Morning, if we can go ahead and take our seats, we're gonna get going. We have a pretty busy symposium. So welcome, my name's Carol Jones. I am the moderator for this session and also the program director for this week. We welcome you to Charlotte. I'm sorry that we have to start off with a rainy day, but it looks like that's gonna move along pretty quickly here. And I know we all wanted to be in Vancouver this week, but for obvious reasons, we had to move it here. But I think everyone's really gonna enjoy Charlotte. It's got a good vibe, good energy, it's good Southern hospitality, and pretty easy to navigate. I would say even easier than Vancouver. You know, we decided not to broadcast today's pre-meeting virtually to encourage live attendance. So we very much appreciate all of you being here. And you will also, because you paid for your registration, you'll have access to all nine ICLs online after they're all recorded. So don't feel like you have to bounce around from one room to the next to avoid missing something. So I'm glad the board made that decision. On that note, just a big thanks to, they're in other rooms right now, a big thanks to John Kwan and Kent Ellington. They're the ones that really put together the pre-meeting agenda with a little bit of oversight from myself and Dr. Cohen. But if you look through the list of speakers and all the topics, it's really a tremendous amount of content and a very, very high level. So to pull that all together and to have 95% of the speakers, moderators here live is remarkable. So fantastic job to the two of them. Just a few meeting reminders. Obviously, be sure to visit the exhibit hall. It actually doesn't open until the welcome reception tonight. And it closes Friday at noon. So if you're thinking you're just gonna kick that can down the road till Saturday, don't do that because nobody's gonna be there Saturday in the exhibit hall. So do it tomorrow and Friday morning. Obviously, the society really, really relies on our exhibitors. It's almost a third of our revenue through the year. So important that we acknowledge them. Take advantage of the industry. Satellite sessions held throughout the meeting. There's a whole area kind of across the hallway where those will be happening. You can, if you don't have the app downloaded, you can download the app and get a nice overhead glance at all that there is to offer over there. And if you have questions after all the talks, if you don't mind just coming up to this microphone here in the middle because we are recording the session and we want to record you folks asking questions as well. CME credit and feedback is all being done through the app this year as well. Another reason to download the app. And lastly, the login is AFS 2021 and AFS Annual is the name of the Wi-Fi network. All right, moving on. So this is the Charcot Symposium and we have a fantastic faculty. What I'll do is just briefly introduce them and then we'll kick it off. We have plenty of cases to show at the end. You know, by design, we made this a two hour session. I mean, it's pretty heavy didactic on the front side but I'm hoping there'll be at least 30, 45 minutes for discussion after all the talks are finished. And, you know, the goal being Charcot is obviously a really, really big topic. Generally broke it down into kind of midfoot not infected, midfoot infected, ankle hindfoot infected, ankle hindfoot clean. And there's going to be a lot of overlap and there'll be some redundancy from one lecture to the other, but generally the structure of this symposium. So the lineup is Dr. Hodges Davis. We've been in practice together here in Charcot for 15 years. We've learned a tremendous amount from each other. It's been a lot of fun. Mickey Penster really needs no introduction. He practices in Chicago at Loyola. He's mentored me. He's probably mentored just about everyone on the faculty for that matter. Just a fantastic thinker and pioneer of Charcot. Dr. Clayton Baten, who did his fellowship in Utah is now in Campbell Clinic. Great to have him on board. He's certainly a rising star in our society. Dr. Reddy, who did his fellowship here in 2008. I was looking up last night. It's hard to believe it's been that long. Very busy Charcot practice in Dallas and part of the Baylor program. I see some of his colleagues behind him there. So great to have you guys here. And last but not least, Dr. Pogbabi, who is the professor and chief of foot and ankle at UT Galveston and who will lead off. So I'll bring him up to the podium now and to speak on kind of the non-operative management of Charcot and avoiding surgery if you can. Vinod. You might see him today. Good start. How does he want to go in the case we can't find him? Well, no one's here to hear about non-operative treatment anyway, really, right? Let's be honest. All right. Well, we'll lead off with Dr. Davis. And I think this lecture speaks to you've done a case and you're not sure if it's fused or failed or infected and kind of what do you do in those scenarios, seriously. Trying to keep you out of trouble. I didn't know why you put the first one on anyway. I thought you did that because Mickey was in the room. No. Where does it go when it syncs, Jonesy? I mean that's what it's been doing. It usually loads up. Did you load your talk? Yeah. I'll listen to it when I get emails from you. Does it go to a download file or something? I thought I had already done that. It's just popped right up. It's synchronizing. Thank you very much. Let's see if the next can do that. See if mine does. How you doing? Not bad. Can you play it? I can't. That's okay. Actually, his talk was working. Thanks for watching! Thank you for watching! Good morning. Good to be back, face-to-face meeting. My name is Vinod Panchpavi. The title of our talk is Avoiding Surgery If You Can. I think it goes without saying Every time you see a patient, you want to avoid surgery as Much as you can, right? You, your family, you want to Avoid surgery if you can. These are my disclosures. There may be a couple of operative cases. So this is a problem. So if you see a patient with Acute sharp neuropathy, as you can see, there's swelling in The mid foot. There's a fracture, Subluxation. Everything is out of place. Bone very soft. So in this acute phase, you Wonder what would happen to this patient. Should you manage this patient in a cast or should you put Some screws or something. That's the question you'll be Facing. You wish you had a crystal ball To see, okay, if i put screws, what will happen to them? They'll get infected, come out. Or if i put a cast, will it be Okay? Will it be stable enough? Will this hind foot continue to drift into plantar flexion? Will this forefoot be pushed up into the ground reaction Forces? We don't know. We really should have a crystal ball or we should be eminent In a few seconds. We look for also evidence-based Medicine, but, you know, for surgical, if you want to do Surgery, you want to see evidence-based medicine. But if you look at the literature, this particular Article says, you know, it's carved through 499 articles and Found no randomized control studies. More recent one, 209 articles, all of them four or five, no Level one studies. So to answer this question, Can you avoid surgery, the better question would be, when Is surgery really indicated? and most of us will agree that There are many things to consider. But one of them is if you have a very unstable fracture Subluxation, you may want to consider surgery. Or if you have a deformity which is nonbraceable or might lead Into a nonbraceable deformity towards the end of the course, You may want to consider surgery. There's one more thing i would say. We see sometimes patients who cannot afford those braces, Total contact inserts or, you know, double upright braces, Whatever you want to do, they may not be able to do so. So if you foresee that problem, you may not want to leave this Particular person with a deformity because they may come Back with an ulcer and then eventually end up in amputation. So this is another indication software maybe. But you will see, I will present some cases, some case Scenarios. There are some cases where you Can say, yes, this patient can be treated in a cast. No, this person needs surgery. You will see. And there are some gray zones. That's where your experience Will come in. So here is a case. How many would want to do surgery in this case? You can see some soft tissue swelling, some problem in the Midfoot, subluxation of the telanavicular joint. How many can raise your hands to say, I can treat it in a cast? Who would treat this in a cast? Quite a few. There are some who might want to be on the fence or do surgery. I don't know. Well, this is what's happening. If you look at the, you know, the tail of the first metatarsal Angle, that's where it should be, really. So the ground reaction forces and the Achilles tendon, very Strong Achilles tendon is causing the deformity. But the question is, will it stabilize itself? For that, to answer that question, you have to look at Carefully the bony anatomy. So here the tail of the head Is nicely locked in that midfoot. Both, you know, AP and lateral. So this is less likely to drift Out of that nicely locked. So this, like most of you do, Can be treated in a cast. But it requires, you know, Obviously you can do total contact cast or whatever you Want to work with. It does require months of Immobilization. But you do have towards the end Of the course a good resolution. As you can see, the soft tissue Resolved, the bony consolidation occurred. And this can go on nicely with good results. So here's another case. In a non-neuropathic patient, This particular patient would be painful, right? And we want to go ahead and fix this. What about in a neuropathic patient? How many would operate on this? Again, the same question. So you wonder what will happen. If you wish to have a crystal Ball, you can see, well, this is going to go on to heal well In a cast. Or you can watch them over Time periods. See, you can intervene. So you don't have to jump to surgery straight away. 12 weeks in a cast, good result, right? I mean, stable, not going to drift anywhere. But you still have to keep an eye on these patients, you know, If they have another attack later. So the scenario on both sides is different. So one is the talus is locked in nicely in the bony contours. The other one, the talus is out. So that may be exposed to Pressure. This particular skin is not Like the skin on the sole of the foot. This can easily break down. Even those can be treated in A cast if they have an ulcer. This is my mentor, dr. He said you can do a stable notch and actually look on the Leg and see the ulcer go on to heal. And those can be managed conservatively as well. This deformity looks like the talus is coming out of the mid Foot and the patient is walking on this and you might think There's no ulcer, right? but even these can be managed Long-term in a crow walker. This particular patient has Been ulcer free for a long time. But obviously, you know, those things cost money. And if medicare pays, that's great. But there's a limitation in footwear. It's not for everybody else. Some patients want to go to the Church on Sunday with cute-looking shoes. Not for everybody. So those kind of things fall Into the surgical category for me. But the patient is happy with this outcome and it's the means To do that. And she came back with the Other side. Again, custom shoes. She's happy. So they are high maintenance. If you leave the patient with a deformity, they are high Maintenance but they can be managed conservatively with a Crow walker or custom shoes and so on and so forth. What do we really aim for after an acute attack? We want a rapid resolution. We want to leave the patient With minimal deformity if possible. Why minimal deformity? because you can see this Particular paper shows if you have more than 27 degrees Deformity in the mid foot, they end up with an ulcer. So we want to leave them at least flat, if not rock or I'm going to say a couple of cases. So a case of dislocation. How many would treat this Patient in a cast? I see no hands going up. Obviously this patient has an ulcer. Highly unstable deformity. You can see the tibia down to The ground. So what we did, we elected to Do surgery. So this is a clear-cut choice In your spectrum from cast to cut. It's very difficult to relocate that ankle. We put a nail to relocate the foot under the tibia. It did well for six months. We came back with a very bad Infection ending in ICU. So what option do we have now? Obviously we have to take the hardware out. The patient is in ICU. Fuss everywhere. Not feeling well. Almost in coma. What option do we have? Can we just remove the nail? Or do we need to do more than just removing the nail? Can we avoid more surgery at this stage? Not just the beginning but also throughout the course as well. So what we did was we just removed the nail. Now what? Will it stay there or will it drift? That's the question you're asking. Again, the management. Every time you're managing this Case, you ask, can we avoid surgery again? Can we avoid surgery here? How many would avoid surgery Here? I see a few hands. Rest may be doing surgery. I don't know. So again, it's not very clear. Some people say, well, this Might drift. I may want to put a nail. Some people say, well, I want to watch. So I watch. And this patient had fibrous Union, very stable fibrous union. So you don't have to operate on a fibrous union. In a neuropathic patient, you might. But in a neuropathic patient, you don't have to worry about That. This patient amazed me. Those big holes in the tibia are completely healed. They kind of wash away the infection. She came back with other side. Maybe because of the various knees. So another case here, midfoot, very dislocated. I thought, okay, we'll put these leaving screws at that time. We got a good consolidation in the midfoot. Guess what happens with that? She came back with a sharp of the ankle. Did I create that stress in the ankle and did I give this Patient another sharp? I don't know. I might have. But, you know, looks like sharp from one joint to another Joint. Again, this is a very unstable scenario here. You know, the calcaneus lying on the side, not visible. So we did the same thing again. But, you see, I want to show you what I do in this scenario. I kind of reduce the lever arm. So that creates a very stable scenario. And this patient did very well. And has been also free for a long time. This particular patient, I said, you know, my crystal ball said He needs to have surgery because his low down. His cardiologist said, no, don't go for surgery. You will lose your leg. Maybe his crystal ball was right. I don't know. He said, okay, I don't want surgery. I put him in a brace. So I got him a double upright brace. He did well for three years. You can see this June 13th, 2016. Came back with an ulcer. I don't know why. Then he wanted, all right, I'm going for surgery at this stage. Very unstable scenario. Okay, I brought the foot down under the tibia. And then converted it into a nail. Everything looked good for some time. But everything fell apart. Fell apart. So what do I do? Braced again. But then he did well for some time. Then came back with another ulcer. He ended up with an amputation. So sometimes you fail. Despite doing multiple surgical interventions. Two years out of his life. So that can happen too. Another case, this is the last one. What good surgery do? So here is a scenario. Tail is dislocated. I thought it was a very easy case. We can relocate it. Maybe it won't drift much. I did a triple fusion. I thought he was doing well for some time. But then he comes back. With a collapse. Of the tail completely. And an infection too. On top of that. Maybe infection caused it. Maybe surgery caused it. I don't know. But we took the hardware out. He ended up with a consolidation. But I thought in my hindsight. I probably should have treated with a cast. So in your experience. In your practice. Clearly yes. I can cast this. He will do well. In some cases very unstable. This needs surgery. It cannot be without surgery. But surgery is not without risk. Multiple surgical interventions. Yet. Failure. Failure can still occur. But it is not just financial. It goes to the family. Back and forth. So the final question. In whom can we avoid surgery? If the patient can have. Or left with a stable scenario. Or can be left with a braceable deformity. Or the patient can afford those. You can avoid surgery. Thank you for your attention. Applause. Thank you. It really is a risk of surgery. Doing nothing. Something we are constantly. Trying to decide. What are the right indications. Dr. Davis is up next. Maybe. My Yelp rating as program director is crashing hard. Thanks for watching! All right, sorry about that, folks, but we're going to change the word a little bit, but this actually makes probably more sense to do now anyway. So this speaks to mid-foot Charcot. I mean, as you know, many of these mid-foot cases do creep into the hind foot, and you'll see examples of that. But generally speaking, mid-foot Charcot that have a clean soft tissue envelope may be a pain ulcer, but certainly not a deep infection. Disclosure, I was on the design team and received rule sheets for the right medical mid-foot fusion nail. I think that's definitely relevant for this discussion. There's a lot of nails out there. I don't think one's necessarily that much better than the other, but when we get to that part of the talk, I certainly have some biases. I thought I would throw up with just a couple of demographic slides. This happened to be in JAMA this month, and the only reason I know that is because I was forced to join the AMA, and then I got a JAMA email alert, which I rarely open, but I happened to, and so this article popped up. So this is a cross-sectional survey, 30,000 people, this has been going on for two decades. This is a massive study done in the United States, citizens of the United States, and they wanted to add the two-year period, 2017 and 2018, to the database they already had. And they're looking at prevalence and risk factors in diabetes. Here's the bottom line. No surprise, diabetes continues to increase in the U.S. It was about 10% in 2000, and it's climbing about 1% every couple years, so we're up to 14.5%, and you know, most of the Charcot patients are diabetics, so obviously Charcot is also becoming a bigger problem. How healthy are they? So they looked at these three targets, blood pressure, A1C targets, and LDL, cholesterol, and only 21% were in the normal range for those three comorbidities, or medical targets. So they're not healthy patients, the numbers are increasing. One-third have a high school education or less, so they're not necessarily a very sophisticated or well-educated patient population, and a lot of them are uninsured. So for obviously the orthopedic reasons, but all these other reasons, you know, it's a really tough patient population to take care of, but yet we still continue to do it. I think it's, I find it fun and challenging and very rewarding, and it does turn out well. It's an incredible geographic prevalence in the southeast, which is obviously where we are now. We call it biscuit poisoning, there's a lot of Bojangles on every corner in Charlotte, you'll probably see why you're here, but the lifestyle choices and the diet in the areas like Charlotte, really the rural areas in the southeast are pretty bad, and that equates to a really high prevalence of diabetes, which is, then equates to a lot of Charcot, which is one of the reasons Hodges and I and our group stay so busy with Charcot. When I talk to my colleagues, for example, in the Midwest, in the northwest, you know, they see a far different number of diabetics. So this talk, I'm going to really focus on the midfoot, in the words of Dr. Pinser, who's one of our faculty, and our goal, really for any level of Charcot, not just the midfoot. Infection, ulcer-free foot, the ability to wear an in-depth shoe, over-the-counter ideally with a custom orthotic, and independent ambulation. And for the midfoot, it's different for the ankle, but for the midfoot, based on the number of series, that can be achieved in about 60% of cases. With Stille, it's 40% that will likely come to surgery for a variety of indications. The deformity that's at high risk for ulceration, that's probably the hardest one to identify as a surgeon, that is, addressing the deformity before something goes bad, weighing the risk of surgery against that. The obvious ones, an unstable, unbraceable deformity, a deformity that's progressing despite immobilization, a recurrent ulcer, and of course, a deep infection. So for the midfoot, who fails non-op treatment, a lot goes into this decision-making if you want to, if you're a pure numbered person. This article demonstrates that if they have a Mary's line roughly 30 degrees or worse on a weight-bearing lateral, that they have almost 100% risk of ulceration. So we do use this number to help guide our treatment. You see somebody comes in for the first time, they've got substantial collapse on a weight-bearing lateral for the midfoot, you may not want to entertain surgery right then, but I think if their numbers look pretty bad, their course may not turn out well, and it's at least worth starting to have that discussion with them about, are we going to watch this, are we going to be aggressive and fix it? I think stability of the midfoot is so important too, just on a clinical exam, here's a lady, she's got a pretty small ulcer, but she is massively unstable at her midfoot when I examine her. And a bumpectomy here is not going to work, it's just going to make her more unstable. You could try bracing it and casting it, you probably would get this ulcer healed, but when they have that amount of instability, it's really hard to get them over the finish line, I think, without some kind of reconstruction. Basic principles for the midfoot, we're going to have pain or deformity correction through arthrodesis and bone resection, there's not much of a role for joint saving or sparing procedures. External fixation, which you'll hear more about from the other speakers, we reserve that for patients with deep infection, not much bone to work with, and then a lot of surgeons are now using X-Fix and InFix. For the purposes of this talk, I'm reserving internal fixation for what we call clean cases, maybe have a superficial ulcer, but certainly not a deep infection. We can talk a little bit more about the presence or absence of an ulcer in a bit. So internal fixation has seen a tremendous evolution over the last 10 years. You know, when I started doing this, we were doing big medial plates, you know, prior to me practicing, and there was some, you know, Lou Schoen had even popularized plantar plates, even lateral side of the foot. Those have sort of fallen out of favor just because of the exposure and the risk of deep infection and the metal load and migrated more towards the beaming techniques with bolts and screws, and then the mini IM rods hit the market probably three or four years ago, which I really do think have been quite a game-changer. Regardless of what you use, I love this term super construct that Dane Winklage described about 10 years ago, forecharco, and that is using beyond the conflict of region to improve fixation. If you often have a large area of crappy bones, you want to go as far one side of it and as far the other side of it to really get a good construct. Obtaining a deformity correction by resecting bone, which in effect decreases skin tension and allows, in many cases, you can even resect and close the ulcers. In my opinion, not a lot of role for distraction osteogenesis or distraction soft tissue reconstructions with dynamic frames. I think in most cases, these patients tolerate being shortened, whether it's their extremity or their foot, to obtain the right alignment. Using the strongest implant tolerated by surrounding tissues, that's always a challenge because the mid-foot's in a subterraneous location and there's only so much metal you can put on the bone without causing problems in the overlying soft tissue envelope. Positioning the device with optimal biomechanical effects. If you look at all this, plate, for example, satisfies some of this, but not all of it. If you look at beaming or the mini-IM rods that are intra-osteous, it really more closely matches what we would call the ideal super construct. Beaming came about, it's hard to know really. If you look back at the literature, I probably would give the Simarcos credit for at least the concept. They didn't use the term beaming, but it's essentially what they were doing. This is a JBGS article in 2009, their experience over five years. And they were placing large PLA screws in an intramedullary position. In their words, no periosteal stripping, avoid stress risers, to just clean the whole bone. Simplify the alignment, it's really hard to have malalignment if you're intra-osteous from one end of the foot to the other, and maximizing your compression. They had 22 patients, and they used a smorgasbord of screws from medial to lateral. They were all ulcer-free at the time of surgery, they made a big point of that in this article. If they had an ulcer, they would cast them until they were ulcer-free, and then they would do the infix reconstruction. This is a picture from their paper, and these were placed percutaneously, and there wasn't really a system available back then, so they were using different size screws, as you can see there, all placed retrograde. Of interest, different to kind of the technique that we're doing now, they did not cross the TN joint in almost half their cases, more than half their cases. And they comment that that may have been a fallacy of this particular technique, this was a get-leg-collapse at the TN joint. So we now advocate, as I advocate, doing the whole medial column. So they had a pretty reasonable outcome, they had 73% solid union rate, which I'd say is pretty high for a series of Charcot. Early one-week Charcot deformity, that's probably what we're looking for, that's the primary outcome. One-third had hardware failure, but like many Charcot studies, it probably doesn't matter, you're going to have hardware failure, but if it doesn't result in a clinical problem, then probably not that relevant unless the hardware requires a secondary procedure. They did have four recurrent ulcers, primarily beneath the first metatarsal head. We have had a lot of problems with that as well. I think when you create this real rigid medial column, especially if you overcook it a little bit into what may look like a small amount of cavus or excessive plantar flexion in the first ray, it's really poorly tolerated because it's such a stiff foot and I've had countless cases where that reconstruction looks amazing and they heal and the midfoot looks great, but then they get a problem under the first met head, which you can treat with a sesamoid excision, first met head excision, dorsiflexion osteotomy, and we've been down many different pathways with that. It can be pretty frustrating. So I'm really careful, I think we're all careful, when you do your midfoot fusion, however you do it, just make sure you don't get too much plantar flexion. So I don't take credit for term beaming, it was not me, we may have helped popularize it, this is RFR 2015, it's really just a technique guide, but what happened was a lot of companies sold systems, and these systems, we needed size appropriate screws, both diameter and length, and there's multiple in the market now. So now you can have one kit rather than having six or seven different systems open because you're not sure what size you need. And many of these systems have solid bolts rather than just tenon screws, so you can do a guide pin, a tenon drill, and you can use a solid bolt, which is much, much longer than a tenon screw. And subhalar fusion has now been included in many of these midfoot reconstructions, and we can talk a little bit about that. So, my approach is, as I mentioned, the entire medial column, so first TMP to TN joint, so it's a medial incision, I typically do add something on the lateral side of the column that, at least a CC joint, sometimes more, depends on, every case is different, depends on the deformity. Sometimes add the subhalar joint, as I mentioned. These last two is all about the joint craft. If it's a really sloppy, unstable midfoot, and osteopenic bone, maybe that's sort of an early Charcot fragmentation kind of stage, then I'll just kind of go joint to joint and just prepare them in situ. If it's a rigid, severe deformity, if it's a big block of bone that's malunited, then I'll do a closing one gastronomy, which is much more effective to get your deformity fraction. This is a case, actually a case from yesterday, which is such a good case in terms of highlighting all the different ways that we think about this that I ended up throwing it in for today. So this is a 55-year-old big guy, well-controlled diabetes, 6 foot 8, foot size is like 17, massive foot. And he's had this for several years. He's got a well-consolidated midfoot, Charcot, with this big bump on the bottom of his foot, never been infected, but he can't stand it. We've tried different kinds of inserts from some good local orthotists, and it just hurts. The bump hurts, and generally he feels like his foot's unstable. So I've probably taught him three or four years before we decided, okay, let's fix this. We talked about a bump acne, which I didn't think was entirely unreasonable in his case. I told him it might come back, it might make it worse, and then we ultimately decided just to get it right the first time. APX-Ray, I think it looks fine. You can see the midfoot there on the right. Primarily limited to the midfoot, but he's getting a little bit of abduction at the T-end joint. Here is my exam just showing you how stable this midfoot is compared to that case I showed earlier. I mean, this will not budge, so this is a different indication. I mean, this is not an unstable midfoot, it's just a deformed midfoot that's painful. So we did a medial incision to expose the joint from the medial side. Different things you can do with the anterior tip tendon, Dr. Davis likes to cut it and just tag it and repair it. In this case, you can see that superior elevator inside the shin rake on the top of the machine. I'm just pulling it out of the way. We just peeled it off, decayed the form, didn't fully release it, but just lifted it up enough so we could get to our osteotomy, and then I'll just tack it back down with heavy suture. Some people just blow right through it and sew it all back together with one soft tissue envelope. It's probably worth doing something somewhat purposeful with it, regardless of how you do it. For the Aquinas contracture, I put a chance pin into the calcaneus so I can control the heel. It's really hard to control the hindfoot, especially if you have a soft midfoot. So we put a chance pin in, it takes a minute to do that, and then we did the triple hemisection TAL. Got a really good Achilles contracture release, and now I can control the hindfoot as I build the forefoot through the midfoot back to it. You can leave that in, but for the rest of the case, it kind of sits in the bed, and it's a good way to control your heel, and you can control your forefoot and match them together as you're doing your fixation. I prepare the TN joint every time. Sometimes it's hard to find, especially when you have kind of a band of mayhem on either side of the foot. So I'll use volume fluoro here just to make sure. I mean, you can get a fluoro shot and you're nowhere near the TN joint, so you just want to make sure you're in the right place. So we started with a TN joint preparation, and then we planned for our osteotomy. The thought was we were going to do mainly a... He's not abducted that much, but he's forceflexed. We wanted to plantar flex him. So we put in these K-wires to do a closing wedge osteotomy immediately. Not a real big closing wedge osteotomy, but more importantly, as you can see on the right, we were going to do a plantar closing wedge osteotomy. Five plantar cut. These are blades we use for our pedal ankles. There's a small one and a wider one. These work fantastic for this procedure. You can run it all the way across with K-wires right across the foot. Big home, nasal, and top and bottom. Fairly safe and fast, and it's not hard to do it. You know, put the K-wires where you want it. Get a general idea of the geometry of your osteotomy, and go for it, nasal, lateral. If I back up here... You know, where you converge here can vary. I was going to prepare the CT joint separately. I thought this was going to be natural. It just kind of ended up in this mess over here. It was just kind of cuboid, but you can direct this wherever you want to allow it. That made the most sense in terms of a good healthy bone that we could resect. So here is... We've done our cut. I've taken off the wires. Here's just removing that wedge of bone. And... Very powerful procedure. You see how much correction we can get. We can flip the foot. Look flatterly how that area is fully decompressed now. Easy procedure to a pretty... Honestly, a pretty small incision. So we've done our TN joint. Did the mid-tone osteotomy. Went to the lateral side. In this case, you may not necessarily have had to do the TN joint. I mean, the subtalar joint, excuse me. I did it just because I thought it would add stability to this construct. It's a big guy. And he did have some heel valgus, which you may not have appreciated on the pre-op x-rays. But I thought it might help with that, too. So one incision with the subtalar and the CT joint. We take BMAC from the crest on all these and just mix it with... If it's a clean case like this, we just mix it with allograft. We kind of gel our BMAC so it's sort of juicy. And whatever your BMAC of choice is, we kind of mold it into a ball. And then we can stuff it into our pieces. There's lots of options there. So now we've prepared the foot. We like the alignment. I mean, the key is... It's like doing a terminal nail. It's all about the starting point, right? It's all about reduction and starting point. I think the key to these foot reconstructions is all about the medial column position, guide pin, and then your nail. So this was done retrograde through the Hallux CT incision. You make a true incision, plantar flexor codes, they're retrograde. And this... You may not get this the first pass. I mean, we'll put our wire up to the base of the first metatarsal and then kind of manipulate the foot and the reduction using the Simon pin. Manual manipulation. Get everything lined up just like you want it. You really want that wire to be fairly centered in the tail from front to back. And this took us five or six passes to get it right. We put in our nail. Then we did lateral column fixation from front to back. With our long chain of the screw. And then the last thing we did was set the tailor to the bottom line. Which there can be some traffic here. You've got to navigate two screws. And sometimes the nail threads are in the middle of the tailor head. So that's our, this is sort of a triple midfoot fusion construct is what I call it. Before we were doing that, I was doing a lot of this. You'll hear different advice about what's the right construct. A lot of it is what is it that I gave you, and then I think use it as much as you can. Honestly, it's time we're out of it all. The 10 and triple is where I've fallen for my favorite go-to, which is the medial column, nail, lateral complexation, we've talked about the back of the front, and then it's up to the other two. 10 to 12 weeks, not only are you going to have calcium, vitamin D, and then six to eight weeks in a walk-in booth, and then transition into hopefully a regular shoe. It's a pretty prolonged non-weight-bearing post-op course. Assuming they're compliant and obviously they aren't all, but that's what we try and do. This is a series out of Charlotte of our original three-year series of beaming. We didn't have the nails available, the mini nails, and we weren't really doing any sub-therapies here. This is our first, it was definitely a learning curve here. Sam Ford is one of our partners now, wrote it up. We had 25 patients, only a 50 percent union rate, not surprising. Again, I think it's so hard to get it to solve union patients, but an 86 percent success rate. Again, in short period, you can find success far differently than other series. Our outcome was a stable plant of great foot, so we got a stable plant of great foot in 86 percent of patients. However, we did have six deep infections. I mean, legitimate deep infections that required IND and three had BKAs. All those patients had an ulcer at the time of surgery. We thought if they had a small ulcer, we could ioban it and not cross-contaminate a vertical field, and maybe you can do all that, but we're now really, really cautious about this in patients that have an acne ulcer. Not saying you can't do it, but you just have to be really, really cautious. Ideally, you wait until the ulcer's healed before you do it, or you just go to the next one. The last two slides, so the mid-foot nail evolution is because we wanted a cannulated device. We were having to take out our guide pins to put in solid spherules, and we did that for patients sometimes. We want a larger diameter, better compression, and somebody to prevent migration. By having an interlock spherule in the nail, you can prevent migration. There's at least three on the market now. They all have different advantages and disadvantages. I first started doing it for revision cases. This is a failed beaming case of my own, which is a pretty miserable, hard operation. I ended up doing a nail for his medial column, and you can actually use these nails for subterragone as well. That was a pretty good salvage. Then we started doing it for primaries. It was working so well for revision cases, so we did it for primaries. This is a 56-year-old school teacher, bilateral tracto. Very nice lady. No ulcer, but just a lot of pain, a lot of mechanical pain. We tackled her left foot first, and we did the mid-foot nail, did that triple mid-foot construct I showed before, and this is her two-year post-op, and we'll do her right foot at some point. It's a big surgery, but I think this construct really does hold up well. I mean, at least get a good, at least get out of pain. In terms of the nail, it's the same procedure in terms of getting your foot straight. It's just a different device that I think's bigger, better, stronger, faster. I don't think anybody would just do that. You can buy a mobile device, and I think that's evolving into the gold standard for at least for the medial column, but there are no, certainly no long-term outcomes that we get on the mid-foot nail. We do see some failings fail a little bit differently and not as often. So when to add a subterragone, we get asked this all the time. I mean, if it's a subterritor deformity, that's obvious. If it's a short foot, it's the same as a high foot, I would have a low threshold. Even if the relationship between the calcaneus and calus looks pretty normal, I do think it helps prop the calus up and adds stability to the whole construct and maybe a better prognosis long-term. Revision cases, and again, maybe all cases. I don't do it in all cases, but I'm certainly doing it in more cases now than I used to, and I know Dr. Dave would feel the same way. He's really the one that kind of got me rolling this bandwagon. Of interest, this is Dan Wukich's series out of UT Southwestern. This was in GFES in December. I didn't realize this was out there until I was being lit for it the other night. So they look, it's not a big series, it's retrospective, and the size is not great, but it is the first paper to discuss it. So does subterritor fusion improve the outcome for midfoot charcoal? 30 cases, 22 had subterritor fusion, eight did not, okay? So 2 3rds had subterritor, oh, eight didn't. We looked at reoperations and deconfections, they had an 80% lower complication rate as in terms of reoperations and deconfection of the added subterritory. So they feel pretty strong as subterritory fusion. I didn't put it as a slide because I didn't want to steal the thunder, but one of our fellows has a paper that you'll see later this week. We looked at the biomechanics of adding subtailor to the midfoot, and we have different constructs. We did it at the Canaveral Lab. It's pretty tight, biomechanically speaking. It's not as convincing as this in terms of adding subterritory fixation. It's actually up for the Golden Award, but it's worth taking a look at. It probably does add some stability. I'm not sure how important it clinically is probably still to be determined. Closing thoughts, as we heard from previous speakers, yeah, absolutely okay to be conservative, but if you're watching a slow car wreck, then stop it, you know? And that's the hard part with truck driving. When do you intervene and when do you kind of let it go? And having done it for 15 years, there's still many, many cases that I can tell you I'm not sure. You can always follow them closely and lay some crates and then jump in when you need to. You don't necessarily just say seam in the air. There's many ways to beam. Find your comfort zone. If I'm back, Dr. Frey, I'll close the news. I would say almost always include the entire medium column, including the pin joint, and I think the midfoot nail that's pinning hard, and they're probably here today. Thank you. Okay, well, it certainly is a lot different than when we first started talking about the Charco foot 20 years ago. And what Carol asked me to talk about was, what is the role of the circular external fixator? So we'll do my disclosures. So here's the lady, here's the reason that we do external fixators. She's 69, she's morbidly obese, BMI of 42. If we think about the pathological disease process of diabetic organ system disease, is sugar chelates to hemoglobin. And that's what glycosylated hemoglobin is. It releases free radicals that damages the basement membrane in blood vessels everywhere in the body. So if you have peripheral neuropathy bad enough to have a Charcot foot, you also have heart disease and renal failure. You've got to have all three. And because of the renal failure, you've got osteoporosis. So you don't get a little bit or a lot. Everybody gets all of these organ systems involved at about the same level. So in this lady, she is, and I'd like you to think about, we're talking about the Charcot foot. But I want you to stand back for a second and think about this lady is really the surrogate for the worst possible patient who can walk into your office or come in in a wheelchair. And we want to think about this. We're talking about Charcot foot. But you can use these principles in other patients. So here's her x-ray. She's obviously, like me, she's grossly deformed. She's grossly unstable. She's infected. And let's think about her. She is the worst possible patient. She's morbidly obese, poorly controlled diabetic. She's got infection. By definition, she's immune deficient. By being immune deficient, she doesn't like foreign bodies put in her body. And she's got severe, we used to call it really crummy bone. Well, she's got severe osteoporosis secondary to her renal failure, which she has to have. So what were our treatment options? Prior to 2000, when we did the year of the diabetic foot, these people all had amputations. Then we got into this concept of staged reconstruction, where we would debride the wounds, we would resolve the infection, or we thought, and then we would correct the deformity with inadequate implants. Let's fast forward to today. And here's an interesting study that we did. There's nothing that damages your opinions more than evidence. So this is a study that we did. This is in the first 78 patients that I did. And we looked at the first 78 with osteomyelitis. So what I wanted, the reason we wrote this paper was these people, the infection was always caused by staph aureus. So the number one cause of infection is staph aureus. The number two cause of infection is staph aureus. And then you get the other things. So that's why we originally did it. But an interesting thing came about. In the people that we operate on, my general practice is, if the patient has ever had an open wound at all, or has ever been treated for infection, they get pathology, and they get bone cultures, bone tissue cultures. We found 20% of our early series that had normal SED rate, normal CRP, no open wounds, and they were infected. So you've got to be very careful. You may think you've resolved infection, but there may be a low-grade dormant infection that you haven't thought about. And this is evidence. 20% of these people had no clinical evidence of infection when I operated on them. No wounds, normal SED rate, normal CRP, and yet they have either a positive culture or they have path consistent with chronic infection. So let's think about what are our options. We can either try to resolve the infection, whatever that means, with debridement, prenatal antibiotics, culture-specific prenatal antibiotics, and then what form of implants do you want to use? And that's a real problem. We have to be strong enough, but the bigger the implant, the more foreign body, the more potential source for infection. Versus doing what I call, actually, what I didn't name it, it was named long before me, a single-stage resection of infection, correction of deformity, and immobilization with a static circular external fixer. And I think Carol made a very, very good point in this talk. You don't want to be doing a lot of gradual correction in these people. That really should be reserved for experts, because when you start doing gradual correction, that's long periods of non-weight bearing in people that are osteoporotic and with a lot of potential problems. So what my observation has been is we like to do single-stage, one operation, where we resect the infection, correct the deformity, and apply the frame just to hold the correction. So here's what she looks like. This is our lady. This is a couple of weeks post-op. And a lot of times, these huge deformities with these huge wounds, when you resect the bone and shorten the foot, like Carol said, you can close the wounds. And we use the resident's lap, because we close all the wounds one layer with number two nylon sutures. We don't futz around with multiple layers. And it fries me to see residents take a tissue force that can crush the skin and add more damage. So staying away from adding more damage. She is at two years. Now, if you had done a BK on this. do a BK, and they have renal failure, which they all do, they volume fluctuate and you can't fit them as a BK. So what you have to do is, if you're going to do an amputation, you either have to do an ankle disarticulation or a knee disarticulation. You can't do transosseous amputations in these people. So my short message, really very simply, is the Charcot foot patient should serve as a surrogate for the worst possible patient that either walks or rides into your office. You can extend these principles to other patients. And what we want to do is, we want to think about what is the role of fine wire fixation. Well, it's real simple. As you go to poor surrogacy, you can't do a BK. things, immune deficiency, the higher you go up on that tree, the more you should consider external fixation versus internal fixation. And like Vinod said earlier, I love that slide where you have the gray zone because there is a place where certainly we can identify the patients that are best treated with a simple operation and which patients are the ones that are severe that require a complex operation. And what do we do with the people in between? And time will tell. As we get, we certainly have much better answers than we did 10 and 15 years ago. Thank you. I always like following Mickey because I think following Carol, Mickey, and we've developed our philosophy. So so the question is fuse failed not fuse We've already talked about this being a difficult patient population for all of the reasons that I love, you know, worst case scenario, and this is the patient we're having. But a couple of key points that I feel aren't talked about enough. The first is the belief that Charco is paying less all the time, and we know that that's not the case. If you don't treat enough of it, you're going to be doing surgery for pain in Charco patients. And the worst case, and I do a little legal work, is you get an expert, quote-unquote, who is an expert in Charco, and they say, well, this for sure is not Charco because Charco is never painful, and we know that's not the case. The second is don't miss non-diabetic charco. And the reason I mention these two is often they're the ones that will bite you as far as getting a complication, both congenital insensitivity of pain. But the rheumatologic charco is really the stuff that I'm seeing more and more with DMEDS and other things. And Jim Brodsky's group reported, and it was not a big series, but it really made me think about some of my failures and how I truly missed a rheumatologic charco. So what I would tell you is in this patient population, complications abound. And the key is to avoid the ones you can avoid and act quickly to the ones that you can remediate. So the first is some of the points. Underestimate or miss neuropathy, the wrong operation in the first place. You wait too long to intervene, and denial of failure is worse than the failure in the first place. So the first is underestimate or miss neuropathy, just like this guy kind of turned his back on the wrong person. But a 49-year-old, long history of RA, multiple meds, and has had some foot pain, but was doing okay. You can see on the left side, there's a little collapse. Two years later, something really changed. The right much greater than the left, and you can see that the TN joint is getting worse. And then six months after that, all of a sudden this has gone south. And so what I would caution is if you have a patient I've started carrying those in my lab coat again, and you can buy them on Google. For 10 bucks, you can get 1,000 of them, and it's worth having. So, rheumatoid with a dislocated hind foot, what do you do? You do a double with an anatomic deltoid, and three months post-op, This is a missed Charco, and now 10 months post-op, the ankle's killing her, and she ends up with a Pantaleon. So beware of those patients, and do the right operation because of that. The second is the wrong operation in the first place. So a 58-year-old diabetic presents with swelling and pain in the right foot. Was put in a boot, but allowed to wait there. Never thought that the first person who saw him that this was Charco. Six months later, there's still no ulcer, but clearly this is deteriorating. And 12 months after presentation, now there's a significant ulcer under this dislocated cuboid. So steel casting, and steel has an ulcer. So did an MIS cuboid resection. not show it. So what I did is I said, well, I can, I can save this patient's ankle despite almost having a vertical talus and did a midfoot triple with the frame. Um, and I, I call this the triangle of life, Carol. So, yeah, we, uh, we have different call for so six months in a frame. I love the frame over the top. So, in my opinion, I think that I probably should have done a TTC fusion initially because the correction And so, whether or not it gets on or whether or not I caused it with the wrong infection. But in retrospect, Dane Wookage wrote this great article, and you know this got rejected by FAI. It got rejected by Journal of Foot and Ankle Surgery. No one wanted it, so he's in at the Journal of Diabetic Medicine, because it's a fairly strong opinion, the consequences of complacency. And what he showed is he compared grade zero Charcot, so something that you can only see on MRI, with a group that was missed at grade zero. So it got picked up at grade zero, missed at grade zero. And the ones that were diagnosed at grade zero, before there was any collapse, those patients did not have complications. The ones that were missed at grade zero did. And so his question is, when x-rays show any progression, should we consider intervening at that time? And the intervention, in my opinion, can be as little as putting them in a frame and doing a TAL. And more and more, if I'm seeing patients with early collapse, I'm doing that. Because in my practice, a good static frame is much safer than a contact cast. So the conclusion is, is that early management, even if it's just offloading them at grade zero, can change the implications and the outcome. Never in any of the notes did they report that she was neuropathic. And so when things started going bad, is this an area where we could have done a primary infusion, infused her medial column, at four months? Or, in many ways, Three years later, she has made the rounds, right? So she has gone to multiple doctors, and she keeps saying that it keeps swelling, and it's unstable. And when she finally comes to me, she now has an ulcer, and she's been caught in the wound care center circle of Picken and Grennan, right? And no one's thinking that her talus is gone. So in my opinion, this is a woman that should have been treated appropriately three years before, and so now we're in salvage mode, right? So she's got a calc, and I did frame, took the infection out, framed her. Maybe waiting in casting is the worst thing to do. 54-year-old, deformity, no ulcer, insulin-dependent, already had a toe amputation, and is starting to fall apart. Comes to see us, probably me, but I'm hoping it's one of our PAs, and at 23 degrees, so doesn't hit the 27 degree, what do we tell him at this point? He doesn't have an ulcer. Now, two years later, has a pain. multiple surgeries at some point should someone have reconstructed this guy. support group, 42-year-old, history of forefoot ulcers and osteo. His ulcers keep returning. He has a history of lower extremity burns after his his boat blew up. And so he's had medial column amputations and now he's got a mid-foot shark bone, right, with an ulcer and he's got horrible skin grafts all over his leg. So on this one I said, well, you know, So I'm feeling pretty good. I thought he was fused. But, you know, I keep getting scared away by his skin grafts. So he's got a clear non-union of his tibia, the cement is high, it's in my way. It probably is what caused the fracture in the first place. He doesn't have any ulcers at the time, and that's yet. So I said, well, I'm going to do this. So I did an antegrade nail. I reamed through the... Now he's got an infected non-union because he's infected, but I'm still in. And now he has a non-infected nonunion. He hasn't had an ulcer in two years. These are high-risk patients, and as I tell the fellows all the time, if you're scared Fundamentals are still there. Thank you, Dr. Bateen, ankle and hind foot charcoal, nail frame or both. pleasure of not only following in about every way possible. So at the end of the day after this talk, I just want you to learn what I think I've figured out after a few years of doing this. Again, tough patients, tough problems. Dr. Penzer so eloquently has detailed the pathophysiology of why this is an issue, but there's a high rate of complications no matter what way you go. If they ulcerate, half of them can end up with an amputation and their life expectancy is about 50% approaching five years if they show up with an ulcer. Amputations are not easy, exactly as been detailed earlier due to the volume fluctuations. So it's a tough problem with the quality of life similar to that of Parkinson's or chronic CHF. Plates and isolation. Sometimes plates are nice when you go to fix these deformities because you can correct the deformity, pin it, slap a plate on there and use that to help correct the deformity that you developed. Problem is, is a lot of the implants on the market are quite thick. So you're only as good as the bone you're anchoring into and you're gonna have prominent hardware such that I don't think a plate in isolation is necessarily the right answer. Dr. Mulligan, one of our former residents and the Duke people wrote this up looking at nails versus plates for TTCs. They found that they had a higher union rate with their nail, but a lower revision for symptomatic non-union with a plate alone. That said, only 12% of those patients had Charcot. This is a different animal taking care of Charcot patients. back. It's a powerful tool to have. You're not going to have any retained hardware when you're all said and done. You can generate a ton of compression through this. People talk about having weight. But if they put all their weight on it, they're gonna fall or they're gonna break their tibia. Downsides to it, pin site infections are absolutely gonna happen. Delayed infection. I've seen this. you need an email address need somebody to clean your pens and those things are actually kind of hard to come by in in some of these patients with these chronic problems. Most patients I've had one that would accept. 15% for your half pins you're gonna break some tibias and that's a bad day the complications vary widely across studies So this is a patient. I did first year out of practice. He was gifted to me by dr Richardson one of my partners who teed him up for me my first week of practice fixed Charcot deformity And I said, ah, I know how to take care of this Put him in a Taylor spatial frame to jack out his deformity before I went in and fused him fused him looked great He comes back He broke through his fine wire site from his initial Taylor spatial frame above his lateral plate that we put put on So in the data look at dr. Fragment at HSS. Obviously, they do a lot of frames there They looked at a hundred of their patients 19 of those patients were Charcot for isolated tibia Taylor arthrodesis Four of them had stress fractures of the tibia two went on to amputation or one went on to an amputation But all three of them collapsed at the sub Taylor joint such that now when they do this They automatically incorporate the sub Taylor joint into the frame. So what about a nail? weight. This is something that's sharing the weight. The downsides, it's limited by the bone you're putting it into. In reality, you're really relying on that fixation between those calcaneal screws going into that nail in the calcaneus. The calcaneus is a bunch of cancellous bone. You're not getting a lot of cortical fit on that. And so, I've definitely had these fail in isolation. out of Dr. Bach's group in Austria, they looked at 20 of these ankles. They had 16 out of 19 limbs salvaged, but has been eloquently stated by Dr. Penzer and everybody before, that's not the answer. It's stable, ulcer-free foot, able to ambulate in commercially available footwear or an AFO. And this paper doesn't really show that. So people that do both, Mount Sinai, they put them into two groups, the group that they nailed, the group that they framed. And what they found is they had a much lower revision rate doing the frame than nail and isolation. 11 out of the 16 nails needed additional surgery. Similar fusion rates, but you needed a lot more surgery if you just did a nail alone. do it. So you think to yourself, gosh, what if I add these? ulcer, tons of deformity, I went in, I fixed him, I put a frame around it, 9 foot nail, he looked great and has absolutely done great. So the frame is going to increase the overall rigidity of the construct, it's protecting your internal fixation, it can allow you to guide the compression. So you can put the nail up, put the frame on, and then compress, and you're guiding that compression across the rod if you haven't locked it proximally. But do the pin sites. frames are not benign. This is a patient, again, thought I did the right thing. Bad Charcot, went in, nailed him, framed him, looked great, but then eventually all completely collapsed two years out with a failure. So, nail and frame, a study out of Egypt where they took care of these combined, they didn't lock proximally, allowed them to guide the compression with the nail, and on x-ray they didn't have CTs, but they had pretty good outcomes with regards to fusion and nobody ended up with an amputation. So, study where they looked at eight patients where they added that antibiotic nail, which I think is a great technique. I use this paper frequently if you're going to do an antibiotic nail. Good outcomes in these eight patients, and then another paper out of HSS, three of these five patients had failed frames, that then they came back and added that antibiotic nail to. So, I do think nail and frame is an option, but you really got to watch that risk of seeding the nail. So, what about a cage? Sam Adams got a great paper here where he talks about 3D reconstructive titanium cages for severe bone loss. 13 out of 15 went on to fuse and only two ended up with an amputation. I mean, that's great, but none of these patients were Charcot. So, it was contraindicated in the setting of infection or uncontrolled diabetes, which is a lot of these, and you got implants that are going anywhere from $10,000 to $20,000 into something that's quite possibly going not infected and getting out regardless of what the x-ray looks like. The titanium cages look cool, but I don't think they really have a role in Charcot deformity. Fulc allograft, Coetzee has got a recent paper, very well done, good fusion rates, femoral head, taking up the bulk of this. However, these are all for total ankles that had failed, not Charcot. My Charcot patients were at no point a candidate for a total ankle, so I don't really think this is broadly applicable to them. So why do we not have a clear answer? As I look six years out from practice and sometimes feeling like I'm more confused than when I started, it's because this is anecdotal medicine. We sit up here and we show pictures of things that worked, things that didn't work. We're drawing conclusions based off of these and we're ignoring the fact that a lot of these are single surgeon studies. We all have different inclusion criteria. Some people do not tackle those morbidly obese ulcerated All the patients are different and then patients. That's a frame candidate. That's totally different than somebody with a terrible a1c Concomitant midfoot shark toe deformity nobody to take care of them. These are all very different problems and Mickey pincer does a lot better frame than I do. He's a better surgeon He's got a practice that's set up for this that really impacts the outcomes So if I look outside a foot and ankle and I say okay has anybody else dealt with problems in Crappy bone Somebody that is absolutely going to walk on it No matter what you tell them they are gonna walk on it. If they don't walk on it. They're gonna fall They're gonna do something else. So they will walk on it. So who else deals with this? promisers So what can we draw from the elderly? Distal femur fracture you have patients that need to walk on it If you don't walk on it after and you're that old you're gonna get pneumonia You're gonna get urinary tract infections and other things. What can we learn from them? nail plate Constructs, so this is something I've started doing in the past year, which I think is is turned out well for me thus far So you mix and match the nail is nice because it's load bearing load sharing the plate is nice because it's load bearing but it's allowing you to engage that cortical bone on the outside of it the Calcaneus and then anchor that to the nail that's going up You can distribute the forces all the way across the foot and it's probably stronger in all planes than either technique alone When you have those screws from your lateral plate going around the nail and allow them They're basically polar screws. They're blocking screws, right? They're increasing the rigidity of the construct and the trauma literature is full of people that are now doing this and allowing those patients to Get up and walk on it right after surgery so There's now a couple patients that I've taken care of bad shark toe deformities using hind foot nail and some of the newer TTC fusion plates on the market more fixation keeping them out of the frame Cons, yeah slightly increase in cost. However, nowhere near what an amputation is going to cost them increased or time Yes, but as I tell my residents and fellows on this case, this is the easiest case we're gonna do today So you get in you get the deformity corrected you get it stable get it closed. Don't get it infected This is a two-hour operation that you do we're closing by turning the time big incisions Full thickness get in get the deformity corrected get a nail up throw the plate on shoot everything locking Fill up every single hole get those screws both above and below the screws going into the calcaneus link that fixation And this is now giving you something very stable that will probably tolerate them to walk on it afterwards I tell them all not to walk on it, but they're not going to listen to that So another patient here that I've taken care of same construct also with concomitant midfoot Deformity that is doing well the new implants on the market really allow you to take advantage of the variable angle locking capabilities They're low profile and thus far had good success So I alluded to the anecdotal medicine the single surgeon stuff and here I am now adding to that So five patients that I've taken care of in the past 12 months with a nail plate construct Four out of the five are plantigrade ulcer free ambulating and commercially available footwear That would be an 80% favorable outcome. One of them is in a bucket. I gave it a shot She refused an amputation. I probably knew it wasn't gonna work, but she was willing to accept the amputation after this failed believe me not This is what I'm doing right now. I think it works, but we'll see how this evolves over time. So, conclusions. Tough patients, tough problems. You have to have a big toolbox, and you then choose the right implant, you choose the right construct based on the patient, based on all those social factors and everything else. You use the operation that, in your hands, gives you the best shot of delivering that. And when in doubt, you ship it to Loyola. Alright? Very good. Thank you. That was great. Thank you, Clayton. Dr. Reddy, wrapping it up for us. So I'm probably ready. I'm down from Dallas. No disclosures to this presentation. You know, Charcot is interesting. There's really no right answer. A lot of times you feel like MacGyver. You're given some yarn, a battery, and you're supposed to stop the terrorists and save the world. Usually through the process you end up feeling like MacGruber because you're stumbling all over the place. Nothing works the way you think it's going to work and it just is ugly. So, you know, why do we do this? So, as everyone stated, these patients are big. If we cut off their leg, they're probably never going to walk again, especially the ones in Dallas. When I first got on to practice, it was pretty quick to amputate thinking, you know, advances in prostheses and prosthetics are pretty impressive. They can walk. They can wear normal shoes. But the problem is they start developing And then if you live in a state like mine, in Texas, where you're supposed to pull yourself up from your own bootstrap, but if you don't have a boot to put on, you're kind of screwed, Texas doesn't pay for a prosthesis if you're over 21. So they'll pay to save this limb, which is approximately the same of salvaging it in terms of cost versus amputation. So they'll pay whatever it takes to save the limb on Medicaid, but they will not pay for a prosthesis. So it gives you another reason to keep trying and saving these people. You know, as everyone stated, it's a difficult. One of the things, it's pretty. their pain is increased or they have a different sensation, they probably have an infection or they're starting to break down in a new process. Otherwise, your physical exam and imaging are going to be important to figure out whether they're infected. The big question when I was putting this together is how infected is infected? Are they acutely infected, grossly infected, draining pus? Or are they kind of chronically infected? When they're grossly infected, my process is to debride the infection, calm it down, get your consults, get your cultures, start the patient on a gives you a little better ability to treat them The way I explain it to the patient, they're big, they're cumbersome, they're uncomfortable. It's like that big Swiss Army knife that you have stuck in your pocket. It's really uncomfortable, but it allows you to deal with a bunch of different problems all at one time. 2-millimeter wire, and you're looking at these X-rays, and they've got a 4- to 5-millimeter hole in their tibia from where that wire was. So you take a 5- or 6-millimeter HA-coated half-pin, that turns into a big 1-centimeter hole real fast, and it'll fracture there. I try to leave enough space approximately so that they can use a knee scooter and attempt to be non-weight-bearing. A couple points in the OR. When I reference my ring, because they're all static, I try to use the anti-weight-bearing. A good team, it makes life a lot better, but a big bump underneath the knee lifts the leg up. One of the problems I first ran into is putting that big bump under the knee, under the calf in these big patients. I think you did a great job, you take that bump out and all of a sudden the calf is sitting underneath. Oh, and don't let your senior partner as well. This patient came in 45 years old, grossly infected, septic. He was actually on the schedule the next week for an elective reconstruction. We took him to the OR. In a single stage, we were able to wash out the infection. Because there wasn't a lot of dead material, we debrided it and were able to get him into this fixator. Like everyone stated, you can close the wounds acutely. But it's interesting, you take all this tension off, you have all this redundant tissue, you close the wound, and they always open up, for me at least, because the damage ratio or the damage radius of the tissue is much greater than that wound. But at least you can decompress the tissue, take tension off of it, and get it to heal, whether it's what's there. wires off the plane of the frame to help with control. The hole was too big for me to close, but I've taken the time. This study by Dr. Pinser had a... that, well, I don't do many. Okay, 45, Talus was dead. I'm one of the new attendees over at Rochester, but I kind of have a question on incision planning. I have a patient, kind of like you showed, Dr. Davis, who was treated like a Liz Frank initially for code, took all the infected hardware, and now he's going to have to go of that kind of medial lisfranc incision up top. That's, I struggled to get that healed. And now do you extend that and kind of do a more dorsal approach? Do you just make a new medial approach? How do you plan around old incisions in these kind of cruddy patients? You know, in that area, honestly, I think it's, it's pretty forgiving. And that, that whole concept of So on that one, if they've got a dorsal, dorsal medial less franx, I'll make a separate new medial incision. If it's a little more medial. Ultimately, I think the midfoot really tolerates, as long as you stay full thickness, having incisions right next to each other. There's a wonderful article by Chris Attinger, who's a plastic surgeon in D.C., and he described the seven angiosomes in the foot. Get that article, and it shows you where the safe zones are to make incisions. You can put seven incisions in the foot if you put one in each angiosome. Yeah, that's actually, I've seen, that's a good article. Thank you. Let me ask you guys a topic question, because I think we saw a lot of different approaches to some of the same problems, but I think just for the audience. So let's take a patient that needs a TTC fusion, Charcot patient, neuropathic, you have good bone to work with, reasonably compliant, non-infected, has some deformity, I'll just go down the line, nail, nail plus frame, frame only, Clayton, you may mention the nail plate construct. So briefly, what you do, and as straightforward as it can get case, and why. So, yeah, I mean, you know, I am for as much stability as possible in the hind foot, so after I put a nail, I'm not satisfied, so I put additional screws to provide, they're outside the nail, but, you know, I want to put as many screws I can get besides the nail to provide more stability. So nail and screws around the nail, I think is a great technique. So I've already published my results that my fusion rate is about two-thirds in that patient, so I'm not so good at it. So Mark Easley has a very nice study demonstrating that if you add fixation to a nail with something else, you're better. So I think a lot of fixation is a good idea, and this hybrid concept that people are talking about makes a lot of sense. So you're doing a nail in a frame, or you still just frame it only because it's work? Nail with large fragment screws. Around it. Around it. Got it. 12 months ago I would have done nail with supplemental screws outside of the plate. Then I evolved into nail with taking a locking 1 3rd tubular and running from the anterior lateral portion of the tibia down onto the calcaneus and putting locking screws in through that. And then now with the newer generation TTC plates, I would be a nail plate construct because I can do it all through the same lateral incision. Yeah, the only, I love your slide and your ideas with the plate and the nail. The only one concern I have with that is just I see a lot of settling with these nails. Any Sharko, really. Post fixation, post arthrodesis, I assume they get some resorption and things settle. And with the nail, I think it's relatively receptive to that. That frame you can adjust. My experience with plates, although I didn't, wasn't doing it with the nail, so it's different, was a lot of migration of the arthrodesis, screws moving, plate breakage, big hardware exposure on the ankle. So it's interesting to see you bring that kind of back in the conversation because I had fully abandoned plate fixation for Sharko. But again, I was doing it in isolation, so maybe that's the difference. Yeah, 100% agree about the settling. And what I've found is you have to do a true TTC plate because you need something that really goes onto the back of the tuberosity so that you can get those screws underneath your interlocking screws for the calcaneus to link that construct to avoid the nail settling. There's a company that has a plate on the market that they market as one that can just shoot around the nail. I'm not a big fan of that because if you look at the actual footprint of where it is, it's all right in line with the nail. And those TTC plates that go back onto the tuberosity are kind of the whole point of engaging that bone and getting underneath your interlocks rather than something just around that solid portion of the nail. Yeah, I've really made the shift to nail with a frame over the top. I think there's multiple reasons. I can manage the wounds. I don't have to strip the periosteum to put a plate on. I can use a shorter nail and compress throughout the process of doing the nails. I started doing it with revisions and now I really like it with primaries. I've got a very quick and easy, I use three rings in the tibia also and only half bends and I can put a frame over the top in 30 minutes. And the other advantage is which you speak to is you don't have to have the frame on for three months. I mean, it could be a six week frame because you've got a nail in place. So it's a compromise. Yeah, for me, after having family members who are non-diabetic and under 200 pounds try to be non-weight-bearing and see them walk around on their surgery, I use a hybrid construct because I just, there's no way they're staying off it. So for me, it's a nail with a frame over the top of it. I keep my frames on for about three months and then take it off. Can I add one point to add on top of everything else? A vial of vancomycin powder is $20.86. There's very good evidence in spine literature that it's a valuable adjunct to a lot of the things we do. And Wayne Dane Wukich did a very nice retrospective case series demonstrating its efficacy in the foot and ankle. So have a very low threshold to put a vial of vancomycin powder in the wound before you close. Yeah, in the soft tissues, there's a good paper that's being presented this week. One of the best papers that speaks to vanc and its effect on osteogenesis, which is not good. So just be careful of your own soft tissue, not jam it in your fusion site. Just Steve Weinfeld from New York. One comment, one question. I've been coming to this meeting for more than 20 years and I think this is the best Charcot symposium I've ever seen at this meeting. Honest and very helpful. The question is, when I see these patients, we always talk about the options of amputation versus reconstruction. The thing I struggle with is what their function's gonna be after, assuming we can get a successful reconstruction, what do you tell these patients about what their function's gonna be? We published, I think we had one or a three-year follow-up using the short musculoskeletal assessment exam. And we showed, which is a pretty well-validated instrument to look at these. The interesting thing is we had five-year follow-up and both the journal and Foot & Ankle turned it down because we only got about 50% because a lot of the people died. But if you are, I think everybody will buy that if our goal is getting them in a shoe, not in a crow boot, but in a shoe with at most a short ankle foot orthosis and they're able to walk outside their house, they're happy. And I think it depends, I like everything, right? It's case-dependent. If I've got a 25-year-old diabetic and she's gone through multiple surgeries and she's raising children, she wants to run the ER with her kids, that's, I think an amputation's very reasonable to her. Understanding the long-term problems with a prosthetic. More often, though, with these 50 to 60-year-olds, their sedentary lifestyle already and I think the amputation, I'm sorry, saving the limb probably is better for them long-term. But I wouldn't say it applies to everybody. I mean, there are definitely exceptions. Dr. Shipper. Great talk, Oliver Shipper here from D.C. So I just want to see if the group here, anyone started dabbling at all with MIS first, doing weather checks in the mid-foot? Anyone had any early anecdotal results or not there yet? You know, want to wait and see. So I think we're still in a bit of a technology, I think the technology will catch up. To do a wedge resection with our present burr technology takes forever and you create an amazing slurry that bacteria loves. So I believe that it's going to come with our present burr types, it just takes too long and I think I would love to see a reamer aspirator kind of thing that would really irrigate and suck everything out. But ultimately, I think we're, but I know people are working on it, but ultimately I think that that's where we need to be. One thing I'll say is I'm kind of a believer that the bad bone's got to go and you can't get that out easily through an MIS incision. I kind of go a little bit against the grain in that I don't think the size of the incision really matters. These people bleed like crazy during surgery, they have blood flow. They're probably gonna heal the soft tissue provided you don't take a four hour or a six hour operation and get it infected. So I make a pretty sizable medial incision, I make a lateral incision, I take the cuboid out. I get a cob elevator and take that thing out. The cuboid's the most overrated bone in the body. And then that allows you to really correct your deformity. You get a beam in the medial side, you get a beam in the lateral side. I don't use the big nails anymore because I like the medial plate on top of it with screws going above and below the beams. The same thing as a plate nail construct for the hind foot. You do that in the mid foot and I've had good results with that and then get it closed under two hours. I mean, I think that the big difference, right, your metrics for your MIS bunions, the swelling, pain, how quick can they bear weight, completely different in this patient population. Not saying we don't appreciate being soft tissue friendly, but I think the efficiency of the surgery and the amount of surgery they need, especially if they're infecting the bad bone out, it seems like it's quicker, better, easier open without really the concern the wounds are going to heal. So a bumpectomy, maybe a small joint prep, I could see it, but some of these bigger cases, I don't see it yet. Our fixation has become almost percutaneous, right? These beams and nails, which is, I think, a game changer. So I think we're very careful with our fixation, but the preparation, I can't, I mean, for me, I'm not gonna go there right now. For me, if I do the MIS, I've done a couple of cases, it's consolidated foot, and the only problem is a tiny bit of prominence, which is causing an ulcer in an elderly lady. So I just, you know, it's easy to burr that off, and then you can see some rapid resolution of the ulcer. And again, when we talked about amputation, don't forget Syme's amputation, which is a great option in this patient population. Pat Brodsky. Yes, Jim Brodsky from Dallas. So how come the microphone's too tall for me and too short for Shipper? I don't know Shipper. So Clayton, I wanted to know if you could say more about what you meant when you said linking the fixation. If I heard you correctly, the question is, what did I mean more about when I link the fixation? Link that. What do you mean when you say you link the fixation? I link, not lengthen, to make sure we're all here in the same room. Link, L-I-N-K. Yes, so what I'm talking about is I've got screws from the lateral construct that are engaged in some way with the intramedullary nail. So when you have that intramedullary nail with your interlocking screws in the calcaneus, you now have screws from the lateral TTC plate that you've shot variable angle both above and below the interlocking screws going from the calcaneus through the nail. In a perfect world, you might be able to get a screw somehow through the nail. I find that hard to do. I like the outriggers and loading up the nail with all of the hardware that was designed to go in the nail, and then the lateral TTC plate variable angle shooting screws above and below those interlocking screws. So you're basically creating a fixation that's above and below the nail. And unloading the nail to some extent onto the plate by doing it. Yes, that's right. The same concept for distal femur fractures. And which do you compress first? So for Charcot, I don't think it's about compression. I think it's about stability. A lot of times in these situations, you've got big bone voids. So I'm getting decent bone opposed to decent bone. I put the nail up, I really do not compress the nail because I think it's gonna change the alignment of the foot. So I get my deformity corrected, get it where I want it, put a nail up, lock it. I've usually gone through the fibula. So I take the fibula, grind it up, pack that into any voids, and then I lay the TTC plate on top of that. So one of my things with this whole Charcot process is we do these huge procedures, especially midfoot, and we leave him with this big flipper of the foot. That's very difficult to shoe, very difficult to deal with after surgery. So are we missing the boat by treating them conservatively in the beginning? When I do mine, if they're not consolidated, I try to reduce all my joints, prep all my joints, and try to recreate a normal quote-unquote foot. But when I do a big wedgerous section, I create a short foot that's really fat on this guy who's six foot six with a size 14 foot now, and he can't shoe himself. That's one of the questions I have for the panel that I've been struggling with. When I see him starting to collapse, am I better off being aggressive than trying to fix that quicker? In other words, to maintain length? Maintain a more normal anatomy. Either way you do it, you're probably gonna shorten their foot, and I think the risk-benefit of any other way is probably too high. I'll take a short foot that's planted grade, also free, and deal with the shoe problems. I think, though, specifically, if the way I've started looking at them, if they're going south, and they're unstable, and if they weren't Charco, would you treat those with RIF or primary fusion? And if they're unstable, just like you would in unstable lisp ranks, I'd treat those soon. I just think to fuse them with the techniques that we have now, the risk is minimal, and the potential downside is horrible. So if they're starting to go unstable, which is the reason why I follow them real close early, I'll pull the trigger, and I'll tell them RIF and fuse them at the same time. Yeah, and I think you're right. The pattern and how fast it's happening. I mean, if it's happening fast, you know exactly what that next visit's gonna look like. Yes, sir? Yes, Mark Eppert from New Hampshire. Could the panel comment on the syme amputation, the role? Because in my hospital, it's either a trans-med amputation or the vascular surgeon's doing a BKA. Well, we've published, it's interesting. We published a paper on a 20-year follow-up on symes, and shows that they function extremely well. This is a great population to do the symes if it's not a salvageable limb, because you save the heel pad and their end bearing, so that then when you make their socket, instead of making a standard syme socket, make it a clamshell socket with Velcro closures. So in the morning, they snug it up, and in the evening, they let it looser. So the symes, I mean, I've done three in the last several months, and you made the point. Two of them came in yesterday smiling, and they look healthy, because their infection is gone, and it was a simple solution for them. We don't have that same level of expertise with symes. In Charlotte, we're trans-med or BKA as well, not to have a last word. We just don't, we haven't had the same round of success. Yeah, I agree. I do one a year, and I call that a Fando, because the fella ain't done one yet. So my patients do not do well. They don't like the way their stump looks. The prosthetists in our area are worthless when it comes to putting us, doing the symes, and my experience is not Mickey, and we've had this conversation before when I went on a symes run 15 years ago, and so I think that's the key. We do the BKAs in Charlotte also, so we don't, the vascular surgeons don't do any in this town, and so we kinda know which ones. Trans-meds, we just finished our trans-med review. 27% within 27 months on average have a BK, and 40% are dead after a trans-med. So we thought our BK, our results would be better than our BK on mortality rates, and that's not been the case. So trans-meds are not great either. Sign of the disease. One last question, and then we'll break. Yeah, hi, I'm Dan Latosinski, plastic surgeon from Portland. Thanks for citing Attinger and angiosomes, Dr. Penzer, really important, super important stuff. Just a question about limb length discrepancy. Say you've done a successful Charcot reconstruction, it's unilateral, now you got a significant limb length discrepancy. Could you comment on doing a proximal distraction osteogenesis to equalize the limb length and get them out of the heavy shoe that's equalizing the discrepancy? If you turn on TV and you watch the Skechers commercials, they make that foam stuff on the bottom of the shoe. It's very lightweight. You know, when you do distraction osteogenesis in diabetics, your distraction rate is half as fast with a higher failure rate. So I think that's a great idea in failed ankle replacement, but I would be, I don't like, I try to avoid whenever possible using gradual correction in diabetics and go as much as possible to using static fixation. Real unpredictable in a neuropathic patient, and then if it doesn't work, you're at a high BKA level, which might have made the situation a lot worse. I've tried to, I mean, like Dr. Patin says, it's a lot of anecdotal evidence. I've tried it three times in distal when I knew I was shortening the tibia, the calc took out the tail, it did a metaphyseal osteotomy. It was a disaster every time, just because, like Dr. Penzer said, the biology of healing in the normal trauma setting is not this setting, so it hasn't worked for me. So to solve that problem, I'm gonna start a journal called the Journal of Bad Results, because nobody submits their bad results. So when you don't see something published, it tells, that's a really strong message. Well, thank you. I'm sorry I did not get to any cases. I had so much to work with here, but we'll save it for another time. Thank you for the panelists and your attention. Thank you.

Charcot foot

diabetes

prevalence

comorbidities

treatment options

infection control

ulcer-free foot

appropriate footwear

surgical intervention

internal fixation techniques

external circular fixators

individualized treatment plans

debridement

nails with supplemental screws

wound management