CME OnDemand: 2022 Advanced Foot and Ankle: Challenging Conditions, Expert Teaching-Symposium 6 – Medial Ankle Instability: My Arch Is Collapsing

Symposium 6 – Medial Ankle Instability: My Arch Is Collapsing

Video Transcription

Okay, can everybody see and hear me there? Are we good? Yes, I can hear you, I can hear you. Okay.  Our next session is Symposium 6 and it's Medial Ankle Instability, My Arch is Collapsing. Let's just start this out.  I find this to be an exciting and ever evolving arena and foot and ankle. And honestly, I still struggle with it. I end up eyeballing everything. And at my age, I can't see anymore.  So that's probably not a great thing. I trained with Francesca Thompson, who was a Roger Mann fellow, and the original paper with FDL transfers and calc slides, she wrote that.  So when I was there, that's all we did, Achilles lengthening, medial displacement, calculostomy, and FDL transfer.  And I got down to Emory where I was attending and I did it all the time. And then a year later, these paces would come back and the foot would look like I hadn't done anything.  But they weren't hurting though. And I never quite understood that. So I'm very excited to hear these talks and where we are now and where we're going.  And so we want to first start this off with Pete, who was actually a little sidebar. Pete was a resident of mine back in the early, when was that? The 90s. Early to mid 90s.  And we did a lot of foot and ankle stuff together. So I'm very excited about who he has become and what he's doing. And I'm really excited to hear this talk, Pete.  Probably why all those patients failed that you had, because I was the resident taking care of them or doing their surgery. So, okay. All right.  So I'm going to fly through this talk because we have four talks and it is an important topic, but I'll kind of skip through some of the early stuff to show you some of the  results I have.  All right. Can everybody see everything? Okay. Go to your larger screen. Yeah. So hold on a second. Let me, let me. Yeah. I did that and it didn't work. It didn't work. So hold on.  Let me stop share again and try again. Cause that was last night when that happened. All right. Hold on just a second. Sorry for the. Okay.  Let's try again to do this. This is what happens when you don't buy a new computer.  Is it up there now?  Not the slideshow.  I mean, we can still see you, but- Yeah, but I know, I know. You're broadcasting your talk before. I don't know why it's not pulling it up.  All right, give me a second.  How's that one? That's it. Okay, got it. All right, everyone, it just, freaking ate your luck. Okay, I don't know why it opens on that one and not the other.  All right, so here we go. So don't forget the Deltoid. And, you know, this is really more about acute deltoid injuries. We're gonna, and it's more deltoid ankle  as opposed to foot, but there is some foot component. And so why should we, we should be thinking about repairing these earlier rather than later. I do have disclosures.  The Arthrex disclosure, I actually don't get royalties from the product anymore, but you'll see one aspect where a product's used that I used to get royalties from.  So why do I have an interest in this? Well, mainly because I had a patient in my own,  I used to get ankle fractures from my partners and they might continue to hurt after their ankle fracture was fixed. And I would just think, oh, it's because my partners don't know  what the heck they're doing. You know, they did the best they could, but it probably wasn't reduced very well. But I had one of my own patients come back  about a year or so out from his ankle fracture, where I did exactly what I was told to do, which was, you know, fix the lateral side, not fix the medial side.  You don't have to fix the medial side. And the guy continued to have persistent pain on the medial side. His x-rays looked good, but he was tender over his superficial deltoid  and medial ankle area. And I couldn't figure out why that was the case. And here was his x-rays. You know, they looked okay. His fibula was out the length.  He had a negative cotton test intra-op. His reduction went smoothly. And so, you know, I said, okay, what's going on? He was still having this pain, felt unstable at times,  especially with push-off. He was relatively, you know, healthy guy.  He got an MRI scan that showed a little bit of edema in his medial malleolus and some deltoid changes, and maybe a little bit of fluid in his syndesmosis.  And when I got into his ankle, his delta, it was just a bunch of scar. You know, there was no real healthy-looking deltoid over in this particular area.  And so I, you know, so I ended up, you know, doing a repair of his deltoid. Hold on a second. And so there we go. And you can see, well, this is how much his ankle moved  prior to me moving his ankle, you know, kind of a little arthritis in there. But, you know, afterward, he had substantially less translation, right?  So his pain completely resolved after I fixed his deltoid. Within 12 weeks, he was back to all his activities and he came in to thank me and say, gosh, this is the greatest thing.  I can get back to playing golf, right? So at that point, I started to look and say, what's going on here? Because I did exactly what I was told I was supposed to do,  but yet the patient continued to have issues. Remember, the deltoid is kind of split into what some people call superficial and deep. I like to call anterior and posterior.  And specifically this tibio-navicular ligament and tibio-spring ligament, I think are the big ones in the acute injuries that occur. There's really a paucity of literature out there  on acute injuries. B.A. Hinchman probably has the most information on this. The traditional thought for an acute deltoid is that they're due to eversion or pronation injuries  that are often associated with syndesmosis injuries, but up to 75% have evidence of a lateral injury as well. So it's kind of a global instability process that's going on.  Typically, they're tender over that area. If you, you'll learn how to do the soft tissue kind of external rotation abduction stress with a medial anterior drawer.  And you can kind of feel, they just don't have a good endpoint compared to normals. And I would encourage everybody to try to learn that on your normal patients,  because the more normals you exam, when you finally see a patient with this, you'll feel it and you'll be like, oh, okay, now I get it.  X-rays, MRI, CTs, all things that you can get. But there's very little in the literature. There's some meta-analyses. It was briefly mentioned  in several of Hinterman's publications. And basically, the old days, Manning Coughlin's book from 2007 just said to cast these injuries for eight to 10 weeks.  Well, by 2007, I don't think anybody was putting anybody in a cast for eight to 10 weeks. The sources were mainly cited from the 60s. The chapter goes on to say that grade ones  just kind of have functional rehab, and grade two to threes, you protect in that boot or a cast for that long to allow the superficial deltoid to heal. So Bob Anderson did some work  where he repaired some of these in NFL players in bimolecular equivalent injuries, and basically was able to get about 86% of those to return to play.  Now, they weren't compared to people who were casted or not casted, but it did show that you could repair these and get people back to play. The current treatment recommendations  as of the 10 years ago were basically to just continue with a boot or a boot with non-weight bearing a little bit longer, or maybe do an operation if it's a grade three type injury.  Hinterman kind of classified these as an avulsion off the proximal attachment of the medium alleolus, which is what I think is the most common type one, a mid-substance type tear,  or an avulsion of the deltoid from the distal portions, which I've seen occasionally, but the vast majority are type ones, and that's really based on arthroscopic findings.  And I would encourage you when you have your ankle fractures to scope all of them, because you'll be able to see some of these changes.  His conclusion was that an acute repair of the deltoid was recommended if the remaining ligament structures  against valgus stress cannot be proven. So if there's valgus instability, then you really need to repair these structures  and you need to do that. Now, he talked about that all the way back in 2006, but we're still kind of slowly migrating that way.  There is growing concern. I think those of us who do foot and ankle see these patients and what happens in these patients long-term of non-operatively treated acute injuries.  So here's an example of a high school. This kid was 18 years old. He had an ankle sprain when he was 14, when he played soccer at 14.  And he came in saying that he was having trouble with his normal side. And this was his abnormal side when I actually got him to fully weight bear.  So he was kind of just holding his arch up when I was asking him to stand. But I said, okay, now put all your weight on it. You can see how much he kind of inverts.  Here's that kind of soft endpoint test on this side, when I do this kind of extra rotation, and I'll usually do a little bit of an anterior drawer with it, there's a nice endpoint.  When I do that on this side, and I grab him and kind of really kind of pull, it just goes further. And you can feel there's no real good endpoint. You can actually pull pretty far  and you can actually get it even further the longer you go.  So again, here's where he tries to do a single heel rise and he just can't really get off the ground very much. If you activate his PT, he'll invert his heel.  This is not a poster tib issue. His poster tib is intact. It's a deltoid issue. And so these, the patients that show up in our office  with these pescalinovalgus feet later, I think they are, and I think they also develop ankle arthritis. And I think this is a problem that oftentimes it's seen you,  but you haven't seen it, just like this hawk that's hiding up in the trees. It's very aware of where you are. You may not be very aware of where it is.  So most commonly these acute deltoid injuries usually occur with ankle fractures. They'll occasionally get an isolated acute deltoid injury. So we're going to discuss them  in the face of ankle fractures, even though there's some overlap here, but obviously the fracture has to be fixed as well. Traditional treatment paradigms, as I said,  revolve around opening and reducing the fibula. We know that fibular malreduction does cause increased contact loading stresses. But many of us, like I said,  we're taught not to open the medial side unless the medial mortise remains open after fibular reduction. So usually that's if the ligament's entrapped in the mortise.  And usually if we do find that ligament entrapped, it's the superficial ligament that's trapped. It's not the deep deltoid.  It's the superficial one. So the traditional treatment paradigms are you don't need to repair it if there's anatomic reduction of the mortise,  and you only need to repair the deltoid if there's medial incongruency of greater than three millimeters on x-rays in the operating room.  However, as I said, I began to see these patients who would show up with persistent pain, and they were just told by the trauma guys, well, you had an ankle fracture.  You're just going to have to live with it, right? There's going to be some pain forever. So a couple of months or about a year and a half before that 1997 study, James Michelson,  he actually looked at doing, he did a complete fibular osteotomy in cadavers, and he found that it did not cause any abnormal motion of the ankle  in the absence of a medial injury, right? Which we all kind of know because if you have a Weber B-type fracture that's got an intact deltoid, you can treat that non-operatively,  and those patients do well. So he, but what he found was that if they had a lateral fracture associated with a major injury to the deltoid, then that had to be treated  either with anatomic lateral fixation followed by immobilization without early motion to allow for adequate healing of the deltoid at its resting length, right? So this is 1996.  So what's changed since then? Why are we seeing these now, whereas 30 and 40 years ago, it didn't? Well, because now we actually try to get people in boots.  We try to get them moving early. We try to have them do early weight bearing. Well, what that does is that causes the deltoid to just stretch a little bit.  You're not seeing them in a cast, like Michaelson said, for immobilization for six to eight weeks, which would allow it to heal in a anatomic position.  Instead, we're moving them early. And so I began to perform arthroscopy and all these bimolecular equivalent injuries, and I found that Hinchman's correct.  There's a lot more deltoid and syndesmosis injuries than we're aware of. You can identify these much better through the scope. And so what we've done is we've changed  our postoperative treatment of fractures and sprains with more early motion and weight bearing,  but we've not changed our intraoperative paradigm, which results in outcomes in not every case. Certainly some cases do fine, but we see more and more of these patients  with medial side instability. So what about other joints? Where do we see a similar concept? What about the elbow, right? When we have a fracture of the elbow  with a combined bony and soft tissue injury, you wouldn't just fix their radial head with an ulnar collateral ligament injury and say, okay, go to town,  start moving your elbow as much as you can. Instead, you would oftentimes repair both of those, right?  You have to repair both of them in order to allow for early motion without long-term laxity. And so what happens in athletes? Well, oftentimes when they have this injury,  it either is gonna take care, you either have to immobilize them for a long period of time, which causes a lot of atrophy, or can we accelerate that timeline  by fixing both the soft tissues and the bone anatomically,  right, treating the entire injury, not just the bone injury, but the bone and soft tissue injury. The benefits of early motion are clear,  or it allows for better ligament remodeling, better articular cartilage regeneration, less muscle atrophy, fewer complications. So early range of motion and weight-bearing  can be effective in returning patients to early return to function.  But if you don't fix their ligament complex, they're gonna continue to have pain, they're liable to develop some chronic longer-term instability,  and difficulty with push-off due to that medial side. So my recommendations is that you repair both the soft tissue and bony injuries at their anatomic resting length.  If you don't do that, then I think you, in order to be compliant with what the regimen truly is, you have to immobilize a patient for six to eight weeks in a cast,  in a slightly inverted position, to avoid late instability complications. So quick case studies, number one, a 21-year-old Division I long jumper, he had an ankle fracture,  he had clear instability of his syndesmosis of his deltoid. So I fixed him in, put a tight rope across him after I fixed him. And you can see, even after I do that,  he's still unstable with valgus stress. So I take him out of distraction, he's clearly still got gapping, his mortise is not anatomic, okay? But now, if I go and repair him,  now that's an anatomic mortise with stress, right? That looks the same on the lateral side as the medial side, this did not.  No longer needed to put the patient in a cast for six to eight weeks, began early motion, early weight-bearing by 10 days, progressed into full weight-bearing by four weeks.  And you can see him walk down the hall here, and this is at about eight weeks post-op, he was able to single hop on his injured leg, right?  There's no way I'd have been able to do that in a patient that I didn't repair their deltoid. There's another gentleman, 288 pounds, lateral mellitus fracture that you can't see,  it's actually kind of a Weber C fracture, it's underneath my glove up there, but clearly syndesmosis injury, deltoid injury. Again, fixed him, syndesmosis,  and I did arthroscopic repair of his deltoid, anatomic mortise, and here he is at seven weeks post-op, and he actually went and did his firefighter test at eight weeks post-op,  and apparently came within about 30 seconds of making, he had to do like an eight-minute mile run, he wasn't able to do his eight-mile run,  but he was able to do all the other aspects of the firefighter test at eight weeks, so he was trying to get in there, so he had to delay him a little bit,  well, at least give him a chance to do that. So you can either do this open or arthroscopic, you basically are doing an open Brostrom-type process  where you're putting a suture anchor in the avulsion, which typically is the anterior inferior medial malleolus, you're passing it through the torn capsule  and deltoid tissue, that tibionavicular and tibiospring ligament, and then you're re-anastomizing that up to the attachment point. So you can either do it open in this fashion,  or you can do it arthroscopic, which we've shown you can do safely, and since I scope all my ankle fractures, I do the vast majority of these arthroscopically now,  and it works great. So here's a patient, he was five years, status post arthroscopically assisted repair, he's back to full activities,  and he still doesn't have a full single heel rise, he doesn't invert quite as much on this side, but he's back and has minimal to no pain and no arthritic changes.  So my proposed new paradigm is that you repair both the soft tissue and the bony injuries. If you don't, then you need to cast the patient  and stay non-weight bearing for six to eight weeks. I'd recommend that all of you who are out there really add arthroscopy to your regimen  for your ankle fractures, look at the deltoid,  it's not just a look at the bony reduction, look at the soft tissue injuries, you'll see a lot more syndesmotic and deltoid injuries that you really never saw before,  and you can get significantly more information about ligamentous injuries than arthroscopy. And so now when you see this 17 year old who presented with a right ankle sprain  in his freshman year, hopefully now you will fix that patient rather than let them kind of sit and do nothing or cast them or do whatever you need to do  to keep that ankle in a correct position so they don't end up with long-term problems. So thank you very much.  Thank you. Thank you, Pete. Fantastic as usual.  That's gonna lead us right into our next topic by Dr. Cesar Neto, who's talking about progressive collapsing foot deformity. There is a ton of new literature out here  as we are reclassifying this problem. So I'm very excited to hear what Dr. Cesar Neto  is going to share with us.  Go right ahead.  Hey, how are you guys doing? We'd like to thank Dr. Mangone, Dr. Bailey, and Dr. Hines for the invitation. Great pleasure to be here. We're switching gears to flat foot  or progressive collapsing foot deformity. I do have conflicts with this, with weight-burning CT, and I do work with companies  and some of the inputs that you're gonna be seeing here. So I like to start from the basic here for some of the people that we know that not all flat feet are pathologic.  So it's not a problem to have a flat foot. It's a problem to have a flat foot that is collapsing. And we know a lot of elite athletes have bad flat feet  and they're doing much better than we are doing. So I like to say that the flat foot million or actually billion dollar question is when patients come to see you and say,  doctor, I have this flat foot for a while,  now I'm hurting, do I have to do surgery? And we don't have a lot to say to them directly to answer that question. So is it okay if we say that if they don't hurt that much,  that we don't have to do anything? Can we let this deformities, can we let it go? If we let all of those go, we're definitely gonna see some of them collapse.  Not all of them, but some of them will collapse. We can get to disasters like this ankle here. So it would be great if you could have like a crystal ball  to detect which ones we have to push the button. Do we have to recommend more aggressive treatment, either conservative or surgical?  And the other question I think is very important, how can we optimize outcomes? If you're doing surgery, like Dr. Bailey mentioned, and the literature is not that good outcomes  and commonly you see patients back and the deformity is pretty much back there, even though sometimes they don't hurt. So this paper literally changed my way  of thinking of flat foot.  It's considered an old paper, it's 1999 and Dr. St-Georges is always ahead of this time. So he used the technology at that point  and he introduced the concept of peritoneal subluxation. I think it's the most important topic of this talk.  And he showed that when they superimpose the articular facets of the subtalar joint for both the posterior and a combination of anterior and middle facet,  you can see here in the flat foot, significantly uncovered articular facet or subluxation. And that was true for both the combination of the anterior and middle  and also for the posterior facet.  He also published on two very important terms and very important facts that I think we have to pay more and more attention because I think they're gonna guide treatment.  One of them is sinus tarsal impingement that you can see here. And so he found 92% of the flat foot patients had it and 0% of the controls. And subfibular impingement,  it's actually the calcaneus healing in the fibula where 66% of the flat foot patients had it and 5% of the controls. More importantly, in my opinion,  every single patient with subfibular impingement also had sinus tarsal impingement  but the opposite was not true. Even an idea that potentially sinus tarsal impingement happens first and then subfibular impingement comes as the deformity gets worse.  With using the concept that Dr. St-Jorgen gave and I started paying attention, this is the same patient. You can see that the posterior facet does not show a lot of subluxation.  You look to the middle facet and you can see a significant amount of subluxation there, almost 50%. So we did a case control study that we published at JVJS in 2019.  You can see here how symmetric the articular facets are in controls and how asymmetric they are in flat foot patients. And we show that the average subluxation  in the flat foot group was 45% versus 5% in controls and that the middle facet subluxation could be very highly diagnostic accurate  for symptomatic flat foot deformity, as you can see here. So these are probably the most important slide of the presentation, in my opinion. Game changer concept.  That we didn't pay attention that much when we were just looking radiographically and clinically into patients. So malalignment of the posterior facet,  there's no time for me to show all the literature, but the HSS group published on this. So you could be born with a more inclined subtalar joint  that would lead you to have more chances of having peritoneal subluxation. We talked about the subluxation of the posterior facet and the middle facet.  We talked about sinostar impingement. We talked about subtabular impingement. And I do think that these concepts here will guide the treatment of flat foot or PCFD  in the next several years. So as most of you guys know, we had an expert consensus meeting in 2019 where we proposed or recommended a change  in the terminology for the pathological flat foot.  Where we wanted to remove some terms  like adult acquired flat foot because you kind of underestimate the problem. We definitely wanted to remove posterior tibial tendon out of the equation here  because we know there's several literature and tons of literature showing that the posterior tibial tendon is just the tip of the iceberg.  And we recommended or proposed a new classification system where the sequence of events would only go from flexible to rigid. And all the deformities can be different  in different patients. and we introduced the classes with the traditional hindfoot valgus, midfoot forefoot abduction, forefoot bearers and medial collar instability,  ankle valgus tilting, and we introduced the concept of peritailor subluxation. So the idea of the classification is, as you see your patient, you say, do you see hindfoot valgus?  So class A. If you see a forefoot bearers, class C. So you add the letters as you see in your patient. So the idea was to be very broad  in a way that you could describe the deformity that you see in your patients clinically and or radiographically. This is just a video that I did with cadavers,  a pretty simple video, or trying to explain peritailor subluxation. So in this video, I left just the interosteous talococanial ligament there. So I'm doing eversion and inversion,  and you can see that there's a maximum eversion, sorry, I'm gonna go back there, where the sinostar, the lateral prostate is hitting the g-sane. So when you get there,  there's no more eversion for you to go. So in other words, there's no more way for your foot to keep going out laterally. And when you do that, if you look from the medial side,  doing the same thing, when you do the eversion, maximum eversion, when you hit your sinostars, the only way that you can keep going  is if you dislocate the whole thing on the medial side and destroy your soft tissue. So sinostar impingement for me is a red flag.  It's a sign that if that patient is already having pain, that things are gonna get pretty bad in the next coming year. So I would recommend at least to follow them up very closely.  We discussed the overall goals for treatment, and this was published by Dr. St. George in the first author, where we talked about rebuilding the coronal plane deformity  or bringing the foot underneath the leg, and also the axial plane deformity by bringing the midfoot and the forefoot in line,  the second metatarsal being in line with the hind foot during the heel rise. And why that? If you look, this is a complex three-dimensional deformity, right?  And we're gonna talk about our lazy brains trying to get back to two dimensions, but everything is happening at the same time.  Even though we try to look into sagittal, coronal, axial, everything is happening at the same time. The foot is dislocating under the talus. You have external rotation,  bowel moves, eversion. You have collapsed of the longitudinal arch. You can see sinostars impingement. You can see subfibular impingement.  And if your heel is not in the same line of your ankle, then the ground reaction force, you're gonna end up putting a lot of stress in the medial structures.  And when you're in the leg stance or on the heel rise, if your ankle here is not in line with your tripod, you're also gonna put a lot of stress within your medial structure.  So that's kind of pretty much putting all your soft tissue structures in risk. And if you correct that surgically, as we can see here, that's the same patient.  Now, the heel is in line with the tibia. So that will facilitate and protect your soft tissues. The second metatarsus is in line with the tripod  and is in line with the center of the ankle joint. So that will also protect the medial soft tissue structures. So goals of treatment, we always try to go back to the 2D, right?  And 2D is very dangerous. You can think about bad stuff about people if you're just looking in 2D. And we try to compartmentalize things. So when we look at this, we see valves.  We wanna do a medial displacement calcaneosteotomy because that's the way the trachea valves. When we see articular and coverage of the tailor head there,  you wanna do a lateral column lengthening because that's the way to correct that. And when you see medial arch collapse, you wanna do a cotton,  you wanna do a lapidus to bring it down. And things don't work that way, right? It's a tripod, it's a three-dimensional thing. And we did discuss that in the consensus.  And with that, we decided to stay inside the box as the first discussion, because we wanted to maintain concepts that people have been using for a long time.  So we talked about when to indicate lateral column lengthening, when to indicate medial displacement calcaneosteotomies, when to indicate first rate procedures.  However, remember, again, this is a tripod. Every single change you do in your tripod, you're gonna change the overall position of the foot.  It's not gonna be, you do lateral column, you just change coverage in the axial plane. You do a medial displacement calcaneosteotomy, and you just change coronal plane alignment.  We love to tell that to cable varus, right? The forefoot-driven hindfoot varus. But we forget that the same thing happens in flatfoot  or PCFD, where you have a forefoot-driven hindfoot valgus.  And when you bring your first rate down, you can correct part of the deformity by derotating the hindfoot if your ligaments are still intact.  The other concept is concept of articular coverage. What really leads to our tri, how do we go from stage one to stage two? A lot of orthopedics is based on articular coverage.  I'm not here to teach you this because I don't even remember that anymore, but we remember the lines to look into where's the hip? Is it sublux?  If it's sublux, this hip is gonna go bad. So there's some periacetabular osteotomy to correct that. And we showed recently that the coverage,  when we analyzed the coverage three-dimensionally, we found that PCFD patients have an average of 47% decreased coverage of the metaphyset  and up to 286% increased coverage in the sinus tarsae. And this is a video that shows that, shows what is going on from a normal foot  going into a progressive collapsing foot deformity and what's going on with the articular coverage of the subtalar joint and sinus tarsae. So thinking about articular coverage  might be one way to go.  So importance of the first rate, I'm gonna talk a little bit about this, more details about these two concepts. I started thinking about these like crazy  when I was at HSS as a fellow, when we were doing total ankles in valgus scenario, and they love to do calcaneal osteotomy. And then we started discussing, well, the first race is,  the lever arm of the first rate is actually much, much longer than the calcaneal osteotomy. So if you still have a little bit of a collapse  where you're trying to protect a valgus ankle, wouldn't it be better to do a first rate osteotomy? Dr. DeLand taught me to do this, that I do for all my patients.  I recommend you guys do check like that.  So you put your thumb in the first metatarsal head or sesamoids, you put your thumb on the fifth and fourth metatarsal heads,  actually better to do with the MTP is dorsiflex. And you can see here that my thumb is much more proximal in the first metatarsal than it is on the lateral side.  And that's what you want after surgery, you want the opposite, you want the first metatarsal to be down and the lateral column to be up.  So you want the first rate to be back in the game. And I did, when I went to MedStar, unfortunately it's still not published just because I've been lazy with writing.  I have to finish this so Dr. Miller will not, or he won't forgive me. But we checked the difference between MDCO and cotton. And we checked the pressures in the ankle  and we actually found that calcaneal osteotomy did not change at all in a normal ankle, did not change at all the average contact pressure.  But the first rate osteotomy or the combination of both was much more influential in the ankle pressures.  I also wanted to avoid the average shortening of flat foot and Alex Valdez don't like shortening of the first rate. So when you're doing a laparoscopic procedure,  shortening is not good.  I was also trying to avoid what I say now that is the necessary evil. So lateral column lampeny is still a necessary evil, but we know all the complications,  we know the re-operation, non-union rate reported in the literature. And most important, if you over-correct the ABduction with your lateral column lampeny,  you can decrease the patient reported outcomes and the outcomes of the patients. And we all know about, if you do too much, you're gonna have overload of the lateral column.  So I don't like this procedure. I did it, I was trained to do it by my mentors and I started doing here, but I wanted to find something else.  So we published these as the technical tip. I started doing the lapidus putting a wedge on it that we, for some reason, started calling it lapicotin,  it's just a plantar flexion lapidus. And I started doing that for my PCFP with the idea of bringing the first rate down. This is a patient of mine,  just one example where it actually came to see me for Alex valve, but you can see the mild collapse of the longitudinal arch. This patient did not have pain on the hind foot,  but when I assess her, you can see some 3D images of the way burn CT, you can see the mild collapse of the longitudinal arch.  She did have subluxation of the middle facet. She had a foot and ankle set that I used in the tripod of 6.35, that is an increased foot and ankle set  that demonstrates that there's increased vulgus and collapse. She had a forefoot arching that was very small. And I went and did a lapidus with the wedge.  And for, again, for Alex valve, you can see the first rate is now down. Here's the wedge that I'm putting there.  This one, I think with an intramedullary nail, I did her bunionectomy and a capsuloplasty distally.  And this is the final x-ray. This is a patient with six weeks.  You can see now a much better position of the first and fifth metatarsal here. You can see that the vulgus, I didn't correct completely. Her vulgus is improved.  I didn't do an MD show. She didn't want, I actually wanted to do the MD show, but she didn't agree with me. So she didn't want anything in the hind foot.  And here is showing the normal range of motion of that NDP after the surgery. And we did correct the comparison only with the lapidus, with the plantar flexion.  We increased her forefoot arch angle. I corrected the rotation, the hydroponation of the first rate. And we did improve her foot and ankle set  without doing an MD show from 6.35 to 2.31. So when you plantar flex the first rate, you're correcting three-dimensional deform. You're not just correcting the medial arch.  We actually published my first 22 patients. These were patients that I used different fixation methods for this patient. You can see here some intramedullar devices,  plates and screws. We've a median follow-up of six months. Those are just not just for PCFP, but midfoot arthritis and Alex valve as well. This is the wedge again.  This, we show that you do correct the arch. So you decrease your sagittal plane or tallest first metatarsal angle.  And inpatient, I was worried about, I'm putting a wedge there in a regular lapidus. Dr. Sean, one of my big mentors said, don't do it. I went against him and I started doing spin.  I think it's been more than a year and a half that I don't do lapidus without a wedge. And when you look here, at three months, 90% of them were healed  in the weight-bearing CT, as you can see here, the images. I did have complications, of course.  At three months, we had two patients that we graded as no absent healing, absent complete healing at three months. And two of them ended up having non-unions,  four non-unions down the road. Now I have 70 cases. We haven't published the follow-up yet, but it had 70 cases. I had four non-unions in 70 cases.  Finalizing with articular coverage, I think this is very exciting. This is a patient preoperative and postoperatively showing that when you do hindfoot preserving  or you don't fuse the hindfoot joints, you can correct articular coverage. So I'm a pusher for not fusing hindfoot joints if you don't really need it.  So you can see here a patient of mine where we decreased the sinus tarsal impingement or the sinus tarsal coverage. We increased the coverage of the middle facet  preoperative to post-op. And here's a video of one of my patients showing when you do here, I did a 10 millimeters MDCO. I was still doing LCLs and an eight millimeter cut.  And you can see how you derotate the whole thing if you still have good ligaments on your hindfoot. It's a rotational deformity that you can correct  when you do your traditional procedures. We're doing a prospective study. I have 20 patients included today, pre-op and post-op,  where average numbers of procedures are five procedures. I did MDCO in 100% of the patients.  Like I told you, I've been doing less and less lateral columns. So now, right now, I have 40% of patients with lateral columns. The other one did not have it.  I've been doing, so people ask me when to do first rate procedure. In my opinion, of course, it's controversial and we can discuss about it,  but my opinion is first rate procedure in PCFP is mandatory. You don't have to check the first rate after you do your hindfoot. If you don't do a first rate procedure in flatfoot,  you're, in my opinion, you're not treating it completely. So I do in all my patients, I did 60% lapidus, 35% cotton.  I did some form of posterior tibial tendon procedure and 90%, the majority of them were just retentioning and the abreatment of the insertion.  I've been doing more spleen ligament augmentation. I have a very low threshold for deltoid spleen augmentation. That's, I know Dr. Mangone will have this topic.  We can discuss about it. I also have a very low threshold to do a gastric recession. I do for the majority of them. And we did notice a significant improvement  in the majority of the measurements that we did, including the mitopacet subluxation from 44 to 22%. These patients are improving the patient reported outcomes,  PAS, PCS, European Foot and Ankle Society score and PROMIS pain interference.  And looking into pre-op and post-op, we were able to correct an average of 15% of the mitopacet coverage, 81% of correction of the interfacet coverage  and a decrease in sinus tarsy coverage by up to 82%. And more exciting is that these improvements in coverage are correlated, are actually explained 70% of the changes  in some of the patient reported outcomes. So you improve coverage, we improve outcomes as we would expect for any joint and the foot is not different.  And what we want is potentially to try to apply this concept in a preoperative algorithm where you can plan your surgery and check for every single procedure you do,  how your measurements are gonna change. So we're using all this data from the patients in front of the various studies that we're also doing here  to feed this software to potentially be able to predict what you really need to do. And maybe you can play around with your size of your MDCO.  Maybe you can play around with the size of your cotton or your first rate procedure. And you can have an idea of where you're gonna get.  So instead of just eyeballing that, like Dr. Bailey said, maybe we can in the future be a little bit more precise and get to the surgery already knowing a little bit  of what we should do to get the correction that we want.  So try to make the difference in the life of the patient, try to think outside of the box. I think we have to try to answer the billion dollar questions we have to try to predict,  have to try to improve the outcomes of our patients. My last two slides where I'm going because Dr. Mangone asking me to add this. So I put this two slides in the end.  I do push the limits for flat foot reconstruction. I try to avoid hind foot fusions, try to rebuild your tripod, bring your foot, your tripod under your ankle joint,  bring your heel under your leg, bring your first rate back to the game.  You can derotate the deformity with any one of these procedures. Don't think that one procedure will only change one measurement, that's not true.  Improve, try to improve articular coverage. And when you do this procedure, you are improving articular coverage. However, we didn't have how to assess that until recently.  Minimize extra articular impingement, try to preserve your posterior tibial tendon. I am a saver, I'm a tendon saver. I think tendons are live structures.  You give better alignment, the tendon can heal. If you can't, if you can't preserve your posterior tibia then the way I decide between FDL transfer  or allograft reconstruction is with an MRI of the leg. If they have atrophy of the posterior tibial tendon, muscle belly, then I go for FDL. If not, I do allograft.  Like I said, I've been augmenting my deformity correction more and more with ligamentous reconstruction. I don't use different than OptroMagnon and we can talk about it.  I don't use the ligamentous reconstruction to correct my deformity or in isolation. It's just an augmentation, it's a check frame.  Minimize or avoid LCLs, that's what I have been doing.  I have to prove that yet, but I think it's still a necessary evil, especially in severe abduction deformities. But I've been very happy with the results  of the plantar flexion osteotomies or fusion of the first rate. Avoid hindfoot fusions when possible. Remember, sinus starts impingement.  This is not arthritis, this is extra articular. If you derotate the deformity, you can still get this patient better without a fusion.  When hindfoot fusions are necessary, we use the subtalar joint and try to preserve your talovicular joint because if you do fuse your talovicular joint, the outcomes will go down.  Save your talovicular, save your ankle joint, don't let it go, follow up closely and think about the red flags. Thank you, sorry that I always go over time, I apologize.  Unshare your screen for us.  I wanna thank you for that.  I know we're gonna have a potpourri of questions about that. You're certainly pushing the envelope.  In my opinion, that's probably the best talk on flat foot I've ever seen. And whenever you see someone push the envelope like you're pushing it,  I really don't know what the hell to do now. So this is gonna be a great discussion from our panel. Next we have Gary Stewart. Gary Stewart is a resurgence orthopedic doctor.  He's one of the foot and ankle specialists in my group in Atlanta.  I met Gary when he was a medical student at a meeting interested in foot and ankle way back in the 90s. He's blossomed into a terrific surgeon. He's the head of diversity inclusion  for the American Orthopedic Foot and Ankle Society and is a leader in that arena and in our country.  So without further ado, I give you Gary Stewart.  It's my pleasure to be invited. Thank you, Dr. Hines, Dr. Mangone and my mentor, Dr. Bailey. I do remember that meeting. You walk into a meeting and it's like a meeting  of two unicorns at an orthopedic meeting. So it was nice to see him and to have his mentorship through all these years. So I'm gonna attempt to share the screen.  Hopefully I don't have the issue Pete did.  All right, so like Dr. Bailey said, I'm Gary Stewart. I'm chief of the division of foot and ankle at Wellstar Atlanta Medical Center,  which means I work with the great residents there. I'm also director of our Resurgence Foot and Ankle Center. And I look forward to speaking with you today.  Here are my disclosures, not based on my talk today. I also, as one of my other roles, want to remind all of you to participate  in the member census by updating your demographic info on our online profile. That's gonna help us to identify who we are and to better serve your needs.  So let's talk about flat foot, okay? So classifications, is it arch collapse? What is it that we're doing? I just wanna make sure that I have this down. And PTTD, AAFD, PCFD,  and also some of the stuff that Cesar is talking about as a private practice, private dynamics person. Sometimes I feel like it's an alphabet soup,  feel like this emoji where my head is gonna explode. And just like Dr. Bailey, a lot of times I would do a procedure and it would work sometimes, it wouldn't work sometimes.  Maybe we treat them with orthotics for a while. And so let's talk a little bit about this classification here, hold on.  This is back in the 90s when I met Dr. Bailey and when I was on Keith Wattner's rotation. And I just, the one thing people know is that I don't like classifications  because really the more memorization you have to do, usually the less kind of understanding you have of a classification, maybe the less it really truly makes sense.  And now with some of the stuff Cesar's talking about and PCFD, this was nice in the 90s and early 2000s, but just like my book right here, I was nonplussed.  And so here we got our AAFD, kind of a linear progression and it was starting to make sense. But again, your classification is getting more and more busy.  This was a great discussion. And then when I was learning in a residency with Wattner and Nguyen,  I then now started teaching this when I became a private academic kind of academic physician. And then I kind of sit, sitting up like my pope here  and kind of thinking, this is starting to make sense. But the more and more that we looked into this, here is that PCFD. And then, I wasn't quite jumping as high as my pope,  but I starting to like it. It's really starting to make sense now. There's less memorization. When I talk to my partners and I say, it's a 2AB and you can go to this  and really kind of have an understanding, that means we're getting there. There's less memorization and we're getting there. And so as a private practice physician,  I don't necessarily have access to, I do have a weight-bearing CT, but some of the ability to evaluate it is still in 2D for a lot of us. And that's how I'm gonna address us today.  Here you go. Yes, you may have this great classification scheme, a better way to talk about it, but it's still all about our physical examination, right?  I mean, you're still gonna look for your too many toes sign. You're still gonna look to see if there's any forefoot abduction. You're gonna do a heel rise.  You're gonna see if that's correctable or not. All of those things, is there pain, is there swelling and is it failing?  And also, just when you're looking at that PCFD classification, it's all about, can you manipulate it? Is it flexible or is it more arthritic or is it stiff or rigid?  And I think, again, radiographic presentation. You know, you gotta look at your tail end and make your own coverage. Is it greater than 40%? Excuse me.  Do you have midfoot collapse on the lateral? And these are all the things in a 2D world, which we're really still in, you have to try to do for your patients.  Because until we really get to the point where we have this all locked down and maybe there won't be, we're still kind of thinking in this sense and people are still hurting  and there are things we can do now. But what are we gonna do? And what are you gonna do?  And so for the presence of this talk today, we're gonna make this relatively binary where we know it's not quite, you know, you can mix and match things,  but we're gonna talk about fusion versus reconstruction. And when I talk about reconstruction today, we're really talking about no fusion.  When you look at fusion versus reconstruction, you know, this consensus statement, you know, I don't like classification schemes, but I do need some rules on how to think about it.  And yes, we are making some, but I think in the next five to 10 years, hopefully some great strides in this, we're still at some of the infancy  of understanding this in all of the dimensions. And so I love this consensus statement. And basically we wanna preserve our joint range of motion,  which means we're not gonna fuse as much as we used to. And that's osteotomies of whatever sort.  Arthritic joints, hey, that's fusions. And sometimes it is gonna be necessary when you have some rigidity and stiffness, unless Caesar and his team kind of really kind of  push us forward to a point where we're not doing any fusion. I still think there's gonna be some views where we can do this. And then it's kind of being seen  that if you have someone with a really high BMI right now, it's kind of a predictor of worse outcomes. But again, putting on my DEI hat, we have a lot of knowledge gaps yet.  And so maybe there are some things that we can figure out in terms of our 3D correction, where BMI is not something that we routinely walk in  and just tell patients that this is the issue and why this is a problem for them.  And also, I hear people talk about age. And I was kind of tall or at least red and kind of thought that if someone's older, maybe we should go ahead and do that fusion.  But we have more information now and you have to be a doctor. The older I get, the closer 65 looks to be younger. And the more activity that people wanna do,  they don't want a stiff hind foot and they wanna have mobility. And if we can preserve that to them, let's do that. Again, what are we gonna do?  And basically, when you look at this consensus statement, you've got your... Our goals are to coronal plane alignment in the hind foot and align the forefoot  with the center of gravity of the body. And you can look at this classification again, and I wanted to put it up because there's a number of ways to do this.  And you can kind of mix and match. I mean, this is kind of like a nice menu here where you can really kind of lock in to the patient how you're gonna correct them.  There are lots of options. As long as you're relieving pain, restoring their alignment, restoring mechanics, and you can get them in a shoe, and you're kind of preventing  some of these other problems I've listed, shoot. Maybe right now, with our current literature, our kind of understanding, you do an MDCO,  a lateral column lengthening, or a cotton. Maybe you add MDCO with a lateral column lengthening. Maybe you just do MDCO with a cotton. Or maybe you don't do MDCOs anymore.  And that's the point I'm saying. Six, seven, eight, nine are still things that we can get to. And then you have the whole wild card of, are you gonna do this MIS or not?  Again, we're not talking about fusions today. There are options to treat malalignment and flat foot or progressive conflapsing flat foot with fusion.  However, again, what we're trying to do when you look at this concessive statement is look at joints where the tail end of the joint has greater than 40% on coverage.  And so if you've got a M, sorry, excuse me, I misspoke there. You're gonna do an MCO if the tail end of your joint, tail end of your joint is covered.  So unlike when you're doing a lateral column lengthening where you have it uncovered, if your tail end of your joint is covered, you're gonna do an isolated hindfoot valgus material  procedure with your MDCO. You have a lack of significant forefoot supination. We're still evaluating that and finding a more concrete way  to kind of let you know when or when you should correct that. Our goal is to achieve a clinically neutral heel, which is defined as a vertical axis from heel  up to the longitudinal axis of the Achilles tendon and distal aspect of the leg. Our typical range of correction is gonna be anywhere from seven to 15 millimeters.  And you're gonna wanna take your traditional X-rays of AP of the foot, AP of the ankle, mortise and a lateral foot. And if you can get a hindfoot alignment view, that'd be great.  So again, we're starting with our MCO. Again, the goal is to create an optimal position. And this is still using the term of AAFD,  but I just wanted to show that there's numerous ways to correct it. You can use a plate, you can use screws, and you can look on this nice hindfoot view  from the article of optimal positioning. The goal is gonna be to have a clinically neutral heel. And then on a radiographic view, mild varus.  And so, you don't wanna overdo it obviously, but it's a clinically neutral heel with mild varus on a radiographic view.  Again, be honest with you, I'm not one of those open guys anymore. I'm kind of trying to do things minimally at this point. And of course it has its function to do things open,  but it works when you do it minimally invasive. And these, I think some of this is literature bears out where they don't have the sore nerve injuries if you stay in a safe zone.  In terms of this, you can see a number of other articles where they had minimal non-unions and a minimum malunions and wound problems. And so if you're careful and you take the time  in your learning curve, you can do this. And so you look at this article here, right? I mean, you have where Dr. Taliesin, who has given some great talks here,  and I really like to hear him speak, talk about this safe zone, which is well-documented. And as long as you stay in a safe zone with your burr, and you can put one or two screws,  you can do an MIS-MBCO very accurately.  So let's break it down a little bit again into two views. And we'll talk about your forefoot abduction view.  Let me get this bar out of the way.  Forefoot abduction view in our lateral column lengthening. And there's a consensus statement for this. And again, these are what we're working on  in a kind of a private practice right now where we don't have necessarily all those 3D options. We're still looking a lot in 2D. When you're doing a lateral column lengthening,  this is still kind of a workhorse for a lot of us. And when you have a tailor navicular uncovering of greater than 40 degrees, you wanna be sure  when you went through this consensus statement that you don't over-correct as Dr. Conte, Matt Conte showed in this article below.  And usually you wanna be between 5% to 10% of correction.  So in terms of some of your choices for lateral column lengthening, you can go with an Evans, and Hinterman, and Vandegraaff, which is more of a step cut lengthening osteotomy.  And to the chagrin of all of my residents, they hate all of these terms. So we'll break it down a little bit. On Evans osteotomy, I do believe you can get  some three-dimensional correction. I think the understanding of how much and what you're doing is where we are. And we do eyeball it a lot in surgery,  and that's where the frustration lies. And hopefully we can kind of dial those things in in the future, but essentially here's what's happening.  You're doing a lateral column lengthening where you're moving the forefoot to try to correct over the tailor navicular joint. And then you can also have some plantar flexion  at that tailor navicular joint as well, depending on the angle of your osteotomy. When you're considering an Evans, 5 to 10 degrees is recommended. If you're doing a large graft,  you can sometimes increase the CC joint pressure, especially in an Evans. Some surgeons don't use hardware. Some use bone wedges, some use metallic wedges.  I'm at a metallic wedge currently. And you've got to be careful not to let this be your fragment shift.  It's a little bit easier, I think, when you do it open and throw some pins across here. But when you're doing an MIS, you've got to really be careful,  and we'll talk about that a little bit later. Obviously, you want to be careful of your peroneals and your sore nerves coming through here.  Your hindermen, I don't use this as often, but I wanted to put this in here for completeness sake. You get supposedly less CC joint pressure, and your hindermen osteotomy  becomes a little bit more posterior. And so that when you're doing your other osteotomy, and you're trying to open that, you maybe have less pressure  if you go maybe more along this line, okay?  And the step cut osteotomy, I saw it described earlier in some of these talks. I don't use this myself, but I think that it has shown that it's got a great healing potential,  gets some good deformity correction, and the clinical scores are showing improvement. But so much to your chagrin.  And I'm sure for some, and happiness for others, when I'm doing my MIS, sorry, I'm doing my lateral column lengthenings, I'm more of an MIS surgeon in terms of it at this point.  This was one kind of early MIS idea we were using, where we were using screws to try to get some more purchase. And this is how I'm doing my Evans at this point.  And then you can add, even do like a double osteotomy and do an MIS MDCO, and then you don't have to worry as much about your skin bridge when you're doing your Evans here.  And you can just, again, just to kind of piggyback on some of the articles, some of the discussions today and articles that are coming out,  this is why foot and ankle is so interesting, because you can start getting, start thinking and getting really creative with how you want to approach this.  And, you know, it's a very powerful thing that we can do here. And, you know, it's just a lot of fun right now, I think, when you're looking at some of the new things we can do.  So, as you know, Dr. Bailey is one of my mentors here  and partners, and we've kind of been working on doing some of these MIS double osteotomies. It's coming out and is seen some in the literature. We have an article, some case studies  that hopefully someone will want to accept and read that we'll be putting out shortly. But this is some of our, again, our earlier MIS work as well.  So, when you're dealing with our forefoot virus, in terms of a cotton osteotomy, you have your consensus statement here in which,  you know, you've got to have a stable medial column. And then it's one of those things where I find a little frustrating because I do like rules. I don't like classification schemes  and I don't do like rules. So, when I'm in the OR, I like to feel confident that we have done our job. And I think that's one of the things that I find a little frustrating  that we have done our correction. And yes, doing that kind of simulated kind of motion to see if you have enough forefoot virus,  I really am looking forward to some of Cesar's research to kind of help me out with that. And so, I do less forefoot cotton osteotomies  than my lateral column lengthenings and my MDCOs, but it does have a role. And it's looking like there may be more of a role in the future. If you have gross instability,  it'll need a first TMT fusion.  And you could have a little bit of instability, but if it's gross, at this point, from the literature I've read, a first TMT fusion is the way to go.  And obviously, you're looking at your mirror's angle and your size of your graph will correspond to correction, but you don't need a huge graph on something like this.  But again, in terms of fixing the flat foot, nothing is perfect. I kind of put this picture here when I was outside of my complex. It looked like someone had a little too much fun  on the Beltline of Atlanta and was trying not to pay. It looks like they're gonna pay a lot. And sometimes that works out with anything, whether it's open, whether it's MIS.  Sometimes you gotta pay the piper with some either infections, non-unions, it could recur, persistent swelling. And then your MDCO, I think there's some,  here's just a literature from Dr. Coleman kind of talking about some of the complications that can occur, especially if you're doing this minimally invasively.  And in Evans MIS, and I talked about how it can be a little bit challenging to make sure if you're doing MIS to hold kind of this anterior piece down,  and this was part of my learning curve. And then sometimes you have to be careful not to have this graph. You look at the little small hole  and you've gotta be careful not to let that rise up and cause any problems.  And in your continuous diatomy, as alluded to earlier,  a study by Matt Conti shows that it's pretty easy to over-correct with this thing. And you can have sesamoid pain. And the one thing you wanna do,  and it happens sometimes when you're doing these procedures is you have someone with a flat foot and you're like, we're gonna take this flat foot out,  we're gonna make this non-painful for you. And you're very happy interoperatively when you're looking at it, you're like, look at that arch I've created.  And then the person stands on it and walks and they have lateral column overload and now they're hating you. And you've gotta figure out how to undo some of the things you did.  But in short, so that we can have plenty of time to talk about options, there's a lot of options in this. And I put this slide here again, because there are so many things  that we have to figure out on this. And I found it kind of challenging to do this study because of all the, excuse me, this lecture, because of all the things in private practice,  you know, you've got your 2D views, sometimes you have your weight-bearing CTs, but we're still trying to kind of normalize what the normals are on that,  at least from what I've seen. And there's so many options and things to do. And there's so many ways to be creative at this point in time.  Please, more literature, because, you know, this is fun. You know, you can write your own roadmap, right? I mean, we've got some basic rules and you can use some traditional things  and then you can do some non-traditional things because there's not necessarily literature out there saying you shouldn't do it.  And so, you know, let's get to this. Let's write our own roadmap. There are some ways on how I correct my flat foot. I use a combination of all these things  with the current data that we have, and I'm looking forward to more data. And so here's kind of our mini-bear procedure, which is our mini bone extra-articular reconstruction  in which we're doing, you know, multiple osteotomies, trying to create a flat foot, sorry, trying to correct a flat foot and create a more well-balanced foot.  And you can add whatever methods of soft tissue that you would like to this, but this is a very powerful procedure. You just gotta be careful of what your correction will be.  So in conclusion, you know, reconstruction, basically correcting a flat foot without fusions in this, what I'm talking about today, is a completely viable option.  It can be done open or MIS. As you can see, that showed that last kind of triple osteotomies was all MIS. And again, adding your flat foot, soft tissue procedures as you see fit.  Here's some additional references. Thank you very much.  Thank you, Gary. That was absolutely fantastic. And that's gonna lead us into our final session. Andrea, are you there? We have Andrea Velkovic,  who's gonna be talking about fusions.  Something that we're being told to not do. So let's hear what she has to say about this today.  So I'm hoping I have the right talk up here right now. And I just wanna thank everybody for having me here. I really appreciate it. Today, I'll be talking about Plano Volga's  fusions to correct flat foot. It's stiff, but it's stable. For a joint preservation surgeon, when is midfoot fusion required? And if you guys know me at all,  I tend not to fuse anything. So I have to find indications for me for a fusion. In general, I have really no disclosures pertaining to this talk. We'll be talking a little bit about  the progressive collapsing foot deformity, thanks to Cesar, as well as the presentation and the relevant presentation as it pertains to fusion,  rigid deformity, a consensus statement on midfoot fusion, treatments, as well as relevant cases. So Cesar, thank you so much for bringing up  the progressive collapsing foot deformity consensus group. This is something that I've believed for pretty much 12 years of my career.  I haven't really believed in the tip post deficiency as being the cause. So when it comes to my talk, really what we're gonna be looking at is these more rigid deformities  or the non-controllable deformities that require fusion. Goals of treatments when it comes to flat foot correction are obviously to relieve pain, restore alignment to mechanics,  facilitate shoe fitting, and prevent further mechanical consequences. And really goals for us as surgeons is to understand the mechanical disorder, the causes of the symptoms,  and to improve our treatment algorithms. From the consensus statement, we know that basically we recommend preserving joint motion. However, in some cases, we do need to fuse.  And when it comes to fusion, this should be done in those joints that are arthritic and stiff, in important sagging deformities of the tail and the vicar joint or midfoot joints,  severe deformities where inadequate correction and TN abduction or midfoot joint deformity is achieved intraoperatively.  There's also some thoughts about BMI. I don't really know fully how this will fit in, in the future, but definitely obviously increased force loads on the foot,  specifically when it goes to soft tissue corrections. So goals, and this is a goal for all surgeons, really is to restore alignments and mechanics.  We need to ensure a good coronal plane deformity correction of the hind foot. In addition, we want to ensure that the mechanical plumb line of that second ray  is in line with the heel during heel rise. And this is important for all patients with planovalgus feet, even those that are the fastest in the world.  Treatment should really prioritize coronal plane deformity restoration in all phases of gait.  So when I look at assessing my planovalgus patients and who needs fusion, we all have to look at, are they platists, are they hind foot valgus?  How much forefoot abduction do they have? How much forefoot varus do they have? I always assess for impingement, whether it be subfibular sinus tarsi,  calcaneal cuboid, or fourth and fifth TMT impingement. I look at single leg heel rise to assess the function of tip post and the varus production of the heel  in single limb heel rise. I look for tibialis posterior tenderness and weakness, and I do a reverse colon block test to see if my hind foot's correctable or rigid.  And I look to see whether or not there's any rigid or painful joints. And this is always important. And this is what that valgus hind foot looks like.  So obviously, quite a bit of collapse of the hind foot in regards to the axis of the tibia. You look for the too many toes,  which indicates abduction of the forefoot on the hind foot, or the midfoot on the hind foot, the tail and umbilical joint. You look for forefoot varus.  So when you correct that heel, does that first ray elevate? And do you somehow either need to bring the first ray down or derotate the entire foot?  When it comes to flexible or fixed, you can do this reverse colon block test, which actually is done simply with a meal block, and you see if that hind foot corrects.  And then that comes to the algorithm of, is it flexible or is it fixed or degenerative? For flexible, obviously you can do calcaneal osteotomies and soft tissue procedures.  For those patients that are fixed or degenerative, obviously fusion or strategic fusion may play more of an adequate role.  This is an example of a gastroc contracture, and this is something that you definitely need to address. And the reason why it's important  is that positive silver skull doesn't allow you to properly use your ankle and makes it that your foot actually breaks out into eversion. I'm just letting my dogs out. Sorry, guys.  And that can be a bit of an issue for the patients.  Then you need to assess the strength of tibialis posterior and see whether or not you have good strength of tibialis or whether the patient recruits their lesser toes  when inverting.  You also want to do that heel rise to see whether or not when the patient does a single heel rise, is the patient absolutely able to invert that heel?  And you can see here that he's not able to do it in single heel rise, but is able to do it in double heel rise.  Finally, you look for that lateral pain, whether it be sinus tarsal impingement or potentially degeneration. You look for impingement here.  And these are all important factors to assess. MRI can be beneficial to assess cartilage if you're looking at a joint preservation technique  or potentially look at atrophy of the musculature. CT scan is beneficial in assessing arthritis or locations of arthritis. And I use, I heavily use SPECT CT  as well as also we have a standing CT in our office and we look for impingements. Finally, when it comes to treatment, don't forget you need to treat the hind foot valgus,  the forefoot varus and the external rotation of the foot. When it comes to fusion, the question is, do you need a fusion? If you do need a fusion,  best place obviously is at the center of rotation and angulation or the location of maximal deformity, as well as if this correlates  with the most degenerative joint, that's the best option. Options for medial column fusion are telenovicular joint, navicular cuneiform joint, first TMT joint or perhaps combined.  And as I mentioned to you, I tend not to be a fuser.  This is a bit of an example of cases that actually follow the consensus statement. So we know that consensus statement said, number two, TN joint fusion should be considered  for the arthritic and stiff joints. This is an example of an 81 year old female. She has a degenerative planovagus foot. And when you look at her foot,  you can see that majority of her collapse is coming through her telenovicular joint. And she has abduction of the telenovicular joint with hind foot valgus.  We know that we want to restore the entire tripod here. In this case, we did an endoscopic gastrocnemius recession and endoscopic medial slide calcaneal osteotomy  to preserve that hind foot, as well as a peroneus brevis along as tendon transfer to detension that abduction of the foot,  as well as add to dynamic plantar flexion of the first ray, as well as a strategically done right telenovicular fusion. In her case, we didn't do any further cotton osteotomy  and metatarsal osteotomy, as she has first ray arthritis in her MTP joints. And in this case, usually I like to see whether or not an orthotic would be adequate enough  to offload that area without actually buying the farm and bringing the first rate down completely.  So you can see here, this is another example of the consensus statement two, where telenovicular joint fusion should be considered  an important sagittal plane sagging of the TN joint or midfoot or in severe deformities. So here's an example of a 54 year old gentleman. He has significant lateral ankle pain,  significant medial ankle pain,  significant weakness of his ankle and inversion. You can see that he has a severe loss of Mary's angle with a core at the telenovicular joint.  He has abduction of the telenovicular joint, and this is the core of his deformity was quite a significant amount of sag. Also interesting features are found  on the contralateral side. High foot alignment is severe valgus, as you can see here. And when you assess the patient, you can see the patient going up,  but he can't do that single heel rise like I mentioned. As you watch him rotate around,  you see the eversion and abduction of the foot. Then as he comes around, you see that severe collapse in the midfoot with that loss of Mary's angle  and that break at the telenovicular joint that's very prominent.  Here, when you look at his first ray, you see that when you correct his hind foot, he has varus of the forefoot. However, when you assess where to do his corrections,  you want to bring that first ray down like Cesar showed you, but here you can actually see that he has first TMT, hypermobility and translation.  So this is the case that maybe you consider doing a first TMT fusion. And in him, potentially, you have to look at that telenovicular joint where he actually, when you ask him,  has about five to four out of 10 pain on inversion.  So for him, what we ended up doing was we did an endoscopic gastrocnemius recession, a peroneus brevis longest tendon transfer,  a strategic telenovicular fusion and a cotton osteotomy.  What's interesting here is that when you do that cotton osteotomy and you do a large cotton osteotomy, you create a secondary deformity to treat a primary deformity,  and you sometimes get the zigzag deformity that occurs. And you can see here that when you look at his post-reduction films, he has a nice correction of his abduction  compared to before, a nice correction of the valgus compared to before. Even his arch actually looks elevated, but it has this zigzag deformity,  which is compared to where he was before. So this is a rule that a strategic fusion of the midfoot can be helpful to correct, but you will get the zigzag deformity.  And as long as you hide that deformity from your sight, you can notice that the Mary's angle has improved.  Then the question is, sorry, it's not TMT, but TNT, that's a typo, I apologize, but you can see here that this is the patient that's 21 years of age.  He has a planovalgous foot, but also has hallux valgus. He has a progressive right lateral ankle pain, medial tenderness, tenderness on the medial eminence.  And you can see here that he has severe abduction of that telenovicular joint. He has a hallux valgus deformity. He has a short lateral column.  So this is someone that I actually should have considered doing a lateral column lengthening, but due to my hubris, I did not do. And he has plantar gaping of his first TMT joint.  So in order to kill two birds with one stone, you may say to yourself, I'd like to use that TNT joint and deal with some of the deformity here.  So here you see the hind foot alignment is in valgus. When you look at his CT scan, his joints are preserved and there's no evidence of a coalition.  So in him, we did an endoscopic gastrocnemius recession again, a peroneus revus longus tendon transfer, and endoscopic calcaneal osteotomy.  But this is someone that I maybe should have considered lengthening that lateral column in addition. However, we did an FDL tendon transfer to the medial navicular.  We did a spring ligament placation, and we did a lapidus fusing using an iliac crest allograft that it looks like Cesar does similar to me at times,  where you actually do a biplanar wedge so you can bring the first ray down and actually abduct that first ray.  And so that's sort of what that looks like when you're completed with an aching osteotomy to refunction that first ray. So that's your strategic fusion there.  You see that you have a correction of that first ray alignment as compared to before. However, there still is a bit of an abduction deformity. And this is where I mentioned  that adding a bit of a lateral column lengthening may be helpful, although I'm not really a lateral column lengthener as I don't like to overpressurize the lateral column.  Hind foot alignment's improved compared to where it was before, as you can see here. And then when you see him actually do his double heel raise,  he's not able to do a double heel raise and invert that heel, and he's doing fairly well. And this is him almost, I think it's six weeks  or three months after surgery, I can't tell for sure.  Then sometimes you need to consider fusing that navicular cuneiform joint. And this is a case courtesy of one of my mentors and partners, Dr. Alastair Younger.  And this is a patient that actually has a cora and degeneration at the NC joints in addition to other areas with a plaintive august foot. And what Dr. Younger did here  was a navicular cuneiform fusion done strategically with his multi-screw technique and a lateral column lengthening. And he's got a nice correction here.  So there is a rule for these things. Again, it's usually not my go-to. I tend to be more of a cotton osteotomy person in this setting. But I'll show you why in some cases  I should probably have done an NC fusion.  Then finally, consensus statement two, telenovicular joint fusion should be considered where inadequate correction of the TN abduction deformity  is achieved intraoperatively. So here's a case of mine. This is a 53 year old symptomatic female with a plaintive august foot. Her problem is she's ligamentously lax,  but she also has various non-concentric ankle degeneration. And I was quite concerned that if I did a rigid construct on her,  that I would end up causing overload of her medial ankle, even more so without compliance, and then require earlier fusion or potentially ankle replacement  or further failure of the ankle. So in my hubris, I did more of a joint preservation technique. So you can see here that her hind foot alignment  is nicely corrected as it was before, but then she slowly loses that correction of her hind foot alignment. And she's not fully corrected here.  And you can see here that she's starting to get a bit of a sag of her telenovicular joint. So what was actually initially done for her was a medial slag of keto osteotomy,  a cotton and FDL tenant transfer gastrocnemius recession. But then over time, she actually lost correction, had sagging of her Mary's ankle and a progressive hind foot valgus,  and she became symptomatic again.  Then to treat this as a result, I did end up having to do a strategic fusion of her telenovicular joints, as well as the first metatarsal plantar flexion osteotomy  to bring down her tripod. So you can see here that her hind foot alignment has improved, her arch has improved. But what you notice in these cases,  if you do some of these strategic fusions, you notice that you start getting an adjacent joint sag. And the question really ends up being,  in what patients do we need to do a double midfoot fusion? Obviously, you can always come back to do this, and she's actually doing exceptionally well.  But this is always concerning to see that when you do that TN fusion, you can also see that NC problem in some patients, not in all, but in some.  So this is the final case I have to show, which culminates quite a few of these thoughts. This is a 59-year-old female. She has significant medial ankle pain,  significant lateral subtubular impingement. You can see here that she has abduction of her navicular on her tailor head, with degeneration of the tail navicular joint.  She has severe sag in the midfoot, which is another one of the consensus statements. She has loss of Mary's ankle, and this fact in this case is negative,  where the medial cuneiform is under the base of the fifth metatarsal, and we know it should be 0.8 to one centimeters above it. We can also see that she has severe hind foot valgus.  She has valgus nonconcentric tipping of her talus lamortis and a dysplastic fibula.  And she has features on SPECT-CT of sinus tarsae impingement, subfibular impingement, lateral column impingement of her fourth and fifth TMT.  Her tip post has some changes in it. She has some changes in her deltoid, obviously, and she has features of sinus tarsae impingement, even on the MRI.  When you look at her full-length standing views, this is actually quite interesting. You see that she has loss of height of her entire white leg as she collapses into valgus  and loses height of her hind foot. This is what you see, that poor-looking hind foot. So as Cesar was saying to you, the normal standard of care here would be a hind infusion,  but like him, I have gone away from this. And this case is probably about nine years old, about nine years old, and she's still not fused, and she's doing fairly well.  So what we ended up doing with her was an endoscopic gastrocnemius recession, as you've seen me done before, the detention of that hind foot so it stops collapsing into valgus.  A peroneus brevis longus tendon transfer, which helps, number one, take away the deformity of abduction on the midfoot, but also gives you dynamic plantar flexion of the first ray  as you evert your ankle.  Distal tibial closing-wedge osteotomy, a fibular malleolar opening-wedge osteotomy to deal with that dysplastic fibula and fixation of this.  And then a scope-medial-slide cochanal osteotomy to bring that hind foot under the axis of the tibia. A strategically done telenevicular fusion as she was degenerative and abducted  to the telenevicular joint. And a cotton osteotomy. And the plan for her is three months later, we would convert into a complete ligament reconstruction of her ankle,  once we'd confirmed healing of her osteotomy site. So that's what she looks like initially. This is fairly soon after surgery, about six weeks after.  She has the nice correction of her hind foot. She still has some valgus nonconcentric tipping of the talus and the mortis. She has an improvement of her arch,  but again, you see that NC change subsequent to telenevicular fusion in someone who's ligamentously lax. So again, maybe I should have considered  an NC fusion strategically versus the cotton. Then we came back about three months later after confirming with CT good fusion, and we did a deep and superficial deltoid ligament  reconstruction with allograft and augmentation with internal brace and removal of hardware. So you can actually see here that we've inserted that graft in the talus  at the insertion of the deltoid, sort of in the non-isometric point, I suppose, because you have the anterior and posterior band.  This is brought through the intercalicular groove up, fixed with interference screw and augmented with an internal brace to further augment the fixation of,  and healing of that graft. Then a superficial component was done of the tibial and the vicular band and the tibial calcaneal band. And you can see an improvement of the alignment.  And then we fine-tuned the first tray and the tripod by bringing the first metatarsal down. But again, I would argue that due to my hubris, I probably should have considered  doing an NC fusion here too, in addition to my TN fusion. But as I'm an anti-fuser, I went with non-fusion initially, but I think it would have been maybe the best option here  to do an NC fusion first. So when you look at this here, you can see a nice correction of that first ray compared to before with the axis of the second metatarsal  in line with the axis of the heel compared to her previous severe abduction. You see now this adjacent joint sagging that I'm concerned about. And this is one of the things  that we need to think about when we fuse and when it's relevant to consider a fusion of that NC joint too. And in this case, probably was a relevant idea.  You see that she has an improvement of her alignment compared to before, where she was before, compared to the severe hind foot. And this is where she is now, by the way.  This is a picture taken many years later. So you can see where she is now many years later compared to where she was preoperatively. And you see that hind foot alignment view there.  And that's what she looks like in terms of her foot. You can see that her right leg is corrected compared to her left. And interestingly, her right knee is compensating  into a bit of valgus too on her full length fuse. So basically when it comes to effects of fusion, the consensus statements of it is that there's little evidence in the literature  whether TN fusion does sufficiently address the breakdown of the medial arch and forefoot supination associated with hind foot periteler subluxation  in this progressive collapsing flat foot deformity. It may have a limited effect on restoration of the medial longitudinal arch and forefoot pronation  when the deformity is mainly caused by collapse in the medial column structures of the midfoot associated with periteler subluxation. And my caution is fusing may worsen  adjacent joint deformities and sag. And this has been seen in people who get triple fusions under an ankle, and then the ankle progresses to valgus nonconcentric degeneration.  And I've obviously shown it to you when you've done a TN fusion and you get progression of deformity either in the NC or first TMT joints with further sagging of these joints.  However, in my viewpoint, fusion plays an important role in joints that are degenerative, have significant sagging, and with recurrent deformity in joints  that have undergone joint preservation techniques. So in conclusion, I say be creative. Some feet need a strategic fusion. However, it's better to get the same results  with osteotomies, soft tissue reconstructed, and selective fusion versus fusing at all. And you can always go back and fuse more if needed. So thank you.  Thank you very much. You can unshare your screen.  Is it unshared now?  There we go.  Beautiful.  That was another tremendous talk. This session has been absolutely fantastic.  Each of you are pushing us forward  in our understanding. I have learned a tremendous amount here.  Pete, we have five minutes.  How would you like to proceed? We have one question that we will- Looks like a second one just popped up. So I'd probably just do those questions and then we'll go to the,  we'll not do any case studies right now. We'd probably get four different answers and four different methods.  So, but we'll, I think let's do the questions and then we'll move to the breakout rooms.  We'll talk about that. For the panelists, the first question is that this physician no longer likes doing lateral column lengthenings because he's had some cases  where he's gotten CC arthritis and he feels the center of rotation at the TN joint is closer to the cuboid. So he's doing lateral column lengthenings  through the cuboid and feels it's more powerful.  Any comments by the panelists?  I mean, I think that's an interesting idea actually. But in general, I tend to avoid lateral column lengthening because I don't like to overload the lateral column.  So it tends to be more of a puller than a pusher. So I'll try to do everything to restore the bony tripod and then bring my soft tissues to my new bony tripod  and open up the lateral column. But that's a very interesting concept that he's mentioning. Because when I do like the opposites, you know, when you do a wilted fusion  for a cave of various splits, you tend to actually derotate through the cuboid and take a wedge out of the NC joints or the cuneiforms.  And that is actually that location he's talking about.  Any others? In general, I avoid, I don't do a lot of lateral column lengthening. So I'll defer to the panel.  I do a fair number of them. I agree with him. Early in my learning curve, I was seeing that because I was trying to treat the X-ray more than the patient, I think.  And the tendency is to try to put enough size wedge in there to really get great TN coverage. And then the foot starts to supinate. So this is not an exact science  and that's what we're working towards. So what I've started doing is I put it where I think it needs to be. And I actually back off two millimeters so I don't get that problem.  And that seemed to have worked, but I agree. This is an interesting concept.  Gary and I have been doing these minimally invasively. It's not really truly minimally invasively. It's a mini incision. We did a cadaver study where we just wanted to see  what would happen if you put a burr where you make that osteotomy.  And 10 feet, we bagged the peroneus brevis four out of 10 times. So, and the cadavers. So what I do now is it's a mini incision and make sure that I put a home and retractor in  and pull the tendons out of the way. And that has kind of corrected that. But the CC joint, that's interesting. That's something I think we should look at  particularly those who do lateral column lengthenings. Yeah, I would say definitely. I'd love to see you publish how that works and how that's what your outcomes are for you.  What I have found is that my tendency again is to just try to do as much correction as possible early on and backing off that urge  and using that literature in terms of not over-correcting. And even sometimes when you fall within the parameters, you'll still get some of that lateral column overload.  And so it's a combination of trying to figure out not doing too much of this, doing too much of that.  And that's why we need folks to continue to publish on some of this stuff.  Our second question. Oh, go ahead, I'm sorry.  No, I don't have experience with a cuboidal for PCFD, but I think it's an interesting concept as well.  Whatever you're doing for the lateral column, I think it's important to interoperatively check like Dr. Bailey just mentioned. I love the trials. So if you're doing lateral columns,  doesn't matter where you're doing your cut.  If you have trials available, just put the trials and feel the foot. One of the things you can do is simulated weight-bearing fluoroscopy and look to the lateral incongruence angle  that Dr. Ellis published about. The other thing that I learned with Dr. Delaney I think is very important is residual eversion. So you test, you bring the foot in neutral  and you test eversion motion. And if you lost too much eversion, you overdid your lateral column. So that's a big, big deal. If you're testing and you don't have enough,  just bring it down. When I was still doing lateral columns more frequently, I would not put more than six for sure. So if I thought I needed more than six millimeters,  I would go for a spring ligament reconstruction and I wouldn't go further.  So it's a risky and potentially devastating problem  that I try to avoid by either avoiding it or controlling as much as possible. And I think it would apply for the cuboid as well  because the same concept, but I agree that it's closer to the center of rotation of that specific part of the.  Excellent. Our next question is, what do you think about internal brace spring ligament augmentation with NBCOs or wedge osteotomies?  Any takers on that?  Yeah, I can comment on that because I do, whether it be spring ligament, whether I do that and I can answer offline about the technique for spring ligament.  There's different methods to do it. I use different augmentation methods, suture tape versus synthetic material. There are some published methods out there.  I just spoke about four weeks ago at a conference on my technique that I've been using that I have to get out in publication, but it uses the attachment point of the navicular  as the access point, not the sustentaculum. And I have about 75% success with that. I think the key though, as we've all indicated here that I think has been a neglected component  of flat foot progressive collapsing foot deformity is your medial column, is that first TMT and NC joint area I think has been a neglected.  Back in the 90s when Dr. Meyerson published on medial column or medial displacing osteotomies and tendon transfers, everybody just did that. And then maybe threw in a cotton.  And I think we're finding that even the cotton sometimes is not enough. I do the peroneus brevis, the longest transfer in every one of my patients now.  I think it's a tremendously helpful, dynamic plantar flexor of the first ray and it decreases the eversion force. And I think it's been a role.  So I think I'm doing medial side reconstructions without calcaneal osteotomy successfully, but you have to have a stable medial column  to be able to do it down near the navicular canform and first TMT joints. And I'm still working out how to best accomplish that in some of those patients.  Thank you.  Okay, we are over time. That was fantastic. I'd like to thank each of you for your participation in this symposium. Pete, would you like to take it away? Sure, thank you.  Yeah, great talks. And as Errol said, leaves you with more questions and answers sometimes, which is all good, which means we're really thinking about the problem.  We're not just doing things and running away and not looking at our results. So I appreciate all the panelists. All right, so we're gonna work on our break rooms.  If you go to your attendee site,  there is a square there that says breakout rooms. If you wanna take five minute break or so, let's say everybody be in there by 2.10 to 2.15 at the latest.  We'll have faculty members in the various different rooms. For each of the faculty, there was an email sent out last night.  If you go to that Zoom link that Elena sent last night to regard the breakout rooms with the assignments, they'll put you into the various breakout rooms  and then we'll just see what happens. I don't know if there'll be people bringing cases or people asking questions. I mean, it can be anything people want it to be  from the standpoint of it's the, this is the participants attendees opportunity to pick the brain of the experts in whatever fashion they feel would work best.  So, and whoever's in each room, maybe just work the faculty members just work together to figure out who will kind of run the show. So, I appreciate it.  So, Elena will leave this meeting, correct? And go to the new Zoom link for that, is that correct? Yep, that's correct. And I just put the link in the chat as well.  So, if you wanna click it now, we'll get it rolling. All right, and we'll go to about 2.55 on that and then we will get out of that link  and go back to this link for the final two sessions. Yep. All right, appreciate it, everybody. Thank you.

Video Summary

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Asset Subtitle

Moderator: Erroll J. Bailey, MD

Repair the Deltoid Early with Ankle Fracture: Prevent Future Issues Now
Peter G. Mangone, MD

Progressive Collapsing Foot Deformity (PCFD): What Are We Learning About Flatfoot Deformity
Cesar de Cesar Netto, MD, PhD

Now It's Collapsed: How to Rebuild the Arch Without Fusions
Gary W. Stewart, MD

Fusions to Correct Flatfoot: It's Stiff but It's Stable
Andrea N. Veljkovic, MD, MPH

Interactive Case Discussion Panel

Support for this session is provided by an educational grant from Artelon.