Good afternoon. Welcome to the afternoon session. I'd like to welcome everyone back. I'd like to extend a thank you to Chris and Casey and Daniel for a great meeting so far, and we're going to continue on. When I saw this panel, I was really super excited about the talks and the names that are on this panel. We have really some heavy hitters and professors emeriti and editors emeriti, and it's really awesome. But I've seen their talks, and what's exciting about these talks is that you can see the wisdom, and you can see their years of clinical insight in their talks, but there are also many pearls in terms of surgical pearls. So I'm sure that you're going to come away from this session both with instilled wisdom, but also practice changing pearls. Super, super exciting. So welcome. Thank you. We'll start off with Keith Wapner from Penn, who's going to talk to us about when to fuse a flexible deformity. Cesar, are you out in the audience somewhere? Because I hope that things are going to be okay when we talk about fusing a flexible deformity. Keith, thank you. So I think Casey asked me to do this because I'm the oldest guy on the panel, and I've been around a long time, and there's not a lot of science for this. So it's a little bit, you know, I want to tell you about some of the mistakes that you can make, and hopefully you don't have to make the same mistakes as me, but just to give you an overview of things. These are my disclosures, which really don't impact this talk. So do the easy one. When do you fuse? Well, you know, if you've got a deformity and you've got degenerative arthritis, it's pretty simple because even if it's passively deformity, if it's got arthritis, you know, well-aligned arthritic joint is going to hurt just like a non-aligned arthritic joint. So that's kind of the easy one. When I started in practice, rheumatoid arthritis was much more perplexing, or much simpler than it is now. It's a little bit more perplexing now because we didn't have demarks. So we used to see a lot of posterior-tib dysfunction that came from the RA, the sinubitis in the sheath. It affected sometimes the peroneals. It should also affect the FDL. So if you're going to do a tendon transfer, it's the same process that took out your posterior-tib, you're going to take out your FDL. And so we would move more to doing fusions with all of our rheumatoid patients because we didn't have the demarks. With demarks, it's a little different, but sometimes you'll still see patients that have significant sinubitis. They can have a lot of signs of joint destruction from that. And if they have those signs, and they especially have a significant deformity, you probably want to think more about doing a fusion. But that's not so easy sometimes because if you realign them, that lateral skin can really be a problem. And so a lot of times in those rheumatoid patients, you can just get away with a medial approach to a double arthrodesis and try to fuse them. So that's probably in rheumatoid disease, it's nowhere near as common that we do a fusion as we did when I first went into practice. Instability is kind of interesting. Sometimes you can see posterior-tib insufficiency from paralytic disorders, and then it's just a question of what else is working. If everything else is working and you can do an FDL tendon transfer and approach that like a normal patient, you don't have to fuse them. But if other things aren't working, then you have to think about your goal is to get some stability. So in a patient like that, you may want to think about doing a fusion. With hypermobility, whether it's Ehlers-Danlos or just generalized hypermobility, again, then it becomes a question of just looking at that patient individually. Where is that hypermobility? Which joints are affected? Is it spring ligament? What's their other foot look like? And that's an important component of it because if you take somebody that has generalized laxity, has bilateral flat foot deformity on both sides, and now has posterior-tib insufficiency on one side, that side starts to become asymptomatic, and you go back in and you realign them to a normal arch, so they have a normal arch on one side and a flat foot on the other, they're not going to be happy. They're not going to be balanced. So you have to look at that patient individually and figure out, you know, is that my last resort? And generally in those patients, it's going to be if there's arthritic changes in the joint. And you can tolerate a little bit more of that continued flat foot because that's where their baseline was. Deltoid insufficiency is always, to me, one of the biggest problems that you run into, especially when you're getting into stage four deformities. And that's a problem because I, in my hands, I have yet to find a deltoid ligament reconstruction that consistently works every time. I think if you're batting 50 to 60 percent on those, it works well. And then you also have to think about, all right, is there deltoid insufficiency with arthritis in the ankle or deltoid insufficiency with no arthritis in the ankle? So you may want to take the approach where you realign the hind foot with a fusion and then try to stabilize the deltoid ligament. And maybe it will work better if you have a fusion so you're taking the stress off the deltoid. Or in other situations, if there's arthritis in the ankle but the foot is flexible, maybe you want to fuse the ankle but then do osteotomies and realign the foot with a tendon transfer. So you have to look very carefully at those patients. And ultimately, you know, what you want to try to not do is have to do a pan-tailor fusion. But those are the ones that are problematic and you really have to look at them carefully. One thing that I've seen occasionally is AVN of the tail or head or body, which is unusual but it can occur. So you want to be aware of that and you probably need to do a fusion there. And then comes the issue of age. You know, when we start seeing these early on is in the 40s. So when you're in your 40s, I mean, they're still making movies about how great your life is and things like that. And most of those patients are fairly active and they're probably going to be good candidates for reconstruction. When you get into 50s, it gets a little bit more complicated. You know, life becomes a little more difficult. You know, you're not quite as active. You know, and you'll see patients in that range looking at a little bit different discussion with their lifestyle. By the time you get into your 60s, then they're writing books about how to get through this last part of your life. And my dad used to have a saying. He said, you know, anybody who could do in their 60s, what they did in their 30s just wasn't doing enough in their 30s. So if you have a patient in their 60s, you want to start talking to them about what their expectations are, what are they trying to get out of this. I'm about to turn 70, so this is my new adage because, you know, my mind is still as tarp as a shack. So the discussion then is more important. Do you want to have that patient commit to, you know, six months to a year of doing rehab? Does that patient want to commit to that? What are they trying to get out of it? What's their ultimate goal? Is it a very active older patient who wants to go back and, you know, be playing tennis and doing that? Or is it somebody that has a more sedentary lifestyle? And I think that plays a role in what your decision is because it's going to play a role in how that patient recovers. Weight can be another problem. I mean, if you have somebody that's 250 pounds, if they're 6 foot 5, that's not so bad. If they're 5.6, it's a lot different. So you got to look at their BMI. There's no good science, just like in total angles. There's some, you know, people say, well, you can do total angles on obese patients. Some people say you can't. There's not a lot of great science on this. But what I've found from my experience is that patients that are overweight just generally tend to have less of an active lifestyle, maybe less willing to participate in their therapy. And it's a discussion you need to have with the patient because I have a lot of skinny patients that won't do their therapy either. And if you're not going to participate in this, you're not going to get a good result. The occupation to me is not as big a deal because if I have a laborer or somebody who's a carpenter or does a lot of things and I do a reconstruction on them because they don't need a fusion because of arthritis, what I do in my practice is I put them in an Arizona brace for when they work. So wear this brace when you work and protect what you're doing. If you're an office worker, it's probably not as critical. The big thing for me is discussion when these patients are willing to participate in their rehab. Because no matter, you can do the best tendon transfer, the best reconstruction, the best osteotomy in the world, but if your patient won't participate in rehab, they're just not going to do well. So don't underestimate the importance of that discussion. Sometimes they may be unable to do that rehab and again, that's going to push you into doing fusion. So there's a social component to this and the only way you're going to get to that is to talk to the patient. Adjacent joint arthritis can play a role. We've already sort of touched on that a little bit in adjacent joint motion. The one thing that I cannot give you is for this degree of deformity, you definitely need to do a fusion. I don't know of any scientific data that will give you that guideline. So this is where the art of medicine comes into play and it's getting to know your patient, getting to know what they want, getting to know the expectations and then you sort of make that decision. So you have a lot of choices for fusion and this also plays a role. What do you need to do for that patient? And again, it goes back to discussing it with the patient. Triple arthrodesis, obviously if you have severe peritailor subluxation with arthritis, triple is going to be the best thing. But if you have a bad deformity but the CC joint looks normal, you know, maybe you don't have to do a triple. You may get by just by doing a double arthrodesis. So you can do that and again, we talked about this in rheumatoid arthritis can be important. To me, BMI does not play a role in this. I think you can do just as well with a double arthrodesis as you do with a triple arthrodesis as long as you prepare the tail and the vicular joint properly and get that to be solid. That's 70% of your motion at that level and that's going to control everything for you. The medial double is a good thing if you're worried about that lateral skin with severe deformities, especially as I mentioned in the rheumatoid patients. And you can get good exposure to do this. This is, you know, one publication on this that I think is worth reading. It just talks about the results of them and it's a pretty well done study. Isolated tail and vicular fusions can be done. I think they have more limited indications. I will generally only do it on a patient with a low BMI and if there's isolated tail and vicular arthritis. Jeff has probably written the most about subtalar fusions and he and Bruce Cohen published this, you know, back in 2001. It is effective treatment and can give you stable, reliable results. Probably not as good as a reconstructive procedure and they said, you know, you may look at doing joint preservation procedures instead. This is also an instructional course lecture that Jeff wrote which I still think is really valuable and if you haven't read it, you should. And I think it's a good guide, especially for the residents. Whether you include the, you know, whether you do concomitant, limited arthrodesis with tendon transfers, again, you know, one is what Jeff talked about with subtalar fusions. The other was when we first started doing lateral column lengthens and the Seattle group talked about doing CC joint fusions. If there's arthritis in the CC joint and you take that approach, I think you're probably better off doing a CC joint fusion rather than a lateral column length and leaving the arthritic CC joint there. And we'll talk more about that as this meeting, as this panel goes on. So I think the indications when you're looking at it, you look for arthritis, look for instability, talk about the age of the patient, what their expectations are, what their willingness is to participate. Discussion about BMI, discussion about occupation all plays a role in this whole thing. And then you go to your decision tree. Do I need to do a triple? Do I need to do a double? Am I going to do a subtalar or a talon or vicular? Or am I going to do an isolated fusion and then incorporate that as part of a tendon transfer? So doing a fusion itself does not necessarily mean you're not doing a concomitant tendon transfer. I think you keep that in your mind. So again, the degree of deformity really is not, I can't give you any good guidelines. There's no good science on this. So again, this is more gestalt and the art of medicine. BMI, again, I just think it's something you have to talk to the patient about. And hopefully you have a reasonable patient that you can have a nice conversation with and get this out and make a mutual decision. So thank you. can be very powerful corrections for a progressive flat foot deformity. So we got Irvin Oh coming up talking about, should we abandon lateral column lengthening? So I want to thank Dr. Goss and Humbert for inviting me for this talk, which is my favorite topic. So I know a lot of you have been disappointed by lateral column lengthening. Sometimes we see patients coming to clinic with a lot of foot pain, stress fracture, collapse of the graft. So some of you had some complications and a patient whining about it. So I understand why we are asking this question. I have one disclosure, which is relevant to this talk. So it was first proposed by Dr. Evans in 1975 and really popularized by Dr. Moskow in 1995. And it stood the test of time. And we use it commonly in our foot reconstruction. It's a very powerful corrective method. But it was not until mid-2000 that we start to see some biomechanical study that explains what and what happens when we do this. Study out of Seattle by Dr. Moskow himself, Dr. Justin Georgian, and Dr. Dumont here, who studied very simple biomechanical investigation of just doing the simple 10-millimeter lateral column lengthening in a normal foot, not a flat foot, but normal foot and looking in under the CT scan that is non-weight-bearing. And what they found is that the transverse tarsal joint is coupled. They showed a coupled motion of the navicular and cuboid. And what it did was it abducted and plantar flexed the midfoot relative to the hind foot. That was one of the first study. And the second study that caught my eye was this one published by Dr. Jeremy Chen when he was in HSS. What he found with this study was that the correction of the forefoot abduction in flat foot reconstruction was primarily determined by lateral column lengthening procedure. He proposed this linear model where you can see that with each millimeter lateral column lengthening, you are correcting about 6.8 degree of that talonavicular joint abduction. They made this angle a lot of incongruency angle and measured how much correction you're getting. And so they proposed 6.8 degree per each millimeter. But if you look at this study carefully, they had a lot of different concomitant procedures. I'm not sure if you can really use that figure as an isolated effect of the lateral column lengthening. So what happens to the valgus heel? So you wonder, if you do a lateral column lengthening, are you going to correct your valgus heel at the same time? And what Josh Baxter at the time at HSS found out is that when you do a 10 millimeter lateral column lengthening on this cutivaric flat foot model, then you can correct about 60% of the hindfoot valgus. So it does correct the hindfoot valgus to a more neutral position. So the clinical implication was that you should do lateral column lengthening first before you do medial carcaniate axiotomy because you may overcorrect if you do the medial carcaniate axiotomy first. So they proposed the lateral column lengthening first and determine if you really need a medial carcaniate axiotomy. In my practice, I still do MCO first and lateral column lengthening for a different reason. But that's something to keep in mind. So to summarize those three studies, you can say that, OK, the lateral column lengthening is a really three-dimensional correction. It adducts the forefoot, translates the navicula, and also realigns the heel. It's not just the axial pushing of the forefoot and midfoot from lateral to medial. I feel like it's more of a rotational correction through the talon navicula joint and dorsolateral to plantar medial side. Complications has been reported, unfortunately. Overcorrection occurs in almost 9% of the time. And it manifests as a lot of foot pain or stress fracture and recurrence about 15%. And that's a pretty significant complication that we see caused by non-union collapse or undercorrection. And sometimes, a coalition that was not detected before surgery. I think it's related with the amount of graft lengthening that we do and the choice graft that we make. And also, it may have to do with fixation device, too. This is my study with Dr. DeLand when I was a HSS fellow 10 years ago already. So what I found is that with each 2-millimeter lengthening, you see a consistently increasing lot of forefoot pressure. And the clinical implication of this was when you're doing a lot of column lengthening, you should really titrate by 2-millimeter. Because even that 2-millimeter difference can make a difference. I don't want to be OCD-like saying that, oh, it's a 1-millimeter, 2-millimeter, but it does make difference. That's what we found. And what I got out of this study was if you look at that figure, there's 6-millimeter lengthening best resembles the intact condition. So in my practice, I do 6 to 8-millimeter. I've never gone beyond 10-millimeter lengthening. And this study just came out this year, which kind of validated what I found before and what these authors, they use a standing CT scan. And what they found is that 6-millimeter log column lengthening restored the alignment closest to the intact foot, whereas 10-millimeter lengthening tended toward overcorrection. So again, be careful when you're going beyond 10-millimeter. There are some variations to log column lengthening proposed by Dr. Hinteman, which goes through the posterior metaphysed, and also Dr. Vindergrind, who proposed step-cut lengthening. And I think the idea is that by doing that, you can decrease a lot of foot pressure and increase the chance of healing without using an allograft. These studies have shown a similar outcome to Evans' osteotomy. Dr. Hinteman proposed that maybe I get less cut cancubal joint arthritis, but clinical implication of that is really not clear. Basically, all these studies have shown that is that they work the same as Evans' osteotomy. And because of the technique, I find the Evans to be more easier for me when I'm doing all-American. So I have been staying with Evans. There are some other more meaningful alternatives that has a different concept. It is more stressing on the importance of a medial stabilization. The first one is the FH attendant transfer by Dr. Woo Chun-Li out of South Korea. He recently proposed you can do attendant transfer instead of a lot of column lengthening to get this correction. The idea is that you bring the first rate down, which will cause a subtalar inversion in talon-navigator joint adduction. To me, it's more like a pulling from the plantar medial side of the medial aspect of the foot to recreate the arch. Same concept goes with Dr. Cesar Neto's lapicotinase fusion. It's more of a pulling from the plantar medial aspect of the foot to recreate the arch. So which one is better, push or pull? Or why not do both? Because the original article by Mosca, it's very interesting to see that he proposed doing the cotinaseum at the same time. There was never really stress because we were more focused on a lot of column lengthening. And the same thing with Dr. Woo Chun's paper in 2007 that he saw that when you added a medial cuneiform osteotomy, it provided increase in deformity correction, but also decrease in a lot of foot pressure as well. So to me, if you have a huge deformity that requires you to do a lot of column lengthening, I think you should consider doing the cotinaseum at the same time. So when should we do this? So a group of our colleagues gathered together a few years ago and they concluded that tonic adjunct on coverage of more than 40% is when you should consider doing a lot of column lengthening. Graft option, I'm not going into detail because Dr. Thordalsen has a presentation on this later, but what we found as orthopedic surgeon is that we like to avoid high morbidity associated with taking out autograft from iliac crest. So we have using more of a allograft. They have similar outcome as at least in front ankle literature. And I think the most common one that we're using now is a freeze-dried or hydrated bone allograft, which is known to have osteoconductive inductive property. However, the osteoconductive properties really can change depending on how much irradiation or bleaching you're doing to the graft. If you're doing too much of them, it's gonna collapse. And that's what was suggested by our spying colleagues who noted a higher rate of graft collapse and shoot arthrosis in freeze-dried allograft. And so they advocated for using the autograft. And this paper also support that fresh frozen is better than irradiated freeze-dried allograft. And that big allograft, because it's taken out of iliac crest, I call it big-ass allograft. Dr. Baumhardt suggested me to use that and that has changed my practice and the way I do a lot of column lengthening as well as incontinence anatomy. There's this 26 to 30 millimeter size and nine millimeter size. I find the 26 to 30 millimeter to be more economical because although it's a few hundred bucks more expensive, when you're doing multiple osteotomies, medial stabilization at the same time, you can carve out as many as you like to use. If you drop one on the floor, you have another one that you can make out of it. Does graft shape matter? The studies have shown that triangular shape is the best because it provides less supination and lateral overload. If you're using a rectangular or trapezoidal that is thick in the medial side, I think there's a high chance you're gonna distract the anterior and middle facet and it's not gonna be anatomic. Some people have suggested using a porous metallic wedge which works, but there's still a non-union that has been reported. My technique, I use a radiographic assessment with pin distractor and simulate weight bearing and I wanna make sure that my hind foot is flexible when I do this. As we discussed, I do a fresh frozen and make a triangular shape and titrate by two millimeter. Our colleagues have agreed that you should be doing five to 10 millimeter, but not beyond. Fixation option, I've used plate, screws, staples, everything, but now I'm migrating more toward no fixation as you can see here. And then this is my case where I did cotton asiatomy and lateral column lengthening without any fixation and still works really great. So are you guys really gonna abandon lateral column lengthening? For me, if it's a flexible deformity, I'm doing lateral column lengthening. Thank you. Thank you. Thank you, but you guys are really staying on time. Okay, so if you look at the title of the next talk, I've got a mallet, a screwdriver, and a saw. What do new technologies teach us about treating PCFD? If you add an exclamation point to the end of that, I ask you this, who better than Dr. Early from the great state of Texas to give that talk? Thank you, John. There's my disclosures. I get busy in my off hours. So, what we're talking about is PCFD, which of course I had to sort of relearn again as it was this is a new topic that's being called. Jim Brodsky told me a long time ago that I will never again be as smart as I am my first day in practice, and he's right. I still have not reached that area where I know as much as I did when I first started. So, what are we talking about? We're talking about progressive collapsing foot deformity. In other words, when we started this a long time ago, we were talking about posterior tib. We were talking about the things that gave us the pain at the end, and probably in the long run, as I look back, missing many of the things that got us there. Dr. Watner had hinted to that in the beginning, but it's this collective thing. We're dealing with the disease process. It's not the tendon. It's not the joint. It's not that. It's this process that continues down. This morning's talk was great in the fact that it was one little stay on that mass that took the whole boat down, and that's sort of the cascading effect that we're talking about looking at this disease process in this format. So, what is it? It's recognized failure of the stability between joints in the foot. The idea that, you know, the hand is different. It has to manipulate. It has to be mobile. The foot's main job is to be able to transfer weight. If it's not stable, when you're on single leg stance, you can't walk. So, it's stability first, mobility second, in progressing the amount of gait forward. So, those things is all the stability issues going there. True foot function requires that. Joint motion requires joint control. The joint is no good if there are not motor controls on both sides to control that entity and make it work right. When you lose a muscle group on one side, the joint goes to the other side. The ligaments can't hold it. There's an equivalent effect provides balance of the joint when you're going forward. The lack of control creates an unstable joint and leads to pressures going in the wrong direction. So, what do the ligaments do? The ligaments provide the static stability to the bones. The muscles cannot work all the time or they will fatigue and fail. So, there has to be a stable position where the muscles can take a rest. They're eccentric loaders. They're fighting the overload all the time. And so, where the ligaments are is where those bones will be. But the idea of the muscles is to protect the ligaments from constant overload because ligaments will stretch with time. It's just the elastic property of the ligaments themselves. They will go to a point where they cannot repair themselves. So, the resting position depends on bone morphology and ligament integrity. Bone morphology is different. The way the talus is built, the way the subtalar complex is, is different in somebody who's born with a flexible flat foot versus a normal foot versus a cavus foot. It's that morphology that's also part of this problem. We have to pay attention to that when we're trying to think, okay, how do we make this foot stable again? Not every foot is stable if it looks right on x-ray. Not every foot is comfortable that way. So, we have to be careful about that. We know that 25% of the population has asymptomatic flat feet, which means they look awful but they don't hurt and they go off. So, the vast majority, they don't necessarily develop the PCFD. So, is that really, do we try to change that foot to normal? So, what is it, what's evolving over time? I'm learning more about this by looking back to see what's going on to do that. But initially, this was posterior tib dysfunction. We were, that was the end pain result and we were trying to figure out how to get, go back from there. But now, it's multifactorial instability issue, which means everything's on the table. It's not just what's happening at the spring ligament at the end or the posterior tib, it's what happened at the ankle 30 years ago, what's happening to the midfoot forefoot issues over time. So, it's the joint instability, it's the motor imbalance and it's progressive. The idea just behind that one mass state, everything comes down after it when the stability of it, of one part goes away. The other way to think of it is a trampoline with the springs all the way around. You take one out, it changes the whole dynamics of the trampoline and leads to overload of the other parts of the system, which eventually break. I think that's what we're looking at with PCFD. So, the hard part is we see them when they come in with pain and the pain is fibular impingement, sinus tarsae impingement. It sometimes is the post-tib, sometimes it's not. It's the spring ligament can create issues. Medial column instability, even transfer metatarsalgia can be the issue that brings them in but all these other things are still going on. The instability, subtalar or talonovicular joint instability, that has to do with the ligaments that were supporting it. The midfoot issues are also there. Motor dysfunction, Achilles contracture, that overloads the midfoot area. Posterior tibialis dysfunction, that's the obvious one that we're working backwards on. Peroneal contracture, the inability to bring the foot back over because of the brevis over a period of time. Hammer toes, in other words, the body's already trying to steal the FDL to sort of hold that position there as they go along. And lateral weight-bearing overload that all occur with these over time. So, in treating this, what I think you start to hear is we start to look at it, we see that there's things we missed, there's things that need to be addressed more over time and there's almost as many techniques as there are for hallux valgus and we know how much fun those arguments are. So, there's not one technique in my mind that works for all presentations nor will there be one fusion technique, one tendon transfer technique that will work for all these. And that, for the researchers, is going to be the hard part. This multifactorial issue means there's going to be a lot of variables. Some of them we're missing now and we'll only come around to later as we go. But remember, the goal is not to provide a nice x-rays, to provide a stable platform that they can weight bear on without pain. And then mobility and agility and everything else is beyond that. If it's not stable, nothing else matters. So, what are the new technologies that may help us? The weight-bearing CT is very interesting because it gives us a three-dimensional look at a three-dimensional problem. X-rays only show us the average of the joints. It doesn't show us the actual tilt or position. Is it a joint that can be salvaged or is it because of the nature of the angle of the joint, is it going to break down the ligaments every time and be something that recurs if we don't fuse it? There are people looking at ultrasound. What's ultrasound do? Well, it gives you a feeling of the dynamics. What tendon is diseased? How is it moving? Those issues going and that all plays a role again in the dynamics of the foot. So, they may help give us some information to do that. Here's an example of weight-bearing CT, looking at two ankles. The one on the, okay, so the one on the right, is that subtalar complex treated the same way as the one on the left? Is doing a lateral column lengthening when you've got that much of an angle in the posterior facet going to lead to refailure over time? When we bring the joint over to do that and fuse it, are we now in making the medial column incompetent as far as ligament control? Because now we've loosened the ligaments if we reduce the subtalar joint and is that why we get this tailor tilt over time even when we think we have this foot correct? So, there's a lot of issues that I think we will see over time become part of the solution to the problem. Another example here, looking at the subtalar joint, you can see the x-rays, the plain films on standing and then the CT scan. I would never see this without the CT scan. Looking at the middle facet, seeing I've now got the middle, the sustentaculum digging into the posterior component and almost completely missing the medial, but you don't see that on the plain film. So, that kind of information, I think, is where it's really important. It doesn't give you an answer, but it tells you part of the whole problem and then you have to figure out what various components are you putting back together to make this work. So, the new technologies out there also, ligament reinforcement, reconstruction using braided suture or synthetic ligament material, I think there's promise in that. The ability to help the soft tissues that are there, to reconstruct the ligaments, to give the joint some stability to do that, but you've got to hit all of them. Really, I don't think there is an unimportant ligament, though you hear some people talk about, well, the calcaneal fibular ligament, we don't need to worry about that and ankle instability. Well, that's a major subtalar instability. Is that what causes problems over time? Don't know the answer yet, but I sure see a lot of it in my posterior tib failures and now I'm going back to treat that, too, if I want to save the subtalar joint. So, the deltoid ligament, lateral ligament complex, the sinus tarsi, plantar naviculocuneiform, that instability there is prominent in many of these. You need to know all of these. What is the position of it? And then, so finally, what's missing, Keith alluded to it earlier, symmetry. If you are not looking at the other foot, you don't know where they started from and you're only seeing what they're finished, but it's the subtleties that are different between the two feet that may actually give you the guide on how to make that foot back to where they're comfortable again. Because I can tell you, you make a flat foot when they're congenitally that way, look normal, they hate it. The alignment is different, the bone morphology is different, the weight bearing and the follow-through is different. Gait relies on symmetry of both sides being as equal as possible to be as smooth as possible. Any change we make changes that symmetry. So, the status of the contralateral foot, I think, is really important. What is the bone shapes? What are the joint shapes? What are the instabilities that are there or not there in the other foot? And I think all of those need to be addressed to try to get this foot back to that stable mass where all the stays are there to withstand all the different pressures that it sees. So again, the classic one is you see patients that have a normal foot and then come in with the other side and you start to go, okay, what's different? What do I have to do to bring that back to that foot? And it's a lot more than just the post-hip. So, the value of experience, you learn what doesn't work in your hands, that's for sure. Because follow-up will show you exactly what you missed and how you're going back down a rabbit hole again or a brand new one. So, don't ever put off the follow-ups. Actually examine them and see what's there that wasn't there before and look at the other foot. If one side has more instability than the other, you're leading yourself down to another problem in the future. You know, that's the issue. We all see ankles now that were at 30 years of instability. They're all arthritic, but the point being is that we could have saved that probably in the past. So, examining the actitic foot, the new technologies provide insights, not answers. The mallet and the screwdriver and the saw, we need to be a master carpenter. Use the skills, understanding when to use the tools, but you got to remember it's about single phase stance weight bearing. That's all that matters for gait progression. Thank you. Thanks, John, and your last slide of value of experience really ties into the next topic. A tail end of a joint looks fine, yet my foot is still flat. The other joints. Jeff Johnson is going to walk us through this. Thank you very much. So, happy to be here, and here's my my disclosure slide. Really nothing that conflicts with with this presentation. So, you finished your flat foot deformity hind foot procedure. Why does the foot still look flat? Well, I think the main reason is that PCFD is really a multi-planar deformity. We have hind foot valgus, we have forefoot abduction, and maybe some sag at the transverse tarsal joint, but and also medial column elevation or forefoot varus. And the problem is that your hind foot deformity correction really doesn't address the forefoot varus in many cases. Sometimes it comes right down, but many times it does not. So, why does forefoot varus matter? Why can't you just leave it? Well, we knew from Fred Cotton's work that, and he brought to our attention this idea of the static triangle of support, the triad of the foot. And if the balance of the of the foot tripod is not right, the foot tends to roll into pronation. And so, you can see in this case, and he recognized this and described the opening wedge for cuneiform cotton osteotomy. So, you can see how the first ray is elevated in this right-footed person. And if you leave the residual forefoot varus untreated, not only do you have some lateral foot overload pain, but as the foot wants to seek the ground, you get a valgus thrust on the hind foot. So, where is this deformity, this forefoot varus? The most common is at the naviculocuneiform. You can see this on a lateral radiograph as naviculocuneiform sag, and it can be isolated first cuneiform, or it can be more global where the naviculocuneiform 1, 2, and 3 are all sagging. This can be stiff or flexible, and this is something you need to look at on exam. The second location is the first TMT joint. You can have angulation through that joint, you can have subluxation through that joint, or in this case, as you can see, you have a combination of both. So, assessing this is critical. I'm taking the hind foot and placing it in neutral with my right hand. I'm then dorsiflexing the foot and getting a sense of how flexible, first of all, can I reduce the deformity? How flexible is it? And on the right slide, a hand slide, you can see that the thumbs up test, this is done with the hind foot held in neutral, and then you put a thumb under the first ray and the fifth ray, and you see where it lands. And you can see on this person's right foot, the first ray is elevated. So, these give me the idea that there is four foot varus. So, if you're going to correct this, what options do you have? It really depends on the location, the stiffness. So, here you can do an opening wedge osteotomy, or cotton osteotomy. You can do a medial column fusion, bigger operation, and you can do a first TMT reduction and fusion. So, let's see how those would be used. Here's a patient, 56 years old, and using the classification system, we've got a flexible hind foot valgus, flexible forefoot varus. And my plan was fairly simple, medializing osteotomy, FDL transfer, and a cotton. You can see on the left side there, the minimal sag of the naviculo-cuneiform joint. She has flexible forefoot varus, a little bit of uncoverage, but a fairly minimal deformity. And so, this is sort of the schematic of making that osteotomy from dorsal to plantar through the waist of the first cuneiform. You can see putting the bone block in, and I think a pin distractor, as you're seeing on the right, is really helpful once you've actually made your osteotomy to keep it open to put your graft in. So, here's just a short video just showing, this is so the hind foot deformity has been corrected. You can see sort of the flexibility of the patient that I think is a good candidate for a first cuneiform osteotomy. The dorsal incision is made. I think taking the EHL and going medial with that allows you a really good straight down view on the first cuneiform. And now that we've cracked the plantar cortex, look at the power that's given by just opening the first cuneiform in a flexible patient like this. It's very powerful. We measured how much this person, we thought, needed to bring the first ray down. It wasn't really very much in this person. As you can see, it's about five millimeters. And this is, Ervin talked about the value of frozen allografts, which is what we use. And here we are with the first ray being down now. And there's always a bit of an apex on the top, which you plane down with your saw while you're there because it's very prominent once you're done. And I think fixing with a K-bar and a number of my colleagues don't fix it with anything. Look at the stability that you're getting from that first ray. So, we've looked at the amount of correction that one can get. We know that the biomechanics of the cotton is such that if you overdo the lateral column, you can reduce, at least in the lab to some extent, those lateral overload pressures by plantar flexing the first ray. I don't think that's a great way to treat overcorrection, but you can do that showing the value of the cotton. It's really difficult, though, to understand radiographically how much the cotton contributes to the overall correction because we're doing a bunch of other stuff at the same time. There have been some some reviews. Chris DeRosa looked up our series and the Thordarson group in L.A. looked up their series and I think the conclusion of these two articles was you get about a degree of correction for every one millimeter of a bone wedge. The HSS group, Scott Ellis's group, looked up looking at the cuneiform reticular angle and in their series they show that one millimeter of graph size was about a two degree correction. Now, basically making the point that maybe you could predict preoperatively how much you need. I'm not so sure you can do that. It's something that I think you do intraoperatively as well as preoperatively. So, here's back to our patient. She's had her first cuneiform osteotomy. The hind foot deformity has been corrected and here she is at six months returning to work and you can see the straight Muri's line. Let's go to another patient with a little more deformity. 63-year-old, flexible, you know, hind foot valgus, forefoot abduction, first ray elevation, her ankle is stable, but look at where the deformity is in the first ray. First TMT instability with pretty straight dorsal subluxation. So, in this patient she was treated with a hind foot deformity correction, as you can see, with double cal costeotomy, but then a first TMT reduction infusion and here she is at 10 years. Hardware has been taken out and a stable construct. So, what about this patient? A little more deformity. She now has flexible hind foot valgus, forefoot abduction, and then D is subtalar joint subluxation. All of that's flexible, but the forefoot varus is not. So, there's a fixed forefoot varus and you can sort of see from this, not only is there dorsal angulation and sag at the navicular cuneiform, but there's also a little anterior translation and joint space narrowing. So, that sort of leads you to think that maybe there's a little more going on here. What I did is this, and it's a big list, but what I want you to really focus on is numbers three and four here, in which I did my best to bring that first ray down and around, and I did a nine millimeter wedge allograft for the cotton, and I did a spring ligament repair. I even used internal brace. And even when I was intraoperative, I just wasn't feeling like I was getting the first ray down. And lo and behold, at a year, she still had some lateral midfoot overload pain. She didn't want anything else done. But I felt that I didn't adequately bring the first ray down. Was my cotton not enough? Should I put a 12 in there? Would that help? I'm not so sure. What do you do when the cotton's not enough? Well, sometimes you're trying to do a cotton on a magnitude that's just too great, and maybe that was my issue. I think, actually, it's this number two, stiff mid-tarsal joints, especially the naviculo cuneiform. If they are stiff, the foot doesn't react to the cotton as well. And of course, you could also be dealing with a deformity above or below the first cuneiform, which wasn't the case here. But I think it's important to consider naviculo cuneiform fusion for more correction in these cases. This has been talked about before. Almost 100 years ago, Oscar Miller talked about his plastic foot operation. And interesting, he stabilized the naviculo cuneiform joint in these adolescent patients. But look what he wrote in his article. He talks about shaping up the foot by rotating the forefoot. So he knew exactly the deformity that we're talking about now. Let's fast forward to 2019, the most recent writing about this. Beat Hinderman and his group talked about combining this naviculo cuneiform fusion with a subtalar joint arthrodesis. He had 34 patients. Only one non-union, which was good, because unlike the cotton, which almost uniformly unites, this is a bit of an issue with this, potentially. All were satisfied, though. And they had a good correction of their angles. So let's go to one more patient. So this is a 41-year-old female. She has even more deformity. She has flexible, however, hindfoot valgus, forefoot abduction. I'm just going down A, B, C, D, hindfoot valgus, forefoot abduction, forefoot ferrous, and then subtalar joint subluxation. She'd had a previous kidney, and this is a longstanding deformity. Look again. Not only is there dorsal angulation on the lateral radiograph, there's also a little bit of subluxation through the naviculo cuneiform joint. So this, I think, calls for the naviculo cuneiform joint fusion. And so instead of a dorsal incision you might make for your cotton, you're over on the medial side, where you can do your tendon work as well. And it's amazing how easy it is to get into this joint with a good distractor. So you can see the osteotome reaching all the way around the naviculo cuneiform joint. You can get all the way to the third. You can curette this out. You can even remove bone medially if you want to adduct the foot a little bit more. But once this is denuded and freed up, you can do a reduction maneuver. And so I put a pin in the foot and use it as a joystick to maximally plantar flex and maximally adduct and close down that joint. I have found that a plantar medially oriented nitinol screw and then crisscrossing or a nitinol staple and then crisscrossing screws is a little less of deformity or less of a metal bulk on the medial side right under your skin incision and prefer that to a plate. But you can use whatever you want. So we did a lot of stuff on her, as you can see. But again, focus really on the fact that we did a naviculo cuneiform 1-2-3 fusion and corrected her forefoot vers along with the hindfoot deformity correction with a medial side. So after all of that, in conclusion, I think I just want to leave you with a few points. And that is that your physical exam, the one that you do pre-op, helps you predict what you might need to do in the operating room. But it needs to be done again when you're intraoperative. So after you've done the hindfoot deformity correction, because your decision about what you might do might change. And you should be kind of ready for any and all options, whether it be the cotton or the naviculo cuneiform fusion. And you should have made your decision already about whether you need to do a first TMT. But the exam and the X-ray is really what drives your decision making. Secondly, a cotton osteotomy, I think, is best indicated for the mild to moderate deformity if it's flexible. And when you're going to use about a 5 to 10 millimeter wedge, I have a really hard time getting much more than a 10 millimeter wedge in there. It also is helpful for mild instability at the first TMT joints, if you have a little joggle at the first TMT. But really, deformities at the naviculo cuneiform, I still think the cotton is very helpful. I think the naviculo cuneiform fusion, as we've seen, is better for the moderate to severe deformities, especially when there's stiffness. And also, if there's any abduction through the midfoot joints themselves. Because you can adduct through that joint as well. And lastly, the first TMT fusion, in my practice, was never really something that I used a lot. Because I felt that these other operations were helpful at bringing the first ray down, mainly for gross instability and degenerative arthritis. Thank you. Seeing more and more technology coming out for substitutes for laticum lengthening, whether it's structural allografts and then autographs, and now metal wedges. So David Thorderson is going to talk to us about driving a wedge between these all options. Thanks, David. Thanks. I'm trying to jam through to save a little time for discussion. I have no relevant disclosures. I was part of the consensus group. Part of this, I ran through earlier, that the laticulum lengthening, please see Irvin didn't say it shouldn't be done. But consensus, more than 40% on coverage. Consider it. Don't overcorrect it. And typically, you put a 5 to 10 millimeter wedge in. For the cotton osteotomy, you have to have that stable amino column arch. When you're doing it, you have to determine this clinically, as Jeff just alluded to. Typical wedge size, the group said, between 5 and 11 millimeters. If it's unstable, a little instability, you can still do a cotton. A lot of instability, fuse it, or if it's arthritic. Now, the primary purpose of this talk is what's best, autograft, allograft, metal wedge. Autograft is obviously a gold standard for union, but I think there are a few people who do it just because of donor site morbidity. Allograft, eh, is it going to fuse? Will the graft incorporate? Are there risks of rejection infection? Probably not. Metal wedge, the rate of incorporation, are there any reactions to those? So we looked at this a while ago, and Jeff alluded to this. Did allografts. They worked in all 23 patients. This is an early series. The very, very little change in alignment. So allograft seems to work, and we actually used freeze-dried. When you look at the literature for these various things, the bottom line is there's no difference. So I can skip the next five slides. Here's one on lateral column. Lengthening, trichorcal, autograft versus allograft. At eight weeks radiographically, there's surprisingly a lower union rate in the autograft group, but by the time we got to three months, it was the same. When you looked at autograft versus allograft, in another study, basically 51 feet, it was about the same CC arthrodesis, which I used to do a long time ago, which had at least one-third nonunion rate. Doesn't work, but anyhow, again, the results are comparable between the two groups. Lateral column lengthening is with a porous titanium wedge. Now this is not a comparative study. Twenty-eight feet, they did it with a porous wedge. They had a 96% union rate, and they improved radiographic alignment. Another study looking at allograft, the lateral column lengthening, again, the titanium wedges, and with 34 feet at a year, there's 100% union rate. So you get the feeling that, and the literature bears it out, that they actually all do incorporate. Now here's one looking at metallic wedges, again, 48 feet, again, lateral column lengthening, and again, their 96% union rate. Lateral column lengthening, autograft, allograft, it even says it in the title here from the HSS journal that the results are comparable between the two. Now this is one thing, this isn't really technique talk, but you have master carpenters like Jeff Johnson who freehand cuts that allograft wedge like I used to in the olden days, and then the companies come out with a pre-cut, precisely cut allograft wedges or your metal wedges, and you have trials where you can do distraction and drop with your pin distractor, drop your trial and say, yep, I want the 7-millimeter wedge, and it's precisely cut. So it saves time, and it's accurate. And when Scott looked at this in his series, they found the patients had less lateral foot pain because they weren't overcorrecting these patients. There is one study I found using the metallic wedges for cottons, 31 patients, 100% union rate. Again, these bones like to fuse. It's cancellous bone you're sticking these wedges into, so they like to heal up. Now, I found this fascinating. Again, I'm not a Google wizard, but I spent 10 or 15 minutes trying to get cost data, and I couldn't get it. I mean, I was looking, I looked up the procedure, looked up the part number, Googled the part number for a given company. I could not find cost data. I asked my hospital. Hospital won't tell me because they have these contractive rates, and they can't, they're contractually obligated not to reveal what they're paying for these things. However, I did get one anonymous company who has both an allograft and a metal option, and you can see that A, list price, which at least our patients never pay when we charge them, you see the EOB, but list price is actually quite high, and metallic is slightly more expensive. But all these are, you know, well above $2,000, but probably a little bit more expensive for metallic. So here's just an example of a patient. You can see the coverage on the AP view, the tail end victor sag in the lateral view, just kind of showing that with some lines. And corrected, you can see that we got a nice correction of that tail end victor coverage. You can see a little cotton wedge in there. No internal fixation for that. I do use internal fixation for my lateral column lengthening because I do an Evans, and I think there's a risk of nonunion. But regardless, you can see, again, the correction was very nice, and that's a 7-millimeter wedge, which is part of the range that we talked about earlier. Here's a more extreme case. Again, this is in a posterior tip problem. It's a kid with a very severe flat foot, you know, 50-plus percent on coverage, and here is a 3-month standing x-ray. As you can see, you got a nice correction. But this is the double osteotomy, both the medial splacement calc osteotomy and the Evans combined with the cotton. Now, I guess the only thing that really sets these things apart perhaps a little bit is what can go wrong. So if you do a correction, and you have a problem afterwards, and it's a metallic device, then you're going to have a little more trouble. So I have two cases. One of my partners inherited from outside. Here's a patient with lateral column pain. Again, this is not with internal fixation. If you don't do the operation technically right, yeah, you're going to have problems. So here's a weight-bearing CT scan. The metal is obviously rubbing on that side, and he ended up taking this patient and burned that down. The contralateral side, you know, did well anyhow. So you can see here on this weight-bearing CT, the metal's not impinging. The patient's not symptomatic. Here is another patient. Now, the point out here is not only is this thing impinging laterally, but look at that CC subluxation. That damn thing's about a centimeter off. So again, if you're going to do this, make sure you don't do this. If it starts to do it, there's techniques for putting a pin in prior to doing your lateral column lengthening, because this thing is way off. So here's the contralateral side. The patient was actually not symptomatic on this side. Apparently, you can see again the CC joint significantly subluxed on the contralateral side. The patient had this done on both sides. But anyway, get the weight-bearing CT. Sure enough, there's impingement laterally, and because not on the other side. But since we have the technology available, get that spec CT scan, and yeah, the bone's angry at you, because you should not have metal rubbing on bone out there. So he salvaged this with my junior partner, Max Mahalsky. He did the CC fusion, because he couldn't leave that joint marginally dislocated. Burred down the metallic components, stopped the impingement, did a calc slide on top of that, and the patient is doing better. That was incorporated. So in conclusion, they all yield similar outcomes. You look at the literature, comparative studies, non-comparative studies, the result's about the same. The fusion rate's about the same, including, you know, the actual ingrowth into the metallic wedges. In the event the operation's not done right, or you have a complication, and there's graft malposition, at least with autograft or allograft, you can take an osteometer raw injure without creating a lot of metallic debris to stop that from impinging laterally. Autograft, I don't personally use it. It has obvious donor site morbidity, and particularly if you're cutting a structural graft out of somewhere. Allograft is what I personally use. Does require a donor, but we seem to have enough of that available. Cost is somewhat similar, but probably slightly more for metal wedges, but I'm only citing one example, and those are list prices. Thank you. All right, well, as Chris opened this session up, hopefully you guys got a lot of pearls from the wisdom from our esteemed panel. I'm going to open the floor to questions. If anybody has questions, feel free to come up. I know Chris had some questions if we don't have any, and I have some as well. I think we got one coming up right here. Drew Harston, Louisville, Kentucky. Dr. Johnson, thank you for helping us to think more creatively. I saw on a lot of your navicular cuneiform fusions that they seem to be accompanied with a subtalar fusion. Is that common? What percentage is that for you, and kind of what's the thinking behind that? Oh, thanks, Drew. My evolution has changed. When I first started, the last thing I wanted to do was a navicular cuneiform fusion, because I thought you had to approach it dorsally, and I think technically it's harder dorsally, especially if you're thinking about putting a wedge or something in to bring the first ray down. So, it's really only been, you know, and obviously I've now since just finished clinical practice, but I mean, I was, at the end there, I was doing navicular cuneiform fusions in the patients that had a longer standing foot, so more likely did they have arthritis of the subtalar joint. So, yeah, I would say, I don't think I feel it's linked to the Biat-Hintermann operation, where the subtalar joint's fused and the navicular cuneiform joint is brought down. I think you can do anything you want in the hind foot, bring it around, and if the first ray doesn't come down or it's a pretty significant deformity, I think that's when the navicular cuneiform joint fusion with a reduction maneuver, that's the key, reduction maneuver, it can be done. So, the TibAnt, so all you have, the TibAnt, sometimes, you know, the attachment on the first cuneiform is such that you just have to lift it away, and that's the other reason I'm not a big, in favor of using a big plate like Biat-Hintermann showed in his. I mean, he gives a beautiful reduction and he's got great results, but the fact, if you just use a little Nitenol staple on the plantar medial side, it kind of holds that plantar flexed and adducted position that you've got, and then you can do just crisscrossing screws. It's buried. If you've got a little wound breakdown, you're not looking at a plate. So, that was my go-to, so, and you're right there for your post-Tib, whatever work you want to do there. All right, we've got a question here to the left. My name is Magid from Doha, Qatar. Could I ask how to assess Berry-Taylor instability and how you decide about sub-Taylor fusion instead of lateral column lengthening? That's not very clear in my mind. Jeff, do you want to take that? Because you talked about the reduction maneuver, which I think plays a role in what he's asking. Sub-Taylor, you're talking about sub-Taylor instability? Right. I think, well, I think with the advent of CT, and really got to give credit to the folks that are looking at this carefully, I think the CT subluxation on weight-bearing CT is going to be a really good way to help predict preoperatively who you might need to do a sub-Taylor joint fusion on. I think, in my view, if I have a, if I see arthritis on there, and if I see the lateral Taylor process has slid down that slope on the lateral view of the calcaneal x-ray, and it's grinding into that, the angle of Gesane, to me, that is lateral impingement, and oftentimes, I think in that case, I'm thinking about that there's enough sub-Taylor subluxation that I'm thinking about sub-Taylor fusion. If I, let's say I'm thinking about doing my lateral column lengthening, and I open that, and I'm looking in the sinus tarsae. On an older person, if I look in there, and there are no ligaments any longer in the sinus tarsae, it's like, okay, okay. Even though the patient was flexible, I think I should bail and not do a lateral column lengthening and do a sub-Taylor fusion. Those are kind of my criteria. I think, just exam alone, I think it's really kind of hard to tell if they're grossly unstable or not. Any other panelists have anything different? Can you hear me? I think that there was a paper by Iowa Group, by Dr. Nero, where if you see a subluxation in the middle of the set, and they're doing the weight-bearing CT scan, that kind of indicates that you have an unstable sub-Taylor joint. So I think that would be one indication for considering to do a sub-Taylor fusion. All right, I'm gonna try to sneak in one more quick question. Hello, Sheldon Lin. Tim Daniels had always told me that a non-union after these procedures is a disaster for the patient. I would love to hear from the esteemed panel, do they use any type of adjunct biologics that's available in our armaterium? Or maybe they don't. Love to hear it. All right, quickly down the row, because we only have 19 seconds. Do you use adjuncts or not? It's a what, John? No, I don't use any adjuncts. Yeah, when it's a non-union, it's a disaster. Jeff? I use frozen allograft out of the freezer, and I augment it, I soak the pieces in bone marrow aspirate concentrate when I put them in. Dave? No, no, nothing to add. Keith? Yeah, I generally use bone marrow aspirate when I did fusions. And Irwin? I just do a fresh frozen, that's my go-to. Awesome. Thank you so much for our esteemed panelists for a great session.

flat foot deformities

treatment options

lateral column lengthening

cotton osteotomy

navicular cuneiform fusion

subtalar fusion

grafts

hindfoot stability

complications