All right, guys, so we'll get started with the afternoon session. Hope you guys had a good lunch. This session is going to be on Flatfoot. Scott Ellis, who was our original moderator, is unable to be here, so Cliff Jang was gracious enough to, he's got to talk, but also gracious enough to moderate the session. So Cliff. Hi. Thank you very much for inviting me to do this, John. It's a huge honor. As you know, Scott's doing fine. It's not COVID, and he's sending his apologies for not coming, but I am your backup moderator today. So John gave us this title for this ICL, Too Much is Never Enough Flatfoot. Let's see here. How about this? Here's my disclosures. And so the title, Too Much is Never Enough, kind of begs the question, is it possible to overcorrect a flatfoot reconstruction? And I'm standing here as proof positive in front of you to tell you that absolutely it's possible to overcorrect them, and I've done them many a time. The question is how to kind of find that sweet spot between overcorrecting on this side and on this side, being in office with your patient six months later, and they're standing on your cold tile floor looking up at you disappointed because they don't think you raised their arch up enough. We have an all-star panel here today to help teach us how to thread that needle and get that perfect correction. What is clear, though, there's still a lot to learn about flatfoot, and the field is actually rapidly evolving our understanding about it, especially with this newfangled weight-bearing CT technology, which has really kind of sparked a renaissance of research in flatfoot reconstruction. Also, we're learning, obviously, from our colleagues still, and if you haven't had a chance to, I encourage you to pick up the October 2020 issue of Foot & Ankle, where if you flip to the back, there's all these articles from the PCFD consensus group where it really kind of summarizes our current knowledge and understanding of flatfoot. As I said, we have an all-star lineup. Seriously, some of these are the gods of foot and ankle here today, so I encourage you to take advantage when we open up the floor to ask some questions and pick their brain. We're going to start with Irvin O. from Yale, and he's going to talk about conservative treatment of PCFD. Then I'll take off the moderator cap, and I'll talk about flatfoot flexible reconstruction techniques, which procedures and why. Mark Meyerson is going to talk about what we used to call stage four, but now what we call class E, or the deltoid-deficient flatfoot, and how to take care of that. Keith Wapner is going to talk about new calcaneal and midfoot osteotomies. Michael Clare is going to help us with that tough decision. Do we reconstruct this deformity, or do we fuse it? And finally, Dr. Dolan, who was not able to make it from New York, but will do it remotely, will talk about management of persistently painful flatfoot after your reconstruction. So we'll start with Irvin O. Hi. Good to see you guys in person. Thanks, Clifford, for the introduction. I don't consider myself as God of flatfoot. I'm more of an angel of a flatfoot. When I first got this topic of conservative treatment, I was like, I would like to talk more about surgery. Why conservative? But I found something, and then I learned something, so we'll talk about it. So, let me, how do I get out of here? Oh, I can end this, right? Thank you. So, thanks for the program committee for inviting me to present on this topic. Okay, this is my disclosure. So, as a forensic surgeon, we're always excited about fixing something when we see a deformity. However, my mentors have told me to do a conjoint treatment as a first line, always, even if it's early or advanced stage, that's something that we have to do first, and that's what the text also says. So, what do they usually recommend is a period of immobilization, either in cast or boot, for six to eight weeks, and then transition to ankle brace orthotics, which is like UCBL, and some AFO brace, like Arizona brace, and make sure to combine that with physical therapy to get a synergistic effect. So, I would like to share the evidence that I found to support those practices. Sorry. How do I go to the previous one? So, this is my case. The lady that I saw about four months ago, a 61-year-old female, who came to me with right foot painful swelling for about three months, which I saw was a lot of swelling and pain on the medial aspect. She was complaining a lot of pain, and there was a heel valgus alignment, and when I got an MRI, I saw fluid around the post-tip tendon, and what appeared to be like a split tear. So, I thought that she was going to need a surgery one day. I'm still watching her, but as learned, I tried congenital treatment first using just generic insoles, a 20 bucks one, and just a generic ankle brace, and when she came back in six weeks later, she has no pain. And I, of course, did a therapy as well. So, what's the success rate of congenital management? It's reported to be somewhere between 70 to 90%, and eventually, as high as a quarter of your patients will be needing a surgical intervention down the road. Sometimes we use a medial wedge in combination with that Spank Orthotics, but I like to go without spending too much money in the beginning. Going back to the history, in 1996, Dr. Chow and her friends in Philadelphia and others, including Dr. Thomas Lee, studied 49 patients with stage 2 and stage 3 flat foot deformity. For stage 2, they placed them into a UCBL that looks kind of different from what I use nowadays, and also molded AFO, they call it MAFO, for stage 3. And what they found is about 67% of the patients had a good, excellent result, whereas 33% could not stand this anymore and had to give up on those brace. They considered that as a fair or poor result. About 7.5% of the patients underwent surgery, but this is less than two years follow-up, so I bet if we follow for longer, probably more patients eventually went for surgery. What the authors concluded that was, because of the success rate, we should definitely try congenital treatment, including this type of brace, to begin with, especially in patients who have a sedentary lifestyle or have medical comorbidities. It should be the first line of treatment. As you can see, UCBL worked for some of these patients. What's the rationale behind it? There's some biomechanical study to show that it works to reduce your aversion moment in your hind foot as well as in your ankle. This group out of UK studied 12 patients with flat foot deformity, and they differentiated the media posting. They increased by two degrees, and what you notice is that there was a linear dose response effect in decreasing the hind foot aversion, ankle aversion moment with this media posting. Media posting is important, and it works. How about this UCBL type of orthotics? It's a study by a Japanese where they basically fit a UCBL for their flat foot patients and studied their kinematics on their 3D CAT scan. As Cliff just mentioned, there's now a 3D weight-bearing CAT scan that we can use to study the kinematics better. This is something that we can nowadays do with a standing, actually, not simulated standing like these researchers did. What we noticed was that the valgus moment arm at the subtalar joint was reduced by this custom insoles. Again, another biomechanical study to show that this really works for our patients. How about Arizona brace? This is a study out of Wash U, a short follow of one year. This researcher kind of used this for relatively early stage, like stage one and two, and some stage three patients, and they noted a significant improvement in symptoms in 90 percent of their patients. But if you look at the stage three patient, if you isolate them, it worked in only 60 percent, so another 40 percent of the patients eventually require surgery. So for higher grade or more rigid and severe flat foot deformity, this brace may not be as effective when you use it in your earlier stage, flexible deformity. So because what we noticed was that some of this Arizona brace had some compliance issues, there has been some variation of this Arizona brace. And this study out of Tennessee utilized a double upright AFO brace. I have not used this in my practice. What I've seen this is in my old practice in University of Rochester, we use it for patients with charcoal neuroarthropathy. When we didn't want to use a crow boot, we sometimes utilized double upright AFO brace. But these investigators used it for their flat foot deformity in stage two, and what they noticed was that there was about 70 percent of their patients liked it and did not need a surgery, and they were brace free at about 14 months after applying this brace. So this is an option, and what I liked about this study was it's probably the longest follow-up of 7 to 10 years. And when you look at the effect of this double upright brace on this patient, it says 70 percent of them do get better, whereas 15 percent went on to surgery. Up to that point, nobody has really looked into the efficacy of physical therapy. So this is one of the first study to look at, what's the effect of physical therapy? Can you combine this with orthosis, and are you going to get a better outcome? And it's yes. Dr. Alvarez from Tennessee and Dr. Salzman from Utah looked into their 47 patients that use either AFO brace or UCBL, and they did this, they combined this with structural exercise program. They named it as a high-intensity physical therapy that consists of high repetition exercise, aggressive plant inflection, aggressive high repetition home exercise with stretching, and they noted 90 percent success rate. This was one of the highest success rates that we see in the literature, and that they believe that it's caused by, it's accentuated by the structural physical therapy program. Similar study was found in California. They studied the effect of stretching versus stretching with strengthening, and what they found is that when you do eccentric strengthening, the clinical result was the best. However, this was only a 12-week follow-up, so we don't really know the eventual course of these patients, but they suggested using a special device like this one, tip post loader. University of Rochester also studied the effect of physical therapy. They wanted to see the difference, is there a difference in stretching versus when you're combining strengthening, and what they found is that by adding a strengthening, you're not really adding too much to the clinical outcome. They felt that stretching worked as well as combining with strengthening, so there's really no difference. As long as you do orthosis combined with stretching, the patient will improve, but what they found is that their result was not as good as Dr. Saltzman and Alvarez's result, and they thought that that's because of difference in the way they prescribed this physical therapy, whereas the Saltzman group had more intensive exercise. The University of Rochester's group was more moderate in intensity, so they suggested if you're going to do this, do it right and do a high-intensity exercise, so that's something that you might want to consult with your physical therapist when you're prescribing the therapy, making sure they follow the regimen, that you do an aggressive treatment. And some patients might ask you, I don't want to do surgery, can you inject something to my ankle, and there has been some interest in PRP, BMP injection, is there any literature support for this? So far, not much in front of the ankle other than some Achilles tendinopathy. There has been no randomized control trials for post-tube tendon deficiency. However, the rationale for this is that this may create an environment that gives you a positive regulatory effect that may promote angiogenesis and increase tenosyte proliferation that may eventually lead to healing of the posterior tibial tendon. However, my question is that, is it really going to change the course of your tendon disease when you have a biomechanical derangement? I'm not sure. I would like to know more about it in the future. So what works? We know that the evidence suggests that orthotics with medial wedge works. Some ankle brace, like an AFO brace, MAFO brace works. In more advanced stage where you want to get the stability of your ankle, there's various different type of AFO brace, like Arizona brace or Ricci brace, or if you live in Philadelphia, you might get a MAFO brace. Make sure that you prescribe physical therapy and make sure that you communicate with your physical therapist to make sure they're doing a high-intensity exercise. Check with your patients. Make sure that they're doing it every day if you want to maximize the synergistic effect. Thank you. Applause Okay, so I'm going to take the next talk and talk about how we reconstruct the flexible deformity. What procedures work and why. And basically I've been kind of tasked to go over the different procedures that I do and also I'm going to review some of the other procedures out there that are available to you. Those are my disclosures. You know, I think when we learn about how to deal with flat foot deformity, we each take a personal journey. And basically it starts with fellowship, obviously, and that's where we first taught how to think about this stuff. And then it's affected further by our daily interactions with our colleagues and our partners. Let's see if this works. And then we come to meetings like this and we read foot and ankle and we learn more and decide more about how we're going to change our algorithm. And then finally we add in that special sauce of anecdotal experience, what's worked for you and what hasn't worked for you in the past. And we come out with our algorithm. I have had the incredible privilege. Oh, this is doing automatic, Stan. I think so. Okay, I got it. I've had the incredible privilege of either being trained by or having been partnered with three of the past AOFS presidents who've each made a huge contribution to our understanding of flexible flat foot deformities. Let's see here. Here you go. Roger, he first taught me. Wait, I got this wrong here. Got it. Got it. Roger was the one that first taught me the importance of eliminating the posterior tibial tendon as a pain generator and replacing it with a functioning motor unit. He also taught me how to aggressively translate the heel medially, which is the same way I do it now, 21 years later. After that I became partners with Mark Myerson here and for all intents and purposes did a second foot and ankle fellowship that lasted for 15 years. Can you imagine that? Mark showed me the importance of addressing the rest of the flat foot deformity, including the forefoot abduction deformity and the forefoot varus and adding additional osteotomies to correct that. Finally, my newest partner, Lou Schoen, is constantly in my ear now yelling at me that I'm making my lateral column lengthening completely the wrong place and that I'm wasting my time drilling a bone tunnel for my tendon transfer. So today what I want to do is I want to go through each individual component of the flexible flat foot correction and explain why I like how I currently do it, but also to show you some of the different alternatives that are out there. Now I think we can mostly agree that there's an imbalance in the flat foot between the inverter muscles and the E-verter muscles and that we should probably do something to correct this imbalance, this deficit. So how I like to do it, I like to do what Roger taught me a long time ago. I basically do an FDL transfer to the navicular through a drill tunnel. Why I like it. I harvest a long length of tendon here and so usually I can get it through the tunnel and stitch six or seven ethel bonds into the periosteum. I rarely have any patients come in to complain that they're having problems with the FDL missing and it just makes sense to have that FDL as your transfer because it's in the same line of pull as your posterior tibial tendon. Sometimes though, hey Mark, that's okay, that's okay. What I don't like about it though is that when you harvest that FDL, it's really wimpy and small, especially if it lost the battle when you're teasing it away from the FHL tendon at the knot of Henry. Also the FDL is the weakest of all the muscles in the calf to transfer. So there's definitely multiple ways to skin a cat here. This is what I was talking about. This is the original silver article with the list of the muscle strengths relative to each other on the left and this is the one that Mark and I published using 3D MRI measurements and they both show that the FDL is dead last as far as strength in the calf to transfer for your posterior tib reconstruction. But in our list, the FHL got promoted above the perineals. So Sal Marco knew this and he knew that it made more sense to transfer the FHL for the posterior tib reconstruction. This is from his original article in 2001 where he's tying the FHL to the posterior tibial tendon stump. What are some other ways to address the posterior tibial tendon deficiency? Well, one way is to retain the posterior tibial muscle. And Valderbano showed that he, well, you know, the way to do that obviously is you cut out the painful diseased segment of the posterior tibial tendon and you either repair it with an allograft tendon or you tend to deshift the FDL. And Valderbano's study where he looked at this showed that if you got MRIs post-op, there was less fatty degeneration of that posterior tib muscle later on and also the volume of the muscle increased. How about other ways to fix the FDL tendon? So besides suturing it into the periosteum like I do. Well, R.J. Sullivan wrote an article where he used a suture anchor in the tunnel to fix it. And that actually helped him to decrease the amount of length that he needed to harvest. Dane Wukich in 2008 wrote an article describing using a biotinodesis screw into the tunnel. And he also made a point of suturing the FDL transfer into the remainder of the posterior tibial tendon stump for extra fixation. Okay, let's talk next about how to correct the hind foot. So I still like to do it this way through an open approach. And I like it because you can expose the soral nerve and protect it throughout the procedure. I think that you get a really good slide with this because I'm able to really strip the periosteum off. And also I can put a laminar spreader inside to really kind of loosen it up so I can push it over immediately. Why I like it, it's very easy to teach the fellows. It's wide open. I don't have to worry about what they're doing. Again, I can get that aggressive soft tissue release and I can protect the nerve throughout. Also, with this open incision, you can do that crush plastic that some people like to do where you can kind of tamp down that prominent leading edge distally so you don't get irritation from it. What I don't love about it, well, dissecting out that soral nerve and protecting it has a double-edged sword because when you sew over top of it, sometimes the incision can scar down on top of it, tag it, and get neuritis that way anyway. Also, when you're doing the double osteotomies, the all-American-type osteotomies, it can be hard to plan out your incisions with the two osteotomies and sometimes you have to cheat the medial slide osteotomy a little more posteriorly than you're used to. What are some other ways out there that you can do calcane osteotomies where what's popular now is this minimally invasive technique where you use a low-speed, high-torque burr and make the cut under flora. Kendall and Paul Cook did a study looking at comparing patient series with minimally invasive calc osteotomies versus open osteotomies, and he found that the minimally invasive group had less wound healing, less infection, and less soral nerve injuries, and he found that the two groups have equal displacement. Okay, let's switch gears and let's talk about how to correct the forefoot abduction deformity. So I still like to do it the old-fashioned way. I do an Evans lateral column lengthening. I make my osteotomy about one and a half centimeters from the CC joint. I make sure to be careful not to distract more than 10 millimeters to try to avoid arthritis in the CC joint. I use a pre-shaped biplanar commercial wedge just to save time, and then although it's not necessarily in a lot of people's hands, I still use a single fully threaded screw to fix it, but this is an inherently stable osteotomy. Why do I like it? It gives great 3D correction, and not only does it correct the tail ventricular abduction, but it also restores the arch, and it's very powerful at correcting the heel valgus, actually, and so in many cases when I'm going in to a very severe flat foot and I've posted for a double osteotomy, I'll always do that Evans first to see what I get, and after I've completed it, I'll lift up the leg and look, and then oftentimes I don't need to do the medial slide anymore because it looks good enough. Again, it's stable, and so you oftentimes don't have to use fixation. I still use a screw for this. What I don't love about it, sometimes you'll do this and you'll see the patient back at six months, and you'll have them standing, and your correction looks beautiful. It's gorgeous, but they're stiff, just like a triple arthrodesis. Also when you're doing the actual procedure, you can get CC joint subluxation that you have to watch out during the case. Definitely there's people I've seen that have CC arthritis as shown here, and there's a group of people after you do your lateral column lengthening, they'll develop this sinus tarsy pain that just takes forever to go away. Are there other ways to do the lateral column lengthening? Well, Dimitri Coppolis talked about this. This is their step cut lengthening calcaneal osteotomy, and he says that there's a broad horizontal limb for union, and then the tail and navicular abduction is actually corrected more by rotation than by lengthening, so that may save forefoot supination or CC arthritis risks. How about this one? This is the one that Lou Shone is trying to bug me to get to do. This is the Hinterman calcaneal osteotomy, and they make the cut not where the normal Evans is, but it's done in between the middle and posterior facets of the subtalar joint, and this cadaveric study by Edinger showed that you actually damage less cartilage doing it this way than by the normal Evans osteotomy. He also suggested that there may be less risk for CC joint arthritis doing it this way. How about other ways to lengthen your osteotomy instead of using just straight bone? Well, Stephen Rakin is a huge proponent of these metallic wedges, and he says they're great because there's no donor site morbidity, no risk of disease transmission, they don't collapse or go into osteolysis, and they have a super high rate of union. Let's not forget the calcaneocuboid distraction orthodesis. In a study by Thomas, he compared a group of people who had the regular Evans lateral column lengthening versus a CC distraction orthodesis, and he found equivalent radiographic correction in outcome stores. However, Steve Conti wrote an article looking at this, looking at the calcaneocuboid distraction orthodesis, and he found 47% of patients had either graft collapse or non-union with that case. Okay, let's switch gears, let's talk about forefoot varus correction now. What I like to do, I still like to do the standard cotton osteotomy. I make a bone cut through the middle of the medial cuneiform along a guide pin. I still use those preformed allograft wedges just because they're easy. And even though it is, again, a stable osteotomy and may not need it, I still use a single screw for fixation. What do I like about it? I think it's great because it's very powerful at correcting forefoot varus and elevation of the medial column, and I can dial in exactly how much or how little I want. It also has a very high union rate. In one study looking at 117 cottons, 100% union rate, no non-unions. What I don't love about it, it's not applicable in all situations, and especially in patients who have either first TMT arthritis or first TMT instability. It doesn't answer that question. Also more importantly, Abu Sayyed and Guyton in a recent article found that half of their cotton patients had lost correction by eight years. And that wasn't by where the bone graft was, it was at the joints either in front or behind your cotton osteotomy. So that's a little concerning. How about navicular cuneiform fusion for treating the medial column deformity? Well, Aegis and Geary did a study where they followed their patients where they fused all three NC joints, and they found that by both stabilizing the medial column but also plantar flexing a little bit, they were able to correct the forefoot-driven hindfoot valgus. Finally, let's not forget the first TMT fusion, and this is especially suitable for people who have either first TMT arthritis or first TMT instability. And in Thompson and Anderson's study, they found a 4% non-union rate. There's one other alternative to the cotton osteotomy, and that's Ling and Kennedy's planter closing wedge medial cuneiform osteotomy. And they found no non-unions in this series. They avoid the risk or the cost of having an expensive allograft, and they just fixed it with two staples. We can't finish a talk about medial column procedures without talking about Stephen Raken's metal wedges again. And again, he loves these. He says that he had, in his series, no non-unions at all and had excellent correction. No osteolysis or graft collapse. Last I just want to talk a little bit about subfibular impingement. You can see on this weight-bearing CT scan, this patient has their calcaneus rubbing on their fibula. And this is kind of what I think about as that fourth malalignment or deformity that we have to address. When we talk about subfibular impingement, we're talking both about subfibular impingement, but also sinus tarsae impingement as shown here. And it's possibly a source for failure in a patient that otherwise, you look at them and they have a beautifully corrected flat foot surgery, but they still have pain. The question is what to do about it. Once you've identified that someone has sinus tarsae or subfibular impingement, how do you correct it? Well, we really don't know right now. Right now, my group at Mercy is prospectively collecting 60 PCFD patients with weight-bearing CT identified subfibular sinus tarsae impingement. And we're following them out a year later, and we're getting the repeat CT scan then to see if we've corrected it or not. You can see here, this is a patient with sinus tarsae impingement, one of our study patients. And then a year later, with the medial slide calcaneosteotomy, the impingement's been improved. Last thing to talk about, spring ligament reconstruction. So Baxter and DeLand, they did a cadaveric flat foot model testing three different reconstruction techniques. And they found that the one shown here, the tibionavicular technique, recreated superficial deltoid and the superior medial spring ligament best, and was the most powerful at correcting the flat foot deformity. The anatomic spring ligament correction was the worst. This is a study by Heise and Malloy, and they did a comparative clinical study now on patients. One group had a spring ligament reconstruction using hamstring allograft. The other one had a suture tape hammock-type procedure using synthetic ligaments. And they found that their final follow-up, 12 months, the synthetic ligament group had both better clinical scores and better radiographic correction than the hamstring allograft group. How do I like to do spring ligament reconstruction? This is the technique that Dan Risman from Mayo Clinic and I published in 2017. And basically, it uses the stump of that posterior tibial tendon that you're about to throw in the trash anyway, and you use that as your allograft. What's nice about that is that one of your limbs or anchor points of your graft is already attached for you. And, oh, by the way, it has a very broad attachment on the navicular. Here's the tendon that we're about to throw out. Here's the FDL transfer all dissected out and tagged and ready to go. We're going to find our drill hole in the sustentaculum. So we mark it under fluoro, and we're going to drill a hole over a guide pin that's just under the middle facet of the subtalar joint, but above the FHL. Don't hit your FHL. Then we'll trim down our tendon graft to 5 millimeters, and we'll dunk it in the sustentaculum hole. We'll pull across to the other side of the foot, and we'll reduce the tail navicular joint to neutral position. And then we'll fix it with a 5.5 millimeter interference screw. So that's my whirlwind talk of flexible flatfoot reconstructions in 12 minutes. I'm going to pass the baton to Mark Meyerson, and we'll keep going from here. How do I maximize it? Oh, there it is. It's already done. OK. Hello, everybody. I'm Mark Morrison, and I'm going to talk about the valgus ankle. So back, of course, we know the Johnson and Strom classification back in the 90s, I added stage four. But there's a problem with this. First of all, stage four really was not an adequate description of the deformity because you can have a rigid ankle. Here, you've got inversion stress, no movement, or you can have a flexible ankle. So clearly, adding stage four meant something, but it was only really in this classification by Eric Blumen, hello, Eric, that we really started to recognize the need for flexibility and rigidity. So when you look at it this way, this is clearly a stage four. But what about this, where you've got a complete rupture of the deltoid, but an intact posterior tibial tendon? So what you realize now, there's another category of people who have an intact posterior tibial tendon, as you see here, but clearly a rupture of the deltoid. It's a different pathology, and something else is going on. Now, when I think about approaching treatment with a valgus ankle, there are two ways to think about it. Is the foot flexible? In other words, PCFD stage one, or is it rigid? Because a deltoid reconstruction of some sort is possible, and perhaps should be done if you've got a flexible foot. If you've got a flexible foot and a rigid ankle, of course, it changes things, and that's where this comes. Is the ankle flexible, stage one, or stage two for rigid? Because a deltoid reconstruction may not be realistic, regardless of the foot, if you've got a very rigid ankle. Now, if you look at the PCFD classification, start with the stage of the deformity. It's either flexible or it's rigid. And then there are five classes. The first four classes, well, we know about. We're not going to talk about here, but I want to talk about class E, which is ankle instability. Think about it. Is the ankle really unstable? We actually made a mistake with this by terming this ankle instability, because it's not, and I'll show you why. Here we've got somebody who had a prior triple. Well, the deformity is flexible. Therefore, it's stage one E. Class E, flexible stage one. Here's a different problem. Here we have a flexible subtalar joint, but a rigid midfoot and ankle. Completely different. So flexible hindfoot, 1A, and the rest is rigid, as you see there. If you don't have a component of the deformity, which is abduction, which is B, you just leave it out. But here's the issue. The use of class E can be misleading. Why? Because as we said, it's instability, which it's not. Here we've got a valgus ankle. Is there actually instability? No. It's actually ankle valgus and not well characterized by instability. So this is what happens. As Cliff showed earlier, when you've got severe valgus with synastasia impingement, you get erosion of your calcaneofibular ligament. And that then leads to instability, where you actually have true instability on the medial and on the lateral side. So you have multi-planar instability. So the real issue for where we're going with this is, what do you do? Are you going to reconstruct it with a deltoid reconstruction of sorts, or are you going to fuse it or replace it? So can we ignore very mild deformity, where you know that there's some compromise of the deltoid ligament? I don't think so. I think once you've got that deltoid going, it's going to go quickly. Can severe stage 2 be treated with joint replacement? I'll show you that the literature supports it. And which deformities need to have a staged correction, where you have to correct that ankle valgus and then follow on with either an arthrodesis, regardless of the type of arthrodesis or replacement. So if you look, let's start with the deltoid and spring ligament. This was part of the consensus statement from the study group. For those of you who are interested in ankle instabilities, I strongly suggest you take a look at Bayard Hinterman's recent textbook. It's fabulous. It's beautifully illustrated, and it's a very, very well-done book. If you go back in time, Eric Blumen, again, and I described this approach to the deltoid reconstruction, which, as Cliff just mentioned, may not hold up in time. But it's one way of doing it. You can see here a valgus ankle, which is flexible. So it's a stage 1E, class E. But you can see the result here with that technique. And this is the technique described. So it's fairly straightforward. It's a double-limbed reconstruction. Zeke Oburu and I changed that very slightly subsequently, where you can go in perpendicular to the axis of the tibia. Now, let's take a look at this patient here, who's got a rigid foot, completely rigid, and a flexible ankle. Well, with a rigid foot, clearly if you've got severe deformity, it has to be an arthrodesis. And frequently, it's a triple. For a flexible ankle, you can do a reconstruction. And that's what was done here. Cliff, yeah, I'm just showing your paper. So Cliff wrote up this series of ours. Not great results. Well, no, we didn't have great results. They were OK, but not great. But you can see one of the patients here with 4 and 1⁄2 years of follow-up. Now, one of the problems is that we now know that when you have a deltoid insufficiency, it's not just the deltoid. There's the deltoid rupture, but you've got it combined with a spring ligament. They are contiguous. The deltoid is contiguous with the spring ligament. So isolated deltoid ligament reconstructions are probably not the way to go. Isolated spring ligament reconstructions may also not be the way to go, because of that combination of spring and deltoid so frequently. This is a technique described by Bayart and Roxa, where it avoids the tenodesis between the malleolus and the navicular. But this is probably where I think things are headed. This is a paper by Kajon Neri looking at structural support extending from the medial malleolus to the sustentaculum to the navicular. And here's a case of Anishkadakias, where if you look at this here, there's clearly instability of the spring ligament. But when you look at what he did here, all he did was a spring ligament reconstruction in osteotomies. There was no lateral column lengthening. And I wonder if this is not perhaps the way we've got to go from the medial malleolus all the way to the navicular, reinforcing it also at the sustentaculum. And you can see the result here. Now, come back to what I was saying. Are you going to reconstruct, fuse, or replace? Well, of course, if you've got a flexible ankle, reconstruction is probably recommended. Fusion, I think, is a matter of personal choice, your choice, what the patient needs. Here you can see a case which could easily have been treated with a supramalleolar osteotomy, a medial ankle reconstruction with osteotomy, or even an ankle replacement. Now, does ankle replacement support? Do we have enough support in the literature for replacement? The answer is yes. If you look at this here, the paper from Seattle, there's no real difference between patient-reported outcomes between those with a fusion and a replacement in coronal plane deformity. Another paper here which supports the use of ankle replacement provided your foot is plantar grade. You cannot do any joint replacement if the foot is not plantar grade. So that then raises the question, are you going to stage it? And we'll talk about that next. So the plantar grade foot is terribly important. This is a multi-center study, and they showed fairly significant valgus deformity, no significant subsequent change in the tibiotalar angle. In other words, no worsening of the valgus, and correction of coronal plane alignment was maintained. So really, this supports it. Now, how are you going to do it? If you look at this case here, fairly flexible ankle, but when you look at where the laminar spreader is on the lateral side, it's not perfect. You still have a little bit of valgus there. So something else needs to be done. You've got to probably release a little laterally. Here you can see what's done after slight lateral release, and now your joint is perfectly symmetric. Now, what that sometimes will do, there you see another case with the laminar spreader and laterally in this joint which is partially reducible. So you know that you're going to be able to do your joint replacement. Maybe you don't have to do a reconstruction, but you certainly are going to have to release it laterally, and what you end up with then is a joint that's loose, but you can certainly compensate for that with your poly. Now, if you look at this here as a patient with very severe deformity, 34 degrees of valgus, good range of motion treated, staged first with the tibial osteotomy, and then the replacement. Here's another case of Jeff Christensen's, and you can see very severe valgus, and when it's this severe and you also have combined foot deformity, I think it should be staged. So this is how he staged it, two cross screws, deltoid and a lateral ankle ligament reconstruction simultaneously followed with the joint replacement with very, very nice stable realignment. Now, I will leave you with a few thoughts. This is a mild tear. What are you going to do with this? Are you going to do a complete reconstruction? So the answer is probably you need, even when you don't have severe deformity, you've got to do some sort of reconstruction. So it's a flexible deformity, but a rigid hind foot, and what I do here is to add a calcaneal osteotomy to the triple or to my subtalar arthrodesis so that I medialize the hind foot even more. It's not that easy to, unless you're going from the medial side of the hind foot, to medialize your subtalar joint axis unless you add a calcaneal osteotomy to it. Now, talking about the staged reconstruction, what are you going to do here? Because this is a failed triple with terrible valgus. Now, if you're considering doing a replacement or even an arthrodesis, think about what happens here. You've got to correct it. Now, the foot is stiff. So what happens when you correct the foot? The forefoot supinates terribly. So you have to anticipate this. So when we come now to the reconstruction, this clearly has to be staged, but you need to anticipate what's going to happen. You can see what this looks like after the staged reconstruction, and then subsequently, you can do whatever you want. You can do a TTC arthrodesis, which actually cannot be done here because if you do a TTC, you've got to convert this to a Pantaleofusion so that you can pronate right through your transverse tarsal joint. So this is what was done, and now you can do whatever you want, whether it's a joint replacement or not. Finally, I think that I've learned that we always have an approach. We go in there saying, I'm going to do this. I can do it. I can do a staged procedure, do a ligament reconstruction, and come back and do my replacement. Not always. Sometimes you go to bail. You have to bail intraoperatively if you cannot get it realigned, and I've learned that the hard way. My final case. This is fascinating. So here's a patient I was going to do a staged reconstruction on, okay? You see the valgus. So I corrected the valgus, pinned it, put cement in the joint, come back and do a staged reconstruction, and that was the plan. So here's the patient. He came back at four months, totally asymptomatic. He wouldn't let me do anything, and I don't know, Cliff, if he's come back to the division, because this was eight years ago. Go figure. Thank you very much. Next, we're going to have Keith Wapner come and talk about new calcaneal and midfoot osteotomies. So, actually when Carol Jones asked me to do this talk, he wanted me to give you a little bit of history of how we started doing osteotomies. And I think it was really a tribute to the fact that he recognizes that I'm an old man and I've been around for a long time. And I've seen a lot of this evolve. These are my disclosures. I think one of the key things and the take home messages that both all the talks we've heard so far is that when you're looking at posterior tibial dysfunction, it's a progressive deformity. And really the decision is you gotta figure out where on that curve you are. And the worst mistake you can make is just say, all right, I'm gonna do the same thing with every one of these patients because you will be wrong an overwhelming number of times. So, you know, there's the question, how do we get there? Is the PT stretch out first or does the spring ligament give way? It really doesn't matter. It's just you have to figure out which structures are injured by the time the patient presents on your door. And it's probably a combination of both. And you get this progressive sag and it's both in the longitudinal arch and the transverse arch. And you gotta go back to your basics and figure out where that sag is occurring. And remember that it's a continuum of deformity. One of the things you learn as you get to get older is that the sag is just inevitable. And no matter how good you started, eventually you're gonna end up sagging. So you gotta understand that continuum. And that's really what's evolved over the years. Mark and I both finished our fellowships in the same year. I went into practice in 1986. And if you think about the changes that have happened since then, it's really pretty remarkable. And it's just understanding that continuum. And the first thing we really started noticing and focusing on was the calcaneal vagus that developed. And then we started spending a little bit more attention on the forefoot abduction and then the medial column instability that you're hearing more and more talk about. But also don't take it in isolation. You have to also think about your associated deformities. And all this goes into the decision-making process of what bony work you're gonna do. You have to think about how it's vagus deformities. You have to remember that there's gastroc contracture associated with this. And all this can be followed prospectively if you measure it carefully and you have to go back to your physical exam. So most of the osteotomies we're gonna be doing are in stage two A and B and stage four deformities that the foot's not rigid. And you go back to your basics. I mean, still go back to thinking about what's going on with your x-rays, looking at your abduction, measuring your angles, looking at the subluxation, looking at the uncovering of the tail or head. And then once you do these measurements, go back and correlate it with your physical exam. And that's very important. I think you have to correlate both. Same thing with your lateral views. Look where the sag is, is the tail and uvicular joint. Look at Mary's angle. Look at the medial column. See where the overlap is and where's the gapping. And that's one of the biggest mistakes people make is they sometimes miss where's that gapping. And it kind of goes back to you say, well, why are our cottons failing? Well, maybe our cottons were failing because their gapping wasn't really at the place, where it needs to be. The Saltzman view is something that came along that gave us a lot better understanding of the valgus. And I think we need to do that in our patients. And then in addition to the weight-bearing x-rays of your foot, this is one of the things Mark pointed out earlier on is you always need x-rays of the ankle. I think if you operate on a patient with posterior tib dysfunction without getting weight-bearing x-rays of the ankle, it's tantamount to almost malpractice because you're gonna miss something important and you need to do that. MRIs are sort of controversial in its realm. And early on, I became a big adopter of MRIs. A lot of the reasons for that was I practiced in Philadelphia. And Philadelphia is the malpractice cesspool of the universe. And so if I had an MRI that showed that that patient had a posterior tib dysfunction and I did the surgery, then the lawyer couldn't say, well, why didn't you get an MRI, Dr. Wattenberg, if they decided to sue me? But I think it's a good teaching tool. I think it's very helpful for patients. They can see a picture and they can understand what's going on. Mark used to always get up and say, you never need to do an MRI for posterior tib because it's a clinical diagnosis. And he's absolutely right. But he didn't practice in Philadelphia. So I think it's, and then the other thing we have to think about using now, and this is really what things are gonna change over the next couple of years, is the weight-bearing CT scans. Because the weight-bearing CT is giving us information much better than the x-rays. And I think 10 years from now, we'll probably have weight-bearing CTs with whole different measurements that we're doing preoperatively and whole different measures that we're doing postoperatively. So what about surgery? If you're gonna do this, it all starts with the FDL-10N transfer. And then you gotta start the decision-making process. And if you go through the different things that you have available, we've talked about the medial displacement osseolomies, lateral column lengthenings, figuring out where you're gonna do this and the different ways of doing it, and then addressing the medial column. Well, how did all this happen? Well, in 1985, it was really all about just doing the FDL-10N transfer. Roger Mann and Francesca Thompson, many of you don't remember Francesca, but Francesca was a force in the AOFES and would have been our first female president if she hadn't passed away on a timely death. But she was a great contributor. And we used to do these tendon transfers and the patients were happy. I mean, they would come back, their pain was gone, but their foot was still flat. All right, well, why was the pain gone? Probably goes back to what Cliff said about Roger Mann talking about the posterior tib being the pain generator. So their pain was gone, they were functioning better. But as we follow these out, maybe we can do better. I mean, we can do something to try to protect this. Is this gonna fail again? Is our repair gonna fail again just like the first repair? So we started looking at doing osteotomies. So if you think about what's happening on this, you've got increased heel valgus and some mild sag at this point. You've got a little bit of a forefoot abduction. And so really it was the idea of going back and utilizing this medial calcaneal osteotomy in conjunction with the FDL transfer with the hope that it would improve the arch and improve the position of the Achilles. Well, this is nothing new. I mean, this is, you know, 1893 was when this was first described, all right? And then Lord in 1923, and then Dwyer, he probably popularized it the most in the 60s. These were all for neurogenic problems with kids, all right? So for the posterior tib dysfunction, Mark is actually the one who first brought it back to the US. And if I remember correctly, you told me that you were at a British Orthopedic Society meeting where they were talking about this. And he decided that, you know, we ought to start doing this. And I remember, you know, we had that conversation, as many of our conversations over the years. And, you know, he was the one that took the lead and really started pushing this and really revolutionized the whole thinking towards posterior tib that we need to start including posterior. 1988. Yeah, yeah, yeah. Mark and I, our sons have the same birthday too. So we have a lot in common. So if you think about why this works, it's kind of fascinating. Some of the people that did follow-up studies, Paul Giuliani, Terry Saxby, I mean, these are the people that contributed and built this whole process that we're working on. And so if you look at this slide, you know, if you look at this, don't have a pointer. Do we have a pointer? So if you look at adult flat foot deformity, all right, after reconstruction, what's happened is the Achilles is back to where it belongs, all right? In normal foot, that's about where it's gonna be. So that's where the heel's gonna be originally. But when you get the acquired flat foot deformity, it shifts out here. You've gotta slide this over to get the Achilles back in the position. Well, what is that, why does it help? Well, there's been some biomechanical studies that have been done about this, and it goes back to, again, why, what's going on with the muscles? Well, what's the deforming force? What's the antagonist of the posterior tip? The peroneals, all right? So you lose your posterior tip, your peroneals start over-pulling, your subtalar joint goes out into valgus, all right? And now, by moving your Achilles back to the medial side and medializing it back so that it's properly pulling and it's no longer sitting over in this area over here, where it's now become an inverter, it goes back to becoming an inverter. And that's why it helps. So that's where this really took off. John DeLand has done some great studies on this as well, so showing that it also reduces the stress on the spring ligament. And then Mel Joss did some studies showing that it reduces the stress on the deltoid ligament as well. So by doing these osteotomies, you're protecting your repair, all right? What it doesn't do is address the forefoot abduction. So we still kept thinking, all right, can we do better? Well, what about that forefoot abduction? Well, you've got that heel valgus and the abduction, and you start thinking about, well, what about lateral column lengthening? Why do it? Well, can we reduce that talonevicular joint? Can we raise the arch? Again, this is nothing new. It's around from the pediatric procedures. It was originally done through the anterior process of the calcaneus, but when we started thinking about this in the early 90s, we were worried about lateral pain and breakdown of the CC joint. And so it was modified when they first started doing this in conjunction with the poster-tib. Bruce Sandorgen and Brian Tulin and Sig Hansen first published this, and they decided to do it through the joint itself. And so the idea was that if you can lengthen this lateral column, you're gonna push back the navicular over the head of the talus. You can do it through the joint, right? And they said, well, let's do that so let's see how the results are. Well, if you look at the results, it looked pretty good. 80% were less painful and got good reduction of the joints. It was pretty encouraging. The problem was there was about a 20% non-union rate, 32% nerve injury, and 71% needed additional hardware. So again, the idea is, well, maybe we can do better. Now, Mike Aronow looked at, maybe if we change the way of fixation. So he published using an H-plate and significantly decreased the rate of non-union, got better results with the same correction. Steve Conti went back and looked at this, and this is where the whole concept of, what do we need to find a better type of graft for these osteotomies? Because one of the things he found was, not only do we get non-unions, but a lot of times we got osteolysis and late collapse of the graft, especially if you had to go in and take out painful hardware. So nothing ruins your day more than you have this great correction, the patient comes back, the hardware's bugging, you take out the hardware, they come back a couple years later, and then all of a sudden the graft collapses. So they sort of moved back to doing it through the anterior process, and that was the next evolution. And there was some concern about, what does that do to the CC joint? Well, again, go back to the literature. In 2000, Moenberger looked at the peak pressures across the CC joint, and when you corrected that flat foot deformity and you did a lateral column lengthening, the forces were no different. You didn't increase them. In some situations, you actually decreased them. So we're probably not ever gonna be above the physiologic loads, and so this makes it safe. So Hennerman and Valbarano looked at, in 1999, looked at doing it through the bone smear, the classic Evans. They had only one non-union, one dislocated graft, and they ended up doing one fusion. So the results were pretty good at two years. Well, this picture is sort of your favorite picture in duolateral column lengthening, because you can just dial in the amount of correction that you want. You just open it up, measure your graft, and then you can go ahead and put that graft in. And it's very satisfying. And I remember when I first started doing these, I was like, these x-rays were great. And one of my concerns was the patients kept coming back complaining of lateral pain. And they kept complaining of pain, and I stopped doing them after about 18 months, because I got tired of the patients complaining. And one of my residents came along, and she hadn't been there for a while, and she decided she was gonna do a, wanted to do a foot and ankle fellowship, and I said, well, Sue Ishikawa. I said, Sue, you really need to get a good paper. She goes, well, I'm gonna go look up those lateral columns that you did. And she brought them all back. They were all out past two years, and they were all happy. It was kind of interesting. So one of the things I tell you about lateral column length, is they do sometimes take longer for these patients to resolve their discomfort. But again, the issues that we saw were non-unions on one side of the graft or the other, dorsal displacement of that anterior process, if you do a classic Evans, hardware failure, the need to remove the hardware, and then worst of all, late graft collapse. Well, one of the things that happened with this is we started to look at combining osteotics, but also the metal wedges came in play. And these actually were, the first group that started using them was actually here in Charlotte, right? Medical came out with the first wedges that we have available. The OC guys started publicizing them. And now a lot of, you know, almost every company has these. I think the advantage is you avoid that late collapse. And I call them bone velcro. You put these metal wedges in there, and it just like locks the bone in place, and so I don't use any additional hardware. But we also started thinking about, well, we've gotta look at what's going on medially. So we're gonna have to look at the rest of the foot. So we have to think about, do we have to combine some type of lateral, do we have to combine a calcaneal slide, do we have to do it with a lateral column lengthening, and do we have to do a medial column stabilization? So this is where we're evolving. And the answer to all this is, well, maybe, because it depends on where you are on that continuum. One of the more fascinating things on the lateral column lengthening that I saw was in 2007, Bob Van de Gruyne presented this concept of doing a step cut osteotomy for your lateral column lengthening. Gives you greater stability, and by doing that step cut, you get that transverse arm, so you can't get translation. You get bone-to-bone healing across that transverse arm. It's much more stable. You don't have to worry about late graft collapse, because you've got that bone-to-bone healing on that transverse arm. And I kind of became fascinated with this, and then I wanted to see if we could take that and use that to do a combination. So we modified this to see if we could use this in a way that we could do both a lateral column lengthening and a calc slide through one incision. Avoid internal fixation, avoid the dorsal displacement, and get bone-to-bone healing. And so what we basically did is we started about the same place, about a sonnet and a half behind, but we made a longer transverse arm. And by making that transverse arm go back further, we're then able to come down plantarly, and we make this step cut, and essentially then doing our displacement through that. And what ends up happening when you make this cut is when you rotate this and you get this gap, you're basically medializing the calcaneus as well as medializing the ant, doing the same thing as your lateral column lengthening. And so we moved to this type of osteotomy, and we moved to the metal wedges. And the interesting thing is the big cost, the big thing we had with the metal wedges was the cost. But when you look at the cost and the morbidity of an autograft, it's certainly much less. And when you look at allografts plus the biologics that everybody adds to the autografts, it's basically the same. So that's how we got it through our VAC committee. And this is what we've started doing and gotten very good correction with this by getting the tail and uvicular joint reduced as well as being able to reduce the valgus of the heel and restoring the arch. John DeLand and his group have looked at some biomechanics as well as clinical stuff with this type of approach. They do a very similar thing, and we've published our results, and I think that this is very good. We have not had any delayed unions. Fortunately, we have not gotten late collapse because you get that healing across that bridge. Superior displacement won't happen because of the construct. And sterile nerve entrapment with all these osteomas, or any nerve entrapment, that's really on you, and you have to be careful. So we've corrected the forefoot abduction, and we reduced the tail and uvicular joint, but we still didn't really resolve the whole medial column instability problem. So that's more things that we have to think about as we go forward in this continuum. And again, the Seattle guys were really some of the people that first pointed this out. And they said, well, you need to think about combining this. Are you gonna do a first MP joint fusion, or do you need to do a cotton osteotomy? And then do you combine that, as the late great Art Minoli told us, with this all-American procedure where you have to fix everything at once? And again, I think this boils down to where are you on that continuum when you do your exam? So one of the key things that you have to think about is where is the plantar gapping? Is it at the first metatarsal cuneiform joint? Is it at the navicular cuneiform joint? And then you use that plus your exam to look at whether you're gonna do a cotton, whether you're gonna do a fusion, and whether you need to do a hallux valgus correction. And that's one of the things, a lot of these patients with severe flat foot have a severe hallux valgus. Well, that means they've got instability at that first ray, and you've gotta get that addressed as well. So I think the key in this medial column is to figure out what's the level of your instability. And if you go back, and again, this article has been mentioned on several occasions, and I think anybody who's gonna be doing this surgery needs to read this article. And you really have to realize that the stabilization and the osteotomies that you do really are where you are on the continuum of the deformity. And that you get by going back to your basics of your physical exam and your x-rays and seeing what's what. So it's a progressive deformity. I think the most important message I can give you in terms of these different osteotomies is not one size fits all. So you cannot have a cookbook approach to this. You gotta look at each individual patient on their physical exam and their radiographic findings. And then you figure out where on that curve it is, and then you figure out what you need to do to get them corrected. Thank you. We're gonna have Michael Clare talk now about the decision between fusing and reconstruction. So I was kind of given the hodgepodge or assignment of kind of covering some of these other esoteric issues within the flatfoot realm. Okay, so disclosures non-relevant to this particular talk. So my, one of my mentors is the now-retired Art Walling used to say that every flat-foot patient is different and so each flat-foot patient needs to be individualized and I think we've kind of heard that as a summary from each of the lecturers today. In terms of individualizing, I think it's also important to think about what's their true physiologic age rather than their chronologic age and along those lines, physical demand level and expectations. So when is it okay to fuse a flexible deformity? I think it goes down to the older, more higher physiologic age type patient, one that's kind of low demand, that doesn't have a lot of expectations to do much activity-wise. Certainly those that have neurologic diseases that may have some motor component to it and those that you just kind of anticipate are going to have bad bone. So as we heard in the last lecture with the new osteotomies, I would dare say some of these step cut or calcaneal scarf type osteotomies are very, very powerful but they are hard to hold in people that have bad bone and I've been burned on it more than once. So advantages of a fusion, assuming you reach union, deformity correction is going to be pretty predictable. I would argue it has a shorter and easier recovery time than a reconstruction. On the other hand, the downside is you're losing essential joints and so therefore going to have some potential for accelerating compensatory or adjacent joint arthritis over time. What types of things do we use when we fuse the flexible deformity? It's a bit of a hodgepodge. Sometimes it might include an isolated tail and vicular fusion with or without a calcaneal osteotomy, the old triple arthrodesis or now the new modified triple or dipple and then selected medial column fusions as well. So isolated tail and vicular fusions, very little in the orthopedic literature as it relates specifically to flat foot but there is some studies out there that show reasonable correction and reasonable overall results. We know from these previous studies way back out of New York that fusing the tail and vicular joint allows for very powerful correction of flat foot deformity in vitro but it does significantly limit the motion of the surrounding hind foot joints. While non-union rate used to be much higher, current non-union rates are going to be in the 1 to 4% and I think that a lot of that goes back to preservation of bone contour, the modern bone graft and biologic options and modern fixation that we have available. So my personal indications, older, lower demand patients, somebody that you anticipate is going to have bad bone, it can still be a flexible type deformity but a disease-free subtalar and calcaneal cuboid joint should at least have some compensatory motion in the adjacent joints. I will typically include lengthening of the gastroc because I believe that this is a deforming force. I'm also going to release the so-called quadruple point or the confluence of where the tail and vicular, calcaneal and cuboid areas all meet and that helps with deformity correction and also address any sort of metacolumn instability or deformity as we heard in the last talk as well. So here's an example, 68-year-old female, low demand, flexible deformity. We see how much forefoot abduction she has. Here's her lateral view. You see the sag at the first tarsal metatarsal joint. She didn't want a big reconstruction. She just wanted to get on with it and so we ended up fusing her tail and vicular joint and added her first tarsal metatarsal joint, good correction interop. Here she is at three years. She's been a little lax on stretching so she sagged a little bit through her NC joint but overall holding her alignment well and she's happy. Here's another example of a 59-year-old female with Guillain-Barre syndrome with a flexible deformity. We're concerned over the look of her ankle. This is an older case. You see the valgus change within the ankle but yet it's still flexible. Here she is on the lateral view. She did not necessarily hurt in her medial column surprisingly and so in her case with the severe valgus deformity, we fused her tail and vicular joint and added a medial slide to her calcaneus in an attempt to protect her ankle and so there she is at her final x-ray and it looks like she has held and so far so good. So the modified triple or dipple was first described by Simarco in 2006 and it was initially popularized as a step to limit compensatory arthritis in the surrounding joints and it was done only if the CC joint was not arthritic. Subsequent studies have described this type of approach through a medial only approach to avoid lateral wound complications with success and has also been shown to have comparable union rates through this medial only approach. My argument with preserving the CC joint is that I believe that it couples with the 4-5 TMT in terms of sagittal plane motion with some rotation and it's surprising how little or oftentimes no arthritic change is noted in patients with rigid flat foot. Art Minoli's last publication before he passed talked about CC remodeling and flat foot deformity and he noted something like 39 consecutive cases where there had been erosive shortening dorsally and laterally at the calcaneus on the CC joint and kind of backed up the context or support for lateral column lengthening. And you can also make an argument in terms of arthrodesis type techniques that notice the gapping that occurs in the CC joint, where's the arrow, there we go, subsequent. And so if that CC joint is included, you can make an argument that it may lessen some of the corrective power by including it in the fusion construct. It can be helpful to include interarticular lateral column lengthening. This was described by Ted Hansen and essentially you're using a lamina spreader between the tailored body and the anterior process of the calcaneus while positioning. And so it basically is just bringing the calcaneus forward but really what it does is help to swivel the foot back around and so there's less pressure through the rest of the joints and I think that's an important component of correcting the deformity. So my personal preferences have been to utilize this DIPL type of approach since 2007. I will typically open the CC joint to look at it and may include a little exostectomy if there's a bit of early change dorsally, but to my knowledge I have not included the CC joint in a primary type of so-called triple dating back to 2007. And I also think that the CC joint is surprisingly forgiving in this realm. Again I think it's important to eliminate major deforming forces so I'll typically include a gastroc recession. I still do a two incision approach so that means releasing the so-called quadruple point laterally to help with deformity correction, do that at the time of opening the CC joint to assess it. You can then add an intra-articular lateral column lengthening if necessary if the deformity demands it and then include something along the medial column where necessary. So here's an example, 66-year-old female, rigid flat foot deformity with a pretty significant hallux valgus deformity and hypermobile first ray. And there she is on the lateral view. You don't notice as much of the sag through the first truss metatarsus joint, but trust me it was rather unstable. We did a modified or triple or dipple combined with a lapidus and here she is at one year. Again notice the gapping through the CC joint in the final view as we've swiveled the foot back around and she's maintained her correction. Finally I'm going to include what we call the atypical flat foot. So this is something that is working backwards and something that Bruce VanJorzen and Art Walling have done a lot of work on over the years. But in essence this is patients that have deformity through the midfoot that is driven by the Achilles or gastroc in which case the posterior tib is often still functional. So the path of anatomy with this is you have a neutral to valgus aligned foot with an associated Achilles or gastroc contracture. Over time the plantar ligaments of the medial column are exposed to the pull of the Achilles and body weight and they eventually attenuate. So here's a cartoon example of a so-called normal foot, normal right foot on the left and this sort of example on the right you can imagine as the medial column attenuates how the whole foot shifts. Over time the medial column becomes unstable, can result in abduction and sag through the midfoot which leads to excessive load and work on the posterior tib and if it's not addressed can ultimately become nonfunctional and more of a true adult flat foot type deformity. These articles are referenced in previous talks but a lot of the decision making in this particular problem comes down to this bony correction. And these sorts of decision makers, now this is all presuming that the posterior tib is still functional so this is not the former but the latter and it's based on presence or absence of increased hind foot valgus, presence or absence of decreased calcaneal pitch and presence or absence of midfoot sag. So these patients that have increased hind foot valgus can be treated with a medializing calcaneal osteotomy. Those that have decreased calcaneal pitch can be treated with lateral column lengthening and those that have midfoot sag can be treated with medial column stabilization. So really when it comes down to these types of patients it's variations of the theme. So if you have increased hind foot valgus but normal calcaneal pitch and no sag that's a simple medializing calcaneal osteotomy. Those that have decreased calcaneal pitch but no sag, no increased hind foot valgus, lateral column lengthening and lastly those that have midfoot sag but normal pitch and no increased hind foot valgus, medial column stabilization. Combos might include those that have both increased hind foot valgus and low calcaneal pitch. You might include the so-called all American or some of these newer combination calcaneal scarf, malerba or step cut type osteotomies. So here's an example, 74-year-old female, has foot pain, her foot has become flatter, she's tender at the midfoot, she has normal inversion strength but she is unable to single leg heel rise because of pain at her midfoot, not so much at her poster tip and she does have an associated gastroc contracture. Here's her ankle view, no increased hind foot valgus. Here's her lateral view, marked sag through her NC joint. Interestingly enough, she hurt more in the sinus tarsae impingement than she did at her arthritic NC joint. And she does have arthritic change at the second and third TMT in addition. So in her case, if we go through the algorithm, she has sag, she does not have increased hind foot valgus and she has normal calcaneal pitch so she's amenable to pure medial column stabilization. We lengthened her gastroc, she still has a functional posterior tip and here she is, we've included the NC joint, the second and third TMT joints and in this particular instance we used autograft out of her distal tibia and she went on to heal well. So as my mentor used to say, every flat foot is different and you can think about fusions in certain older and low demand type patients, might include isolated talon-avicular fusions for selected stage two deformities and the so-called modified triple or dipple in which you can spare the CC joint and look for these patients that have the atypical mid-foot driven flat foot because they are certainly out there, thanks. So we are waiting for Dr. DeLand to get loaded up, we have about five minutes, are there any questions now that we can quickly shoot to the panel? So, so one of the problems with that joint is if you fuse the medial NC joint is it, you can't compress it because the other two joints are still there, the cartilage is there and it's very, very difficult and I think that that has something to do with why we were encountering delayed and non-unions. So I'm very much in favor of all three joints, but then the question is, when and why? And that's so difficult to answer. There are cases where you have severe sag and it makes it easier, but we and others have published that when you do an aggressive cotton osteotomy, it does improve the sag both at the first tarsometatarsal joint and the navicular cuneiform joint, so of course the question is, is it really necessary and when? And then I think that the next thing to say, well, if you're going to do it, to use more modern fixation techniques that are specific to the navicular cuneiform joint, because if you're going to use the traditional approach to breed and maybe try to get a screw or two across there, you have problems. Yeah, I would agree with Mark and one of the things, I mean, I don't like using all three. I think that's just a nightmare to, it's like my least favorite thing in the world to do, but I think that using external, using a compression device when you're actually doing your surgery, so the approach that we'll do is we'll go in, we'll de-breed the joint, put in our graft or we're going to put in a graft, but we'll actually put some pins in and use an external compression to get the joint reduced before we put our fixation in and when we started doing that, that made all the difference and I don't think that's a joint that you can fuse with just a screw. We use plating and I'm partial because I developed the CP plate, so I use a CP plate, but I don't think it makes any difference, but I think if you use the combination of the external compression so that you know your joint's compressed and then use a plate to hold it there, you're probably going to have more success. Yeah, I agree with your statements. It's a booger of a joint. The last time I was in Davos with Dr. Hansen, I asked him if he had any words of wisdom as to how to get the NC joint to heal better and he said, no, I don't, but I think what I've kind of learned by trial and error with the reduction is compression screws planterly. It seems like in a lot of these types of medial column instabilities, there'll be some erosive changes dorsally and I've gone to autographed to try to fill that. I think a lot of the basis of why it doesn't heal to begin with is the navicular just doesn't have great blood supply to begin with, but cortical lag screws to compress planterly and some type of buttress plate dorsally to kind of protect the lag screws. Dr. Sanders from Houston, anyone have any experience with a plantar plate for the NC Fusion? Okay, I think we're ready to go with Dr. DeLand, are you there Dr. Land? Is there another quick question that anyone has or waiting for this to finish up? So, um, I'm this is dr. Lance. I'm like, you know, I'm still in the zoom. Can you see me? Okay That's the the tech in the room okay, and so Will I be able to how will I know when they're introducing me? I guess is the question I think they will send you a message in the chat box. Do you have the chat box open? Um, is there anything you can go now? No, okay Okay Uh, okay He's introducing now Okay, and then they will then i'll just they've got my volume i'm in my volume's on so Yes Okay, so that shouldn't be a problem Yeah, and can you see my message? Oh perfect. They can hear you. Oh, okay So i'm good to go Okay, um good after I can get rid of this right or just Uh, good afternoon. This is jonathan to land. Um And i've been given the task of telling you What to do when things go wrong? with flatfoot your flatfoot reconstruction Uh full disclosure i'm a consultant for arthrax and a consultant for zimmer in the past And I have no conflicts of interest So the primary problem Um in my experience that comes with failure and problems of flatfoot reconstructions in terms of Flexible deformities is what i'll be talking about. Not not triple arthrodesis uh is is as A lateral weight-bearing hindfoot stiffness Is the most common complaint? Uh, I I think that can occur or they can make a flatfoot flexible reconstruction Hurt, okay. We'll we'll go over some other ones as well and the reasons for this the reasons for this dissatisfaction um is is one or two or three of the following reasons One is over lengthening the column. Okay, in other words putting too big a wedge in I believe that's the most common cause But if you're sliding the heel Immediately as you usually are a significant deformity, you can also Overslide the heel and so it can be a combined problem. You can also excessively plantar flex the first ray So you have to look into all three of these I would like to point out that in the operating room when you originally do the procedure that your Your fluoro shot with with the wedge in or with your Sizer trial sizer in and you're you're putting the foot In an everted position and you're taking this ap fluoro of the tail and avicular joint It should it should look like this. Okay, in other words in that lateral corner at the tail and avicular joint. It should be congruent Um, you should not see the tailor head drifting laterally subluxing laterally Because that will be a sign of overcorrection highly likely So here is such a case, so this is a patient patient of mine actually, um With overcorrection and there's that tailored avicular joint which you think might look good. Oh, it's nicely centered in the navicular it's actually adducted and We know from past studies, uh that we have done that this is a Radiographic sign that the patient highly likely Has too much stiffness lateral weight bearing And is uncomfortable So this this is is is is overcorrected On the lateral view you can also see like okay the foot rather than a flat foot is almost turned like into a cavus foot so that the You know, you have a higher position of the talus at the tail and avicular joint in the lateral view You may have some increased calcaneal pitch um These these are these are these are these are also signs of overcorrection So Truthfully also it can look pretty good. There are cases that I have seen This makes life even more difficult where a patient won't look so over corrected in the words like this patient Not really over corrected radiographically, but they can still complain of foot stiffness and lateral pain even with x-rays that look good So The first thing I i'm gonna i'm gonna tell you how to fix the problem But i'm also going to tell you I want you to know how to avoid it Okay, and to me the most important thing in knowing how to avoid it is the following Don't just look at x-rays. Okay, you must assess The eversion motion of the hind foot with your heel slide pinned And the lateral calm lengthening pins To the amount that you're going to lengthen it And then and then judge and then and then and then evert the foot and see that it everts easily That you get at least two-thirds of regular eversion motion Because if you don't and it feels stiff that patient's going to feel it and they're probably going to end up being A complaining patient. So if that happens to me, even though the x-rays look good I will take away one or two more millimeters of lengthening. Okay I like the x-rays actually some of my Happiest patients look under corrected meaning that okay uh On the lateral view maybe their talus still sags a little bit on the tail and avicular joint on the lateral view Maybe it's a little teeny bit a a you know a b-ducted Those patients are highly likely to have good motion and as long as they are not impinging At the subtalar joint, which you can check at the time of the operation And that the that the tail and avicular joint looks really mostly corrected That's the most important judgment you make And so don't just make this judgment By fluoro in the OR or the arch looks good So Here's a video i'm going to play of me in the OR with the lateral column lengthening pin um The first metatarsal fusion that was done in this case, uh pin And and the and the heel pin so I don't fix anything till I judge the foot as a whole And here we go and you'll see me go through several swings But look at the last one and you'll see really the eversion motion So Oh, let's see, let me try to reverse the slide to get the video moving maybe this one will move Oh, so I must say it looks like the video is not working, but you would see me swing The heel and the hind foot to the outside and I can easily Do that motion and and feel that motion if it if it feels like it moves just a little bit. It's not enough It's it's got to move almost like a regular foot, uh because This is a very important field, but you should feel good eversion Motion and you can look at the sinus tarsae make sure there's no subtalar impingement But if it's coming down close to a little impingement That's probably fine. Uh I sometimes will trim a bit of the lateral process of the talus Make sure it doesn't impinge but good eversion motion is the key Okay, so um, so now here's a case of over lengthening so Up in the upper left here. That's where you see the adduction of the talus navicular joint This heel is probably into too much varus. So, um, and looking at the patient from the back. I will decide not just to To take down the lateral column lengthening, but i've moved the heel back Um, and and this looks a little bit like a cavus foot but not terrible and a lot of these patients will obviously Uh be hesitant Even though they're uncomfortable to go back and and do this procedure. Um, but I would encourage you to say, okay Treat it conservatively for a while But say look at you know, we can probably make this better. You don't need to be miserable or feeling too much stiffness uh, and it's and it Is usually worth going back. However, i'll Um, so here is this patient so Here's the pre-op views that I just showed you There's the adduction. There's the heel. So this is after so you notice there's it's still slightly a deducted on the on the admittedly on the AP view so I think really in this patient I could have taken More of the lateral column down what I do is I go in and I take a very small wedge of bone And pin it see that the motion feels better I also go in the sinus tarsae clear out any scar tissue along the front of the posterior facet Um leave the interosseous ligament intact Uh, and then here you can see the heel is better aligned, you know, it's not it's not so immediately So i've i've taken down lateral column length and i've taken on the heel And and the patient, uh, the patient definitely felt better. Okay was even trying to return to running I'd say still couldn't run. Well, but but definitely, uh, you know was happy that she did it But I also want to say very admittedly. I don't think these patients are ever the same there can never be They're usually not as good as patients who you you do it Right the first time like you really leave good eversion motion and they even can look slightly Undercorrected radiographly to me those patients are the best and I think once these patients get over corrected you can't return them to that um maybe for reasons I don't fully understand or maybe i'm not doing enough of the Correction of the over correction so to speak but um, that's been my experience So I want to emphasize this with you to take home from today Probably most important. Please leave good eversion motion in your flexible Patients when you're not doing You know a subcalar effusion or triple arthrodesis so Correct each part of the over correction though Don't just go back and think I need to take down the lateral column lengthening if that heel is in any varus Put it in valgus put it back in some valgus. Um, so So so if you've over slitted some immediately or appears that way then slide it laterally Do look at the first ray if that first metatarsal is prominent that promises the first metatarsal can I can obviously Get translated, uh, uh through the midfoot into the hind foot So I would I wouldn't hesitate to make the first metatarsal head Equal to the second so to speak with a dorsiflexion osteotomy there So in in in in in these cases that are over corrected, uh, don't under correct the over correction, uh, Be careful to be I would fairly aggressively shorten the media shorten that lateral column You can take just a bit several millimeters two or three millimeters and then see how that feels and then do more But but do more if it doesn't uh, if it doesn't feel like that motion is is coming, uh back um pay attention to the position of the heel and the first metatarsal head as I've just said sometimes I will also if a patient's particularly complaining at the base of the Of the at the fifth metatarsal they'll they can complain of pain there plantarly I have in some patients just shave the base plantarly Or at the med head if the same thing is happening at the fifth med head shave the plantar condyle That has helped do I convert these patients to a subtalar fusion to try to really get them back? No, I have that I haven't done that. Um, Uh, I I think with the way i'm Kind of correct You can kind of correct the over correction um I don't think there's real advantage to that unless it's an extreme case and I haven't had to do that uh, and I and I would be worried if you're doing that that it's not necessarily going to uh, fix the a deduction of the Tailor navicular joint you may send the subtalar joint in some valgus But I but if you're not taking down the lengthening of the lateral column You may not take away the a deduction of the tailor navicular joint Now I want to give you a glimpse into the future i'm coming to the end of the talk now But this is something I think you should pay attention to so there's hope you know lateral column lengthening I think it's by no means a great operation. It's problematic to judge as we've just discussed You have to pay attention. So what happens if we could really get rid of it or there's so little of it, you know We're not going to take much of a chance of over correcting. That would be wonderful all for it So I think there's two procedures to watch here That I have personally, uh, uh seen and uh, I I would keep track of One is is thanks to a wu chung lee in korea an article. Uh, Produced, uh, um in my his mentee jay young kim is at this meeting and was talking about the procedure I believe tomorrow Very interesting procedure that I didn't think would work and i've i've done it on a patient myself I haven't followed the patient long enough out to say definitely, but it appears to Have worked and I I I i'm amazed at how well this worked. I wouldn't have guessed it would But what they're what they're doing in this procedure? Is they're disconnecting the fhl tendon? Distally and uh, they are plantar flexing the first ray and medial column and and and Putting that fhl tendon into the plantar aspect of the base of the first metatarsal Having to go out dorsally and fixing it with a biotinous type screw So they are not doing a lateral column lengthening. They developed this specifically because they had trouble with lateral column lengthenings And so they're taking a case like this believe it or not. They are sliding the heel But they're not doing a lateral column lengthening a pretty severe case like this And they're getting this kind of result post-op pretty amazing, right? They're even as you can see Closing the plantar gap At the first metatarsal tarsal joint, you know without fusing it also pretty amazing uh, and and they have they have a very big number of cases of these and And and we'll be presenting more about this. Listen. I think this is a procedure to watch And um, and we'll be presenting more about this listen, I think this is a procedure to watch Um, and obviously you're not lengthening the column. So here's another case, uh, not the same one I just showed you so obvious incredible plantar flexion deformity pretty good size abduction deformity However here on the on the ap view and then here they are post-op telenevica joints Uh a good year The the the telenevica joint in the ap view is not over corrected. Um, and Uh, they're not having this, uh, uh lateral overload um problem, I think to any significant, uh, effects so um, this is a procedure, uh to watch and another one is one Developed by caesar dinetto is at the meeting. Um, and he's published uh, kate's report on this and is doing a series Uh, and and this is in effect a lengthening of the first ray pretty interesting, uh using a a device and in planting in in the first metatarsal tarsal joint and and something like a potentially eight millimeter Uh, mostly rectangular uh or slightly tapasoidal wedge Uh and uh, so lengthening the first column and he's finding that that that in cases Um, even even without like doing any lateral column lengthening is is giving correction at the subtalar joint and is Of course being caesar, uh documenting how well this is doing, uh, you know via weight-bearing cts So I think this is another potential Really good way to stay away from lateral column lengthening um and the stiffening that it can create and you're you know, he he is, uh, I've not had significant problems to my knowledge with uh, with plantar flexion or too much prominence of the of the med head with this So he's careful not to lengthen too much and retain the motion of the first mp joint. So, um, This is something to watch out for as well. So in summary how to avoid overcorrection Most importantly Assess eversion motion and have good eversion motion remaining when you're treating the patient I've also learned don't leave the patients in for a cast too long Put them in a boot at two weeks or three weeks and and get them moving uh, so so, uh, they don't develop scar tissue and the sinus tarsae or the Joint and start mobilizing them early um You know during the procedure obviously also make sure the tn joint is not a deducted that the heel is straight to slight valgus I like a little valgus and the first ray not plantar flexed So how to correct the overcorrection we've gone over that You got to correct each component and correct them adequately as we just talked about with With the lateral column shortened enough the heel In valgus feeling like you're getting some good eva from motion remaining take scar tissue down in the sinus tarsae you restore motion, uh, and don't have that first rate plantar flex, but Uh, there is a good future to this. I am hopeful Where we can shorten the lateral column lengthening less maybe still do it a little bit in the severe cases, obviously But I mean not at all right now. My more common lengthenings are not seven millimeters. Okay Even i'm getting away from six. Okay, and and if I if I have a patient who hardly has any abduction I will not do a lateral column lengthening because I think that's the most high risk group That you can create over stiffness is people who don't have that much deformity. So my lengthening Are going down to like five or four millimeters, and I wish i'd started doing that uh years ago and I have happier patients, uh, so Um, but the with these procedures mentioned the lapicot and FHL transfer, we could be getting away from lateral column lengthening in most or many cases. So there is hope. Thank you all for listening, and I'm happy to answer questions. Thank you, Dr. DeLand. I think we should do some cases. Dr. DeLand, can you hear me from there? Can I ask a huge favor? These guys have old eyes, and they're not going to be able to see the x-rays from there. Can we have this row switch? Dr. DeLand, can you hear us? Yes, I can. Oh, great. OK. So how do I get out of this? Thank you, Dr. DeLand. Welcome. OK. How do I get to my talk, my next one? I'm going to start now. He's done, but we want to still talk to him. experts. All right, Irvin, you go first. Irvin, get over there. One of the requirements of me taking over moderator duties was that I go through again and practice together with you guys the new PCFD classification system, so we can get good at it. And luckily, we have Mark Meyerson here to tell us if we're screwing it up or not. So again, we want to classify it first into flexible or rigid deformities, and then we'll just build from back to front, classifying each deformity as rigid or flexible. So we'll go from Heinfeld-Valgas. of Baris, Perry-Taylor suffixation, and ankle instability. So each case we're gonna practice that together. Okay, first one Irvin. This is a 55 year old healthy woman, was doing a lot of hiking in the spring, and then developed pain and swelling over the medial ankle. Now she's always had flat feet all her life, but she noticed that the left side's become flatter more recently. She's failed conservative management, even had an Arizona brace. BMI is 27. She's a young 55 year old. On his AMG, he's got flexible hind foot valgus. So how are you reading the tea leaves here, Irving? Irving, you got the mic? So it was a 4th varus C. It was a 2C, the rigid 4th varus. And the flexible valgus was a 1A, 1A and B, 1AB and 2C. So I'd say it's a flexible abduction method. lateral column lengthening cotton or first TMT. Looking at the lateral side, I'll probably go with cotton. Okay. So that's basically my plan. I had posted her for an All-American. It was a very flat clinically foot, so I posted her for both lateral column lengthening and medial slide, FDL transfer, cotton osteotomy, gas truck, and this is one of those ones like I was talking about where you do the Evans first and you take a look and you go, oh, it's pretty straight. I'm gonna hold and not do the medial slide. So here's my intra-op photographs. 10 months later, she's back to hiking and hiking five miles pain-free. How would you critique this? Go ahead and tell me, what would you do differently? What did I screw up? Is she in pain now? No, she's doing well. Yeah, I think you did a good job. me. Do you usually fix your cottons in your lateral comb lengtheners? Yeah, I do. I put just like you do. I'm not always a cotton. Sometimes I don't put anything. I just leave it. Okay. Mark is ready to rip me a new one here. Go ahead, Mark. Do what you want. No, no, no. You know, this is almost along the lines of what Jonathan said earlier, and that is that AP looks great. Lateral does not look so good because you've got peritailor subluxation, and if you look at the impingement of the lateral process into Gissan's angle right in the sinus tarsi, I would imagine that on a weight-bearing CT, you'll see impingement. Sinus tarsi impingement. Sinus tarsi impingement. So you know, this may be perfect clinically forever, but when I look at this, I worry a little bit about what's going to happen with the sinus tarsi. So did you think that she had sinus tarsi impingement to begin with, or did I create it by lateral column lengthening? Well, can you go back, please? Yes. Okay. So one of the things that I think is very, very important, why we get sinus tarsi impingement, regardless of where you do your lateral column lengthening, whether it's here or here going that way, as Beatrice described, you're trying to move this part of the forefoot hinged around the axis of the tail and navicular joint. That doesn't happen. You get both anterior shift, but also posterior shift of the tuberosity. And that's why you end up with sinus tarsi pain in so many of these patients. So if we know that we have sinus tarsi impingement going into the surgery, how do you correct it? What's the best answer for getting rid of it, if your weight-bearing CT shows it? So I think you need to be a little bit more aggressive with medializing the calcaneus. And in some patients, if you go to your lateral now, post-op, so it looks nice, but your calcaneal pitch has just not been restored. It's quite flat. So perhaps something needs to be done to improve that a little bit. When you do your medial slide, do you cheat and slide it planted a little bit to try to cheat pitch? If I can, but then, of course, I really have to watch the gastroc. What was the reason that you did not do a medial slide from the get-go, and did you do a gastroc? Well, I thought she had a lot of tail and navicular uncoverage, abduction. So I didn't think the medial slide alone would take care of it. I went in planning for both, but then I was happily surprised that the lateral column lengthening had taken care of my valgus enough. So the question is, so she's 10 months out, she's hiking, she's happy. What's the problem? No problem here. So are we treating a patient or are we treating an X-ray? Patient, sorry. Okay, so if we're treating a patient, the patient's doing fine, I'm not sure there's anything to worry about. I mean, it would be different if she was having a problem. I mean, it's better to have an X-ray that doesn't look great with a patient that's happy than an X-ray that looks great with a patient who's unhappy. Agreed, 100%. Okay, Mark, you're next. This is patient number two, a 52-year-old male real estate agent, and he's complaining of worsening ankle deformity, medial ankle pain, and swelling when he's shown in his homes. Can't wear shoes anymore, can't exercise, he has diabetes, but no neuropathy, A1C is okay. On exam, rigid hide foot valgus, rigid forefoot abduction, rigid forefoot varus. This guy's fixed. So because it's rigid, in stage two, that's okay. Rigid abduction, that's rigid valgus is 2A, rigid abduction 2B, rigid forefoot varus 2C. And I'm assuming from that, you did not mention anything about sinus tarsae nor the ankle, so... So then this depends on whether it's flexible or rigid. Flexible. So anytime I see these, I'll take them to Floro in the office and make sure I can reduce them easily. So 2A, B, C, one of the problems, and I'd like to just point this out to all of you, we recently met again, this whole consensus group. And we tried to clarify, what do we mean by peritalis subluxation? It's a difficult concept. What is it? Is it sinus tarsae impingement? Certainly on weight-bearing CT, it's very easy to diagnose. Cesar Neto has done some wonderful work on what constitutes that lateral shift causing sinus tarsae pain. Clinically, if you've got pain in the sinus tarsae, you probably can't get that without peritalis subluxation. So then I would say this is a 2A, B, C, D, 1E. Rolled right off your tongue, 2A, B, C, 1E, right? Yes. Now, the fact that you've left out D implies to me that there's no sinus tarsae pain. And then you can just ignore D. So my question is, when I'm pushing around that lateral side of the hind foot, can I really distinguish sinus tarsae from subtalar arthritis, subtubular? Exactly. Is this mostly a radiographic part of a radiographic clinical classification system? Exactly. So it is something that I'm struggling with now. And there is a poster downstairs on just this, on what is the inter-observer reliability. What is everybody? How do they rate this? And class D is one that many people got wrong, because we don't quite understand that. I just want to make sure we do it the Mark Meyerson approved way. Do you want us to put alphabetic order or numeric order? Should this be 1E, 2A, B, C? This is another very good question, Cliff. So it's a problem. When we examine somebody, we start at the ankle. We go to the subtalar joint. We then go to the transvestosal joint. And we then go to the forefoot. So actually, when we sent out the second phase of the study, everybody was answering it that way. E, which is the ankle, then you go to B, then you go to D, and C is the last one. So I'm really not sure. I think it's probably the way you're comfortable. This is the way we originally intended it, but I don't think it really matters. OK. But Mark Meyerson says alphabetical ordering, basically. No, forget about Mark Meyerson. That's not it. I think it really doesn't matter. OK. All right. So what are you going to do, Mark? So I would do a triple with a deltoid spring ligament reconstruction. All right. So that's what we did. We did a triple arthrodesis. We did the deltoid reconstruction the way that me, I'm sorry, Mark, Eric Blumen, and I described it. And we did a TAL. So this is the triple. And this is at three months. And it's holding pretty good there. Can you do differently here, Mark? No. It looks lovely. You know, one interesting thing that, if you look at the pitch angle of the talus, it's really curious. Now, sometimes, of course, as you will know, when you're trying to plantar flex and reduce the talon-avicular joint, this is exactly what happens. You end up having to push it down. And inadvertently, the force on the medial column then pushes the talus up ever so slightly. Now, I don't know, in the long term, if that makes any difference. I really don't. But it's just an interesting observation. You've got great correction. But your talar declination is down. Now, I do know that there's some people anticipating that would put a bone block in the subtalar joint in order to lift up the talus and improve the talar declination angle, anticipating that this may be a problem. This is that same patient, pain-free, at five years. It looks great. This is one in our paper. Yeah. This is one that we're following. OK. Pass the mic. Keith? This is a 57-year-old man, manual labor, digging ditches. He actually digs ditches for NASA. And he twisted his right ankle stepping out of the pickup truck two years ago, and he's had pain on the inside of his ankle ever since. He started noticing the foot starting to turn out a bit, history of rheumatoid arthritis, BMI 32. So on exam, I can correct his heel, flexible heel valgus, forefoot abduction correctable. He's got kind of a sloppy first rate. So I think he might have some... How does that play into it? Well, because if this is somebody that's got significant rheumatoid disease and periarticular erosions elsewhere and has advanced it, for me, it's going to push me right into the fusion. Yeah, no, there's not that. a laborer with the I didn't. Can you go back? I'm so sorry. I wasn't paying attention. I was actually looking at my shoes. Everything's flexible. I'm going to buy a new pair of shoes. I was looking at this. He's got some nice small birds. All right. So everything's flexible. So this would be one. Go back, please. One A, heel valgus, forfeit abduction, one B, flexible, one C. And you ignore D and E then. Now, this guy came with an MRI. And Keith, I know you always get MRIs. So this guy has some edema in his sinus tarsae. Right. How does that change what you do or what you're thinking? Well, when you go back to this whole concept of sinus tarsae pain after these surgeries, I think this is where the MRI is very valuable. Because a lot of these patients with significant deformity already have arthritis in their subtalar joint. And so even if you do a good correction and you're not seeing that because it's not always evident on the x-ray because you don't get a good view of the subtalar joint on plain x-rays, if you're getting weight-bearing CTs as your x-ray evaluation, a lot of people who have the But again, I think that that's the type of All right, so I didn't listen to Keith, and I did a lateral column lengthening, first TMT fusion to take care of that instability, FDL transfer, and gastroc recession. So in general, if they have no, the rest of the posterior set's clean, but they just have the sinus tarsi edema, you'll err towards fusion. And not try to correct that, or however we correct it, not try to spare the joint. Let's say not in this patient, but in a healthy patient. Yeah, and a lot of it goes back to what John Delanet said about those patients having pain afterwards. to avoid lateral column lengthenings in people with that kind of sinus tarsy edema on MRI or with sinus tarsy impingement on weight-bearing CT? Some of them will actually even have subluxation where the poster facet is sliding down into the calcaneus. It's hard to know because right now the alignment looks good. It's not surprising that the footage. Do you think we save them anything? Like this patient felt as if as a triple arthrodesis. Do we save him anything by doing this instead of the triple long-term wise by leaving the joints open? That was your talk, what do you think? Are we saving him by leaving the joints open, even though they're just as stiff? I guess it depends on how stiff his stiff, as he truly has- He feels like a triple arthrodesis. All right, you must hold on the mic. You're next. This is a patient for a 49 year old male HR manager. This is a really good guy. I mean, he's a Boy Scout leader. He coaches two youth lacrosse teams, not just his daughters, but someone else's kids teams. He was a formal collegiate lacrosse goalie, and he told me he took a lot of hits to his ankle when he was in college. But six years ago, he was playing laser tagging and went to go take a run, and he felt sudden pain in his left ankle, and he's failed conservative treatment. His main pain is really over the tail and avicular joint. This guy's rock-solid rigid. On exam, rigid heel valgus, rigid forefoot abduction, rigid forefoot varus. So 2ABCD, right? 2ABC, yeah. Let's see what I said. Oh, add this. This is, he had a weight-bearing CT scan, too. So you can see the cyst in his tailor neck head. You can see subfibular impingement. And you also see some cysts in his NC joint. And you kind of see the relative subluxation of the calc relative to the tail. So he's got to be, that's peritailor subluxation. Got to be. So 2ABCD, and then do you have anything in the ankle? Ankle's OK. If I don't show the ankle, the ankle's OK. So then we ignore that. All right, so let's see what we've got here. 2ABCD. Yep. Nailed it. OK, what do we do now? 49, stiff. Stiff, I think that's one that, despite his age, I don't see any way that you could get that corrected and be able to spare his motion. I think that's something that's going to have to be fused. And I think you'd have to, that's a prime example of one where interarticular lateral column lengthening, when you go to position it, is going to be invaluable to be able to get the calc back under the talus and help swivel it over. So tell me your technique for doing that. That's why I picked you for this, what you were talking about right there. He's talking about the talus is slid down on the calc. So in that instance, two incision approach, whether you do a tip of the fibula to the base of the fourth or a modified olease. I do a modified olease. That's how I learned, and that's how I've always done it. So everything's prepared. Everything's been released. You've prepared your joints. You've drilled. You're ready to position fusion and so forth. And I usually start with the subtalar joint first. And so as you're putting guide pins up from back to front, stopping just shy of the subtalar joint, and you're kind of anticipating that it's going to, your calcaneus is going to move forward. So as you do that, lamina spreader between the talar body and the anterior process. And you have to be kind of careful not to jack it open, but to translate it. So you're trying to bring the calcaneus forward relative to the talus. And as you do, if you've done it right, the head of the talus should be up, and the calc should be back underneath it. And so it kind of needs a second set of hands. And at that instant, once you're holding it, then you drive the guide pins across and then double-check the position, x-ray and clinically. And are you worried about the metatarsus seductus? Are we going to swing that over even more than it already is? Got to be a little careful about that, for sure. Avoid that. You might need to. But it also might be one where you might settle for a little less than what you would consider ideal, as far as the talonovicular joint, with the idea that with this kind of skew deformity, if your talus lines up with the first ray in the end, that's probably a win. How about the NC joint? Do you want to include that in it, because you see that little cyst in there? If he hurts there, I would think about it. But if not, I wouldn't. Yeah, it's a lot of surgery. He doesn't hurt there, so I left it alone. OK. So we did a triple arthrodesis, like I said, TAL. And we did exactly your technique, where we put that laminar spreader kind of right here between the talar body and the anterior process to just push it back up the hill to get it where we want it. And then that kind of effectively kind of put the talus back where it belonged. It was almost like a medial column shortening. I wasn't bringing the navicular immediately. I was bringing the talus back underneath the navicular. And so it usually involves a lot of laminar spreaders and clamps. You bring up a good point, though, because it's really powerful. And you have to be careful not to kind of over-lengthen. And if you have a big gap in your talonovicular joint, you worry about that being able to heal. So in that instance, if you notice that, you've got to take a little off. So how did I do? Looks pretty darn good. So I just saw him actually last week for his one-year CT scan follow-up for the study. He's back to coaching lacrosse, doing OK. What do you think about that NC hump? Do I have to worry about that later on? Am I coming back? Wait and see. I assume you did something with his Achilles as well? Yeah, we lengthened the Achilles. So this is a CT that we did last week for his one-year checkup for the study. And you can see that NC cyst is still there. But it looks like it's, I don't know, maybe going away. And then the important thing is that we got rid of his subfibular impingement by doing this. So we still don't know what the best procedure for getting rid of that impingement is, but it worked on this case. Do you think you could have also added an NC hump to that? You would get the Achilles instead of the ballast. I think so, yeah. I could have made him a little bit prettier. But he's happy now. He just actually came in for his one-year checkup because his opposite right side, same exact deformity, is starting to hurt. OK. Pass the mic, Irvin. Oh, actually, Dr. DeLand, are you there? Yeah. It's 4 o'clock. Oh, it's 4 o'clock? Yeah. Oh, I think we're done. I'm here. Absolutely. Oh, OK. Do you guys want to go? Or you want to listen to Dr. Land do one last? You're good? I need to. OK, all right. Mark's got to go. Hey, thank you very much. Dr. Land, sorry, we got to go. Thank you for the panel. Thank you, everyone, for your attention. Good job, all. Thank you.

surgical approaches

flatfoot deformity

posterior tibial dysfunction

arch collapse

Achilles tendon position

calcaneal osteotomy

lateral column lengthening

forefoot abduction

weight-bearing CT scans

associated deformities

physical examination

imaging

symptom correlation

step cut osteotomy

transverse arm bone-to-bone healing