures can be very effective as well. However, it obviously does require a second surgery, potentially to remove the hardware in the future if it becomes painful. So what I want to show you a couple of things here. So pre-op planning, I really do think a CT, and I like these 3D renderings here. We often talk about the constant fragment and calc fractures. There's often, and as I've looked at mine, there's always this plantar lateral piece right here that seems to be intact. So I often think about trying to build everything back to that, and that's where this 3D printing comes in hand. So why is that? We have the spring ligament, and that's also, you know, so that's going to kind of hold onto it. And that's also where we get some blood supply. So hopefully that constant fragment will maintain some of our plantar blood supply. We want to get back to that for our reduction here. So they showed relatively decent results. None of them went on to arthrodesis as long as they had healing and good reduction in their study. So complications, by far, probably the most common one is going to be arthritis or, you know, persistent pain afterwards. In this study, there was about a 20% risk of arthritis and, or AVN, and then a number of them had their hardware removed as well. And then this was also the study that showed single fracture better than multi-fragment and better than dislocation. Okay, so if the common issues are arthritis, non-unions, AVN, you know, what can we do to try to address this? And obviously, arthrodesis is probably going to be the most common one that we see here. For me, if I can find a reason to fuse a subtalar joint at the same time, I usually will, because we're already going to be eliminating most of the hind foot motion, and I think adding some stability, so that we will make it hopefully less likely to have a non-union at the TN joint with the fusion. This is a study out of Duke. I'm not a good enough hand and foot surgeon to do these little microvascular transfers, but they did try to show this, and for patients who had AVN, in addition to the non-union, they converted into fusion. I think it's a little questionable how important this is. Two of their eight did not fuse, and they revised that with standard iliac crest bone graft. But this has been described and is out there. Also from Duke, and in light of our upcoming 3D printing and orthopedics from Dr. Adams, and I had a chance to ask him about this case and the patient was still doing well, last I heard, but I don't think this is something that he's doing commonly, but I think he really enjoyed this case, and according to him, at four years, the patient was back to high level with minimal pain, and the CT showed nice fusion to the 3D printed implant there with retained motion of the hind foot. So I love MIS, and I think one way to move into the future to try to preserve that already tenuous blood supply is to consider MIS fusions. So instead of doing a big open procedure, as you see on the left, we can get hind foot fusions, and this was a patient I did for Charcot condition. I did a percutaneous triple, and he was quite happy at the end, and I think this, more and more for me, is something I'd go to for my fusion reconstructions. So we looked at this. We can get adequate joint prep with this technique, open compared to MIS, and we're looking up some of our results for those as we speak. So in terms of principles, we have to look at bone erosion. Where is the tailor head? If it goes into that lateral defect, you can get sort of this planovarous deformity, which sounds very weird to say, and I have to keep saying it over and over again because the heel will twist into varus while the midfoot collapses, and so we want to restore the length and midfoot geometry. So coming full circle back here to my first case. So this was my patient, a 24-year-old carpenter. So he had this type three navicular fracture, seen different lateral pull combination. The tail is just ducking laterally, and relatively poor bone suck. I don't think I was going to be able to get any screws into that lateral fixation, and so you can see here, this was interop. You can see the pieces of bone and cartilage that were just free floating in there after I was done, and so I opted for the bridge plating technique here. So I was able to get a little something laterally. We put that down. I pinned it to help maintain the reduction. I put these two plates across the front to help hold us out to length, and I kept that in, I think, for about six months. So this was him early on. He healed everything up at six months. So, oh, he was walking by three. Let's see. I had a CT, which looked like things had fused. I was a little concerned about maybe some AVN in here. He was having more pain at the top of the foot with motion, so I did take those hardware out, and then this was at two years here, and he has a fairly arthritic joint, not surprising, but he comes back twice a year for steroid injections. He wears rocker-bottom shoes, and he's eager to avoid a fusion, at least for now. So overall, pretty happy with this in terms of getting his alignment back. So thank you very much, and thank you to the panelists. Let me stop sharing. Okay. So I got a lot of questions for you guys, and I wrote a couple down, and just honestly, you guys had such amazing talks, it's almost embarrassing to go after you guys. But Max, I have to say that as sort of the youngest on the panel, I'm so impressed with your very thoughtful and thought-out approach to these complex patients. And you know, one of the things that I've always thought about with these issues is we're managing like multiple competing factors at once, you know, and maybe talk a little bit about how you came to this, I mean, it's almost like maybe a trauma response, you had to adapt or drown, but you know, you get these labs, what do you do with them if they come back abnormal? Do you, are you sending them to nutrition analysis, like, how do you work through that workup for yourself? Yeah, it wasn't always this thorough, and it's a trial by, you know, fire approach where they come in, and at first, you're just like, oh my, I don't know what to do, now I'm behind a clinic because I'm, I don't know what to do with this, that's always on my mind, but eventually, thankfully, good or bad, I've done enough of them now that I kind of have gotten into that. But yeah, so the nutrition labs, we have a pretty good, actually, trauma service, and they have a whole nutrition packet that we've worked, that they've worked on, and I've adopted, so we get all those labs, and we have a whole handout of what they need to go get, and even some of the patients, we have a thing where they can get their protein shakes on the way out the door as a prescription, they actually get them leaving the hospital. So that's helpful. Vitamin D, I check on basically every case, and I just put people on 50,000 units, D3, once a week for six weeks, and found that that seems to get them back, and it doesn't seem to ever push them over into something crazy high. So I don't even remember where I was going with that, but yeah, it just became a gradual process of learning how to manage these and not always be pissed that they're in your office. Now, I texted you the other day, I think I had three of these come in on Monday, like really three failed ORFs, infected, schizophrenic, diabetic, and I was like, it's kind of exciting, I feel bad for these patients, but I just, now I have a role, and I realize I can't answer every question right away, and I have the confidence to tell them that, look, I'm not solving this today. We need, you need to do homework to help me, this is what I want from you, and then I can actually take the time to process it, and that's why I take all those pictures, because I'm sitting there, and I'm like, wait, what am I going to do if I know exactly where I can get to or what I can't get to? Yeah, you know, Max, I'm going to get to some questions here from the audience here, but it just reminds me of a saying, you know, you don't rise to the level of your ambitions, you fall to the level of your systems, right? And I think that you've developed a really high level system to keep you on track. Question for Dr. Halim, what is your technique for making your antibiotic cement coated nail? Chest tube versus manually, do you keep the nail indefinitely, or do you exchange down the road? Yes, that's a good question. I always use the chest tube, I started out with the rolling, freehand rolling technique, it's so time consuming to get the mantle uniform around the nail, so I don't recommend it unless you have a fellow resident that can move forward with the remaining part of the surgery as you roll or vice versa. It's a 12 millimeter inner diameter chest tube, or cardiac perfusion tubing, I use low viscosity cement premixed with gentamicin and I add 1 gram of vancomycin and 1.2 gram of tobramycin and you can up that to 2 grams of vancomycin and 2.4 of tobramycin per batch. Usually one batch is sufficient per nail. I put the nail in and as I said before, I've never had to take a nail out for infection, I believe the mantle protects it. Have I had nails go into a non-union, no, because I usually use the frames initially and then I exchange the frame for a nail even with 80% or 90% consolidation, and I find that the nail serves as an internal splint and it prevents further short-calling. Some people have published about concomitant fixation, ring external fixation and nailing, I do think that's a little bit of a treacherous patch, I have not tried it, but I believe if you get a pin tracked infection that tracks to the nail, then you're in big trouble and you're looking at a below knee amputation. Dr. Mikulski, a lot of these questions are for you, you got a lot of interest out there, so are these 2.4 or 2.2 plates for your dual plating technique? And actually only 1.3 in thickness, but the screws in them are 3.5s and a lot of times actually those synismatic ladder are locking, so I'll put them quad cortical lockers, works pretty well for neuropathics or diabetics, but the other alternative fixation, ring fixations, just kind of share this quickly, you know I'll put X-fixes on there, you can either do it like that, so this is basically a poor man's ring fixator where I put a Steinman pin across the midfoot and across the heel, that gave me control over inversion, eversion, all that, after I fixed it, this is the one that lost the reduction on that intra-op that I showed, he had an open common peroneal nerve crush injury and calf lacerations, I couldn't even splint them, so I've done that, or here's the locking screw, or if you're fast out of the frame and you plan ahead, this person was diabetic, COVID, pulmonary hypertension, can't go prone, and can't get general anesthesia, so I perked screws on her and just put a frame on and let her walk right away, so she actually walked 30 feet post-op day one and walked out of the hospital, so thankfully, story's not done yet on her, but the frame's off and appears healed, but you never know. Max, while you're here, what do you do if they have an elevated ESR CRP? If they haven't had a wound, I'll aspirate the ankle and assume, if that's negative, then I will assume, you know, not infected, but pig cultures intra-op, if it is, they've had a wound, this is infected until proven otherwise, I'm taking everything out, cultures and probably either splinting or possibly an X-fix. John, you said that you had a question. Oh, yeah, thanks, Chris, so, you know, as I was hearing these talks, I was realizing that this is really about revision surgery, this section of the course, even Dr. Miller's talk, because a lot of his patients go on to need revision surgery, but, Chris, that was a joke, so, anyway, you know, one of my questions to the panelists is about previous incisions, okay, so, you know, if I'm converting something to a fusion, I really don't worry about the incisions so much, because I can do joint prep and put a hind foot nail in through any incision, very small incisions, but, you know, when we're doing revision ankle fracture surgery, we're always dealing with previous incisions, and so I wanted to hear the panelists' thoughts on that, like, for example, one of the common scenarios I run into is I have to revise the syndesmosis, but the previous surgeon did a direct lateral approach to the fibula, so I'm challenged to get over the top and look in the incisora. I think the other common situation I run into is I have a direct medial incision and someone has put two screws in to fix a medial malleolar fracture, and I have to repair the posterior tip, and so that incision is limited, so I just wanted to, you know, hear people's thoughts on previous incisions. You know, I love Max's idea of taking pictures, and, you know, when I was at, when we were at BI, I would take pictures and send it to our plastic surgeon, you know, whoever it was at the time, and sometimes I'll, you know, even ask, hey, where would you want me to put an incision so that if I get in trouble here, you can bail me out? And I think, you know, tomorrow we have a whole talk by one of the plastic surgeons to hopefully help us understand some of that, those questions, but, you know, I think it depends how far out are you, is it, is it within a couple months, I'm going to be much less willing to go close to that incision. If it's, you know, a year or two out, I'll probably go pretty close to that incision with less fear of having a thin bridge, but I'm glad you have your hand up. Yeah, maybe I can, I prefer the old saying, big surgeons, big incisions, so I go through the same incision and extend it proximally and distally, and I try and elevate as much of a flap as possible, a thick flap to avoid wound dehiscence, and then go in, just like you mentioned, John, so if I'm trying to try to reach the caesura, I'd elevate that flap anteriorly. If I'm looking at the posterior tibial tendon through the medial mal, I'd elevate it, again, extend it proximally and distally and elevate it to expose it, and that's my go-to, besides, of course, consulting, like Chris said, his plastic surgeons. Yeah. Max? Well, one, I think John is the most qualified person to answer his questions, but for that medial side, I, you know, a lot of times people make that like an anterior incision and they perk those screws, and yeah, it's in the post-tib, and that incision is nowhere near it. I've basically just done that, the regular approach I would do, but I just lower kind of at the bottom aspect of that post-tib, because that's something like, you can really lower it down there, because it's a convex incision that you can always flip that way. It's hard to think the concave side anywhere, so I'm always thinking about concave convex of the flap on a convex side can always lift up and get back to you that way, so you can always go low on the post-tib, just be careful, obviously, for the bundle, you go too low, but, and then you can lift it up really easily to get at that one, like the one I showed earlier, she had an anterior incision, and I had to go real low, because it was an open transverse in last hit, so I went real low and then armed up to that. Yeah, we have another question from the audience here, how do you manage midfoot, forefoot when doing a telectomy and TC fusion, so for Omgod? Yeah, so we have that concept of the flipper foot that came out in the neuropathic world among, you know, again, it's just anecdotal amongst us all, but it is very, very good to leave a motion segment for these patients to be able to dorsiflex through, so if I'm doing a complete telectomy, as you saw through my picture, I'm leaving that navicular abutting the tibia and creating a little bit of motion and a flipper for that patient to walk on, so that's my goal too, I always leave that segment, sometimes you can leave the tailor head, but I do not recommend that, because it's still going to be an avascular bone that you leave through the way, but if you're going to do the complete telectomy, let the navicular above the tibia, and don't pin it, don't fuse it, and let it just slide there as a motion segment. Yeah, Max? I have a question for John, is there room for a plate on that lateral calcaneus underneath the fibula? Because people, you know, you showed those pictures of the impingement, and those are all pretty thin plates, are we, is this happening probably more often than we know? I worry about it, you know, because, you know, before I was getting more weight-bearing CTs, I was just assuming the pain they were having was from their cartilage damage from their initial injury, right, but the corona weight-bearing CT really allows us to see that impingement, and so it's been honestly a little eye-opening for me, because, you know, I always thought I was doing a good wall, a good job to press, you know, reducing calcaneal width and getting that lateral wall in, but, you know, maybe we're not doing as good a job as we think, so I'm just kind of more cognitive of it, because, you know, you're looking at the tip of the fibula when you're doing the sinus tarsae approach, so I'm just really making sure that my plate is nowhere near that. You know, John, I remember talking with Sam Georgian, the senior, and he was talking about calc fractures, and he said that he does, I mean, he does a lot of them all percutaneous, and he worries about the shape of the bone, but he, it seemed like he was implying that he worries about the shape and a little bit less about getting the joint surface completely perfect, and I don't want to put words into his mouth, but that's one of the takeaway I got. What are your thoughts on sort of getting something into the, very close to the ballpark, setting yourself up for a subtalar fusion that would be like primary fusion, even if you may not have completely perfect reduction at the joint line for a calc fracture? Yeah, I think that's a really good question. So, if I could have anatomic reduction in my posterior facet, but say I had a wide calc or I had it tipped in a little varus, I would rather take better extra-articular alignment, perfect extra-articular alignment, and a less perfect joint than having a perfect joint and poor alignment otherwise. You know, and maybe that's a little bit of the pessimist in me, thinking that, you know, I mean, the cartilage may look good now, but we know it's going to go bad, and whether I get my reduction perfect or within one millimeter, you know, maybe it doesn't make a difference, but, you know, extra-articular deformity certainly does. Yeah. I mean, there's a study from Dr. Sanders that looked at his, you know, Sanders 2s and 3s, and like 30 and 60 percent or something ended up with a fusion within 10 years. And, you know, if he's getting those and they're going to fusion, is that really a failure of treatment, or is it, you know, for a certain percentage of people, sort of the expected thing, and if you can get them better outcomes with an initial reduction, like, I think about that a lot, and that's something that you taught me early in practice, so thank you. I mean, you also taught me to get the joint right. Just direct cell death from the impact that caused it to shatter the bone like that, of the cartilage, that great, you're lining up dead cartilage, and it's just never going to, doesn't matter what you do with it, still the impact was there. Yeah, let me, we have a couple, a little bit more time for a couple more questions here. I guess this is for Max, or, you know, John, how do you manage chronic syndesmotic injuries? Yeah, I think that's a really good question. It's, we could probably talk about it for a couple of for a couple of hours. Let me simplify my thought process, and so, you know, assuming it's an appropriate patient for revision surgery, probably the first thing I think is, do they have arthritis at the incisora or no? Because if they have an arthritic incisora, my treatment is a syndesmotic fusion, okay? If they don't have an arthritic syndesmosis, my next thought is, do I have malunion, right? Because, Chris, I think we wrote a paper on this, right? You can't overcome, you can't get to an anatomic syndesmosis or an anatomic mortis if you are dealing with a malleolar malunion. You won't get there, right? So then that's my second thought, is if there's no arthritis, am I dealing with a malleolar malunion? And, you know, if you are, then the question becomes how much, and can you technically correct a slightly malunited posterior malleolus or fibula or things like that, right? And then if I don't, if I'm not dealing with a malunion, and I'm not dealing with arthritis, then it just basically becomes understanding what the contralateral side looks like, the breathing, the syndesmosis, getting it anatomic visually, whatever intraoperative means you want to use fluoroscopically, stabilizing it, and then augmenting the ligamentous structures. You know, I think the failure is when you revise a chronic syndesmotic injury just by putting more screws in than the other surgeon did. Yeah, and, you know, I'll say to anybody who's listening, there's a great paper that I really like that I think Anish Kadakia wrote in 2010 in FAI that sort of goes over his approach to revising ankle fracture malunions, and if you haven't seen that, I would look for that. Sorry, can I just throw one thing out? Yeah, join in. So I guess, Max, looking at all your slides, you had lots of pictures of big screws going across the syndesmosis, and I wonder if there's ever a role in your mind for flexible fixation of the syndesmosis, you know, maybe screws and flexible fixation, you know, what your thoughts are on that? Well, so I definitely, I use flexible syndesmotic fixation in primaries, that's my go-to. In revisions or these diabetics, you know, then I'm usually using a lot of screws. I'm just basically using it as another way to just get more strength in the fibula rather than actual syndesmotic fixation. I definitely, I mean, there's a role for me putting both in and one breaks, and then you have the syndesmotic backup, or as John shown before, where I was a fellow, we put a tire up across and put a plate on both sides. So we put it through the plate on the lateral side. On the medial side, we put another plate there. So basically, they need to either pull the plate through the bone or break the fiber wire to loosen up. So I think there's a role for it. Just in primaries, I use flexible revision. I'm putting a lot of screws. Yeah. Can I chime in about that? So, you know, hopefully Cliff isn't on the call here, but, you know, when I was a fellow and we were just starting to use a suture button for syndesmosis, we'd put a suture button in and back it up with a screw just in case. Cliff was like, yeah, we're just going to put a screw just in case. And so I've kind of come full circle and in revision cases, I will do that because one, I know if I open reduce the incisora, the syndesmosis, it gets me down to about a 15% malreduction, right? I know if I use the contralateral side as a template, it gets me down either even further. But I like to put a flexible device in first because cinching that down probably gets me that last couple of percent of anatomic reduction that I can't see with my eye. But if I got a post-op axial CT scan, I would probably see the fibula aligned in the incisora. But it's flexible. It doesn't control rotation that great. Certainly doesn't control axial instability. So then I back it up with a screw for revision cases. Great. I think maybe one more question and we'll wrap it up. This one for Quan. In a badly malunited calcaneus with a bad prominence plantarly that is symptomatic, do you come across any plantar closed wedge osteotomy to address that? So will you do a plantar closing wedge osteotomy with subtalar fusion or would you consider just an isolated exostectomy on the plantar surface? Yeah, that's a really interesting question, an interesting thought. You know, when I have patients who have a large bony prominence after a calc fracture plantarly, in my limited experience with these, I've seen these more with blast injuries and not necessarily, you know, the classic mechanism, but they end up having a big spike of bone on the bottom of their foot. I've gone to usually just doing an exostectomy to treat that and then addressing whatever else that I need. But I think it's an interesting idea, kind of like a reverse Zadig maybe. Right. I've seen a couple of those. I've actually used the MIS Burr to take down and it makes me a little nervous, but, you know, it has worked really nicely just to decompress one of those spikes that comes off the bottom. And I agree, I've seen that. I don't see a lot of blast injuries, but the sort of really high energy car, you know, the whole thing is just completely smashed apart. Well, I think we're going to call that tonight. I just want to thank all the panelists today. This was an amazing talk. I learned a ton from both of the sessions today. And thank you to Liz and to Jacob for helping us do all this. So we will be starting this last day tomorrow. So that will be starting Saturday at 9 a.m. Central or 10 a.m. Eastern time. And we'll be starting off more malunions and malalignments, but now talking more midfoot, you know, failed lapidus and flatfoot and other issues of great import. So I'm really looking forward to all of it, and I hope you guys will join us tomorrow as well. Thank you. Thank you. Thanks, everyone.

AOFAS

foot surgery

ankle surgery

bunion recurrence

Hallux varus

minimally invasive surgery

Dr. Christopher Miller

Dr. Jacob Seid

Dr. Elizabeth Cody

Dr. Scott Ellis

tendon transfers

calcaneal malunions

revision ankle ORIF

surgical techniques

post-operative management