We'll just restart the recording and I'll get going. Everyone can see my slides okay? Just one nod makes me feel better. Yeah, it looks good. Okay, good, thanks. My topic is on Charcot neuroarthropathy. Should I operate early or wait? And these are my disclosures, but none conflict with this presentation. Other than this additional disclosure is that these are the most common treatments for Charcot in my practice. So I think I can answer the question from my own perspective is that I will often wait. But I'm gonna go through what I can find in the literature and after talking to some folks who might have a little bit of a different approach. And just some general concepts around Charcot because Alistair and Jason are gonna go into some of the operative techniques and that's not the purpose of my talk. But in general, the findings we see when patients present with Charcot are neuropathic fractures and dislocations, usually in conjunction with a loss of protective sensation. And really the consequences are what we're trying to avoid. And that's significant deformity, increased morbidity for the patients, decreased quality of life and then ulcerations and at times amputations. I tried to look into to find any update on whether there are medical treatment options that are successful for Charcot. And in the endocrinology literature, basically there were a lot of trials and attempts trying to see if bisphosphonates might be helpful in this patient population. But really there's no evidence of any faster healing or improved clinical outcomes. And in fact, there's one study that showed worse clinical outcomes and slower healing with zoledronic acid. More recently, the literature's taken a look at denosumab which is a monoclonal antibody against RENC-L is showing some promise, but I think the jury is still out in terms of any large scale studies. The key principles of treating patients with Charcot are early recognition. So any of your diabetic patients presenting with a warm, painful foot, you need to have a high suspicion. That being said, many of these patients may not be presenting to an orthopedic foot and ankle surgeon with this type of presentation and they show up in primary care or urgent care. So potentially education of our colleagues in this early recognition is even more important. And we know that less than 50% of diabetic patients who have neuropathy are aware that they have neuropathy and up to 40% already have ulceration of some sort on presentation. And even though when we talk about Charcot, we mostly think about diabetes, we will see patients who have non-diabetic Charcot. And I think Jason's written about that actually. Having a few patients in my practice currently with alcohol-related Charcot, spinal pathology or even post-chemotherapy drug-related peripheral neuropathy. But in those patients, all patients, optimizing them medically is important, including nutritionally, as well as if they're diabetic, getting their diabetic control under wraps. And so assessment can be challenging and we can see X-ray changes related to Charcot for up to two years from their diagnosis. And radiographs are really used for following disease progression. You do want to rule out infection when you're assessing a patient for potential Charcot neuropathy and that differentiation can be challenging. These are the classic findings of weight-bearing radiographs. I don't need to go through those in detail as I'm sure most of you are aware. And then we talk about the Eichenholz classification for staging Charcot. And really this is to help us understand at what stage in the disease these patients might be when they're presenting to you. Early on, they have significant swelling, warmth, and erythema and often bounding pulses. They may even have normal X-rays or very early findings all the way up to stage three, which is when the swelling, warmth, and erythema are resolving. And then on X-ray you're seeing findings such as sclerosis, fusions, findings of arthritis or a consolidated deformity. And as we've said in many talks today, especially with some of these patients with complex deformity, the goal is a stable plantigrade foot. And whether that's chewable with over-the-counter shoes or just chewable with some sort of brace or orthosis, at least if they can walk and stand and get around, that's usually considered a successful outcome in this patient population. You do aim for osteostability. And Pinzer, who has really done a lot of work on the Charcot patient group, has found that about 60% of patients can achieve these goals without surgical intervention. And then non-surgical management involves the primary goal being offloading and immobilization during the phase of instability. This may be total contact casting with frequent changes, and that can go on for two to six months, sometimes longer, or considering something like a double upright AFO, which is much more commonly used in Europe. And when do we operate? So there are times when we're forced and some may choose to operate more frequently than others, but patients who fail non-surgical management, so non-healing ulcers or recurrence of ulcers despite non-operative management. Osteomyelitis is making a patient sick, significant pain or instability, and severe axial malalignment. And then there has been some work done showing that lateral column emboldenment of the Charcot does portend a higher risk for failure of non-surgical management. So you do need to watch these patients, especially those with greater deformity, very closely. The things we don't know are these and many other things, obviously, but the optimal fixation method. I think there's been great progress made in this area, which you'll hear about in the next talks. Timing of surgical intervention. We don't fully know what the right timing is, and I'll talk about that a little bit more. What are the outcomes of limb salvage versus amputation in this patient population? Unfortunately, the research is not particularly robust. This is a systematic review done in 2016 by Sheencloth and their group, looking at the procedures done for Charcot arthropathy. And you can see here the most common procedures performed are TAL and exostectomy with TTC nails, or TTC fusion followed closely behind, which is interesting because the most common location for Charcot arthropathy is the midfoot, whereas it is looking like we're moving towards the fact that the more common surgical procedures are for the ankle and hindfoot. And that may be because midfoot Charcot has more potential for being treated non-operatively than at the ankle, or maybe the surgeries we have for the ankle and hindfoot are more successful than those for the midfoot. Amputation rate is variable in the literature, somewhere around 10%, but up to near 30%. And amputation being required is much more likely if there is an ulcer, a deep ulcer present. Like I mentioned, midfoot is the most common location for Charcot, but these are the kind of most common surgical locations, hindfoot, ankle, and midfoot all being relatively common, with hindfoot being the most common. So some principles that you can consider in treating a patient with Charcot is if they're stable, you could consider an exostectomy for an ulcer at a bony prominence. But if the foot's unstable, you may need to consider arthrodesis with or without deformity correction. And then if they have forefoot ulcers and Achilles lengthening, it can be a treatment of choice. So a gastroc slash Achilles lengthening can be considered to offload forefoot ulcers like you see here. But then when it comes to timing of surgery, there's really no study directly comparing timing of surgery in Charcot orthopathy. Since about 2010, there have been some increasing studies looking at surgery in stage one. But before 2010, patients with stage one Charcot were essentially excluded from the literature. You do need to make sure that there are a few criteria met before operating though. And one is ensuring the patient has sufficient vascular status in order to heal whatever surgery you're going to perform. A patient with active osteomyelitis is a negative prognostic factor for successful surgery. You need to look at optimizing their blood glucose control, which can require a significant delay of surgery and playing into the decision around timing. And you need to understand and establish a relationship with the patient so that you and the patient can achieve their goals, but also engage their support systems where possible. And really the evidence for early surgery in Charcot neuropathy is still very much inconclusive. There's a lot of talk in the diabetic and Charcot literature around super constructs first described by Simarco and their group, looking at fusions that extend beyond the zone of injury, including those joints not affected by Charcot, recepting enough bone in order to shorten the extremity, allowing for reduction without soft tissue tension, using the strongest device that can be tolerated by the soft tissue envelope and applying them in a position that maximizes the mechanical function. And just brief overview of some of the options in terms of midfoot constructs, you can do plantar plating, locking plate technology can be used and then axial screw or beam fixation, which you'll hear more about later. In one study by Albright and their group in 2020, they did look at the cost-effectiveness of different treatments, including non-operative embracing. And they found that reconstruction of midfoot Charcot was the most cost-effective treatment option. The goals of midfoot so-called beaming were to reduce hardware failure, although there's still significant complications as one would expect in this patient population. However, you can see here that limb salvage rates are quite high above 90%. And this is looking at a systematic review, not just one case series. And there's a x-ray just showing you what that concept is. We'll talk about that in detail. Limb salvage in a patient with osteomyelitis. So this can certainly be a possibility in a patient with Charcot, but this is the concepts presented by Gallo-Mittal looked at a group with similar limb salvage success in a really complex patient group, about 90% with the principles of debriding or keratoging the infected bone, treating with appropriate antibiotics, then elevation and total contact casting with close follow-up and wound care. In the hindfoot, it's been found that there's equivalent rates of limb salvage with external and internal fixation. Now that's not a single study. That's another systematic review because the research we do have is just an amalgamation of many small studies. However, hindfoot nails are gaining in their prevalence for treatment of ankle Charcot. And this is just a really quick case of my own just before I finish up, is a patient who developed Charcot of the ankle after fixation by another provider of a trimellular ankle fracture. Took me a really long time to get her ready for surgery, almost to the point where a fibula came out through her lateral skin because she really struggled with a lot of social factors as well as bone glucose control. But she did go on to a hindfoot nail and thankfully we've achieved a stable hindfoot without major complications a couple of years out now. The outcomes are that really the literature is heterogeneous and it's really hard to make any conclusions, but fusion rates are as high as 85% with a not an insignificant non-union amputation rate overall with wound complications and infections being very common. With combined internal and external fixation for Charcot, again, the primary issue is being wounded is in some deep infection with IM nails not being immune to complications, including around 15% hardware removal and complication rates. So surgical takeaways, you need to consider the soft tissue condition, doing appropriate and meticulous joint preparation techniques, considering that you need super stable fixation and the most success you'll have is if you're reducing the deformity that's present. So in summary, look at the big picture. These patients do not come without usually multiple medical comorbidities and other complicating factors. There's really no recommendation to pursue early fixation as of yet. Non-operative treatment does play an important role and modern implants may make surgical success more feasible. Thank you all so much. I'll stop sharing. Thank you, Kelly. Appreciate that great overview. And I think as you discussed in your previous talk as well about when you're doing complex hind foot reconstructions, the role of identifying which patients socially can have this done, you could end up trying to do something that might look great on x-ray, but if they have a wound issue or and they live in a terrible situation, it could end up costing them their limb. So don't always try to hit a home run here. Sometimes just a single is enough for these patients with bracing and appropriate care. So it's terrific knowledge. All right, we're gonna appreciate it. One other thing I want to remind people of before we get to the end, sorry, Jason, just real quick is one, for your claim, if we lose some people claim your CME on the site at the end of the thing, you can go to there. Two, don't forget there are two on-demand sessions. I forgot to mention as earlier. So you can go to those on-demand sessions, one on helix frigidus, the others on trauma. So those are accessible like the program will be in the recordings. Those are accessible for a period of time afterwards. So don't forget about that. All right, we're gonna have Jason who's down at Emory talk to us a little bit about fixation for these complex deformities. Great, thanks, Pete. I really appreciate you inviting me to talk. We're gonna talk about intramedullary fixation when thinking about it in the setting of Charcot reconstruction. These are my disclosures. I did change some of the cases just to not show stuff that I have royalties from. And so what we're gonna review is just do a couple of cases to sort of get us thinking about reconstruction, review the options, discuss the pertinent literature for intramedullary fixation, and then think about the key points and technical pearls that I've come up with by talking to the partners, talking to colleagues and doing some of these cases and then review those cases at the end. And so this is a 55 year old diabetic. He's got this unstable midfoot. He's developing ulceration. We've optimized him. And now the question is, what can we do to sort of get him through? And so how do we fix this? What's the best way to fix this? So, sorry. This is just another case. It's a 60 year old female with neuropathy, got her A1C optimized, had previous surgery at an outside hospital, but now has deformity in a plantar callus. You can see in this non-weight bearing film. She then went through surgery and tried to have this medial column stabilization, but on her CT scan, she still has this significant prominence. She now has instability at her hind foot joints. And so how do you address this and bring her around? This is a third case. This is an ankle case of Charcot. It's a 75 year old gentleman who was super active, walked into my clinic and has this chronic callus with intermittent ulceration along the fifth metatarsal. And we just continued to talk, continued to talk. And finally he decided to get stabilized. And so what we know about Charcot arthropathy, it's a slow to rapidly progressive, non-infectious destruction of bone. It's a difficult and challenging dilemma to identify and to treat. And often patients don't get identified early. We know that there's a Brodsky classification and type one of the midfoot is the most common. And conservative care is the first line of treatment. But the question is when conservative care fails, what are the best surgical options and what are some of the new tools that are available to treat patients? And so when I think about Charcot, I'm just like Kelly in that, the goals of treatment are a plantigrade foot, an intact soft tissue envelope, and the ability to weight bear in a crow, a brace or a custom shoe. And whether that requires surgery or not is not always definitive. And I think coming back to Pete's point where he made hitting singles here, for me, these are the things that define a home run. It's not what your X-ray looks like. It's the ability for that patient to weight bear. The soft tissue envelope is intact and the foot is plantigrade. If you can do those three things with a bad Charcot of the midfoot, the hind foot or the ankle, I think you've won. And so again, surgical options like Kelly talked about, you can do an exostectomy at the ankle. You can do a nail. You can do an external fixator. You can do a hybrid reconstruction in the midfoot. And when I say midfoot here, I'm really thinking about midfoot and the telenovicular joint as well. Again, external fixation, plate fixation, and then intramedullary fixation with screws, bolts. And then ultimately, if they're non-reconstructible, thinking about an amputation as a reconstructive option is also something we have to think about. And so intramedullary fixation, first we're gonna talk about the biomechanics of why I think intramedullary fixation is taking a big part of my practice in taking care of these patients. And then review the literature for reconstruction with intramedullary fixation in the ankle and then in the midfoot and the hindfoot. And so first let's define some of these terms. So what's the difference between a beam, a bolt, and a nail? You know, beams are essentially cannulated screws. They can be partial or fully threaded. Bolts are just solid screws, again, partially or fully threaded. And then thinking more if a nail is an intramedullary device that has screws to cross-fixate it. It may or may not have threads on the distal end. And there's hybrids of all of these, but these are sort of the terms that we wanna get down when we're thinking about intramedullary fixation. And so what is the biomechanics that make us think, you know, intramedullary fixation is better? It's sort of the same stuff we talk about when we are all residents doing tibial nails. You know, the bending moment is basically the force times the distance. And so the force experienced by a shorter device, a smaller plate, is higher than if you put a nail or a longer device. You have to think about total length and working length, which we all reviewed when we were studying for the OITE. And then thinking about larger diameter devices increasing the stiffness to allow us to have a stiffer, more rigid construct that will hopefully allow the bony area to heal, but will also allow those patients to hold up. Because we all know these patients are gonna challenge any device that we use. They're gonna push themselves to get on top of this device and use it as quickly as possible. And so thinking about using those large diameter devices. Again, also thinking about the strength, the bending rigidity is again, proportional to diameter to the third power. And the torsional stability is proportional to diameter to the fourth power. So these just, these circular intramedullary devices can hopefully hold up a little bit better. And so when we think about these, you know, in the tibia, we know that we wanna put a larger nail and how big a nail, but a lot of these devices are in the first metatarsal you know, how big a nail can we fit? This is a cadaveric study performed, which basically showed that up to 60% of metatarsal size eight nail would fit into the internal canal without getting into any cortical bone. And so just thinking about trying to figure out which device makes sense and how you use that device to allow you to have as much strength as possible, but as rigid a fit as possible. And so there's been some studies in the biomechanics of intramedullary devices. This is a cadaveric study. They compared one type of the beams to plating of the medial column. They use right and left as their controls and they denuded the specimens at each of the joints and then compared them biomechanically to see which one held up better. The beams had a more robust strength. They had a higher load to failure. And I think they had less reliance on the bone size and the bones quality in the sense that when they did this study, they looked at bone quality by DEXA scanning of these specimens. And there was an association with plating and the DEXA scanning to failure that wasn't seen with the beams or the bolts. Another biomechanical study was performed looking at four different Charcot specific implants and they did three point and four point bending. There was no clear winner here, but the article suggested to consider use of titanium as it better matches the modulus of elasticity of bone. I'm not sure that this article changes practice a lot, but it's sort of got us thinking about sort of how we want to think about these devices. What is the strength of these devices and how can we understand them better? And so thinking next about, do any of these devices or thinking about intramedullary fixation have patient outcomes? And so we'll look at some of the literature for the ankle. We'll review some of the literature for the midfoot and hindfoot together. And so first thinking about the ankle, this is just a retrospective review of 82 consecutive TTC nails at one institution, but it shows that the patients that we're talking about at baseline compared to normal patients with a TTC have a higher rate of complications, specifically of nonunion and hardware complication. All of these patients with Charcot, you know, often, or excuse me, not all of them, but a vast majority of them have diabetes, have an elevated A1C, and the diagnosis of Charcot itself was predictive of failure. And so being careful with these patients and understanding that you have to do a good job taking care of them and picking the right patients is important. This is another article published this year, and they're looking at the predictors of metalwork and nonunion after Hindfoot, Charcot reconstruction with a nail. They looked at 70 consecutive patients with 54 months of follow-up. They had a greater than 80% union rate, which I think is great. They felt that a good fit of the nail and supplementation within screws improved results. This was talked about by the Duke group a few years back. They looked at putting a nail posterior, or excuse me, putting a screw posterior to the nail to supplement. We've done that a few times. And they also noticed that lack of the media malleolus was predictive of failure. This is another study that's out there. This is a systematic review of 16 studies. The four were level three and 12 were level four. So lots of stuff. But basically when they got all of the review together, they felt that an IM nail was preferred if there was no ulceration for the patient. But if the ulceration was there, hybrid fixation versus an X fix alone was preferred based on the results of this systemic review, systematic review. That same group then took, excuse me, this is a different study. This is a midterm results of some Hineford arthrodesis with a retrograde intramedullary nail on 24 patients. They had a mean followup of 45 months. They had really good results. 23 of 24 went on to fusion. However, they're not out of the woods completely for superficial infection. So we have to be careful, but no deeper, no deep infection or return to the operating room was required. Again, this is that meta analysis that I was referring to before. So it took those four studies from the original systematic review that had comparative or literature. They combined them together and got 117 patients and basically showed if there's no ulceration present, an intramedullary nail was preferred. But if there was ulceration present, the X fix performed better. So it shows that the ankle I think is doing well, but what about the midfoot and the midfoot and the, um, the, the tail and avicular joint specifically. And so this is a systematic review of our current surgical interventions of Charcot neuro arthropathy. And basically it showed that there are still high range of complications, uh, an amputation rate of approximately 6%. Uh, there's greater than 40% complications. Um, and so there was still a significant problem. Uh, and this only had a few studies where they were looking, uh, complete beaming alone on these are very small studies, uh, you know, four patients, eight patients, seven patients. Uh, um, and so, uh, the external fixators however, uh, had more sort of higher level of patients. And so it's something to keep an eye on. This is a good study by the group out of Charlotte or out of Charlotte. They looked at 25 consecutive patients, uh, with intramedullary beaming of the midfoot. Uh, they had a good option for reconstructing to a plantar grade foot. Uh, half of the midfoot osteotomy is huge, but still had a high complication rate with 60% of patients having reoperation and up to 16% of patients went on to amputation. And again, pre-op full thickness ulcers were a risk factor for continued infection. And so again, is, is reconstruction at the time of ulceration going to be something we need to think about. Now, this is another study looking at seven patients, uh, with isolated, uh, beaming. Uh, they had three patients go on to amputations. They had no fusions, uh, and not enough to be used in isolation. And this is using a medial column support with a midfoot fusion bolt. Um, they felt it was insufficient, uh, to provide, but I think there's some factors to think about, uh, in the midfoot that has led to failure here that may not, um, that we can maybe address, uh, and improve outcomes. Uh, and so this is a systematic review of intramedullary fixation, uh, for midfoot, um, Charcot neurothropathy, uh, look at 16 studies, all retrospective. Uh, they looked at Charcot specific implants versus a control group of non-Charcot specific implants and a mean follow-up of 25 months. The study group actually did worse with complications, migration, infections, and non-unions, uh, of note though, they felt that the, the, this one, uh, device that was primarily used had some known documentation. And then when they did a follow-up study where they modified that device, uh, they felt that they got better results. Uh, this was by grip blasting, uh, the surfaces, uh, to reduce loosening. Uh, and it, uh, the initial concerns were improved. Uh, although I think we definitely need longer and more robust outcomes, uh, for the midfoot and the hind foot, uh, for Charcot. Uh, and so this is an interesting question of, you know, should we be doing this or should we just consider X-fixing, uh, these patients? Uh, this is a study, uh, a systematic review where they combined 23 studies, uh, 12 with internal fixation and 11 with external fixation, pretty good results for internal fixation, uh, with, you know, 275 cases with 90% success, but 6.5% ended up in amputation, uh, for the external fixation group, um, and which are likely more complex patients, more, more likely to have osteo at the time of surgery, a wound at the time of surgery had a lower amputation rate and a higher success rate. And so, you know, for, for, for me, it's thinking about this, there are really two types of surgeons. And I think it's similar to this. This is a video I saw the other day. It's a short video, but it shows that there are some dogs that really sort of love water. Um, but as you watch this video, I think these dogs that love water like dogs that like X-fix, but I'm one of those dogs that's sitting over there. I'm not good at an X-fix. I can't figure it out and make it work in my practice consistently. And so I need to find ways to do, uh, internal fixation. And I think intramedullary fixation at the ankle is good. I think intramedullary fixation in the midfoot and in the hind foot, I think we need to figure out better and get better results. And so some technical pearls for me, uh, at the ankle, I think shortening is okay. Uh, I think they need to be able to clear their foot. I don't do any 3d cages or femoral heads. Uh, there's a study, uh, that Meyerson published, uh, where they had a hundred percent non-union rate for diabetics, with a femoral head. Um, so I don't use these cages, um, uh, in my practice, um, for the ankle, if there's an ulceration, I think you got to at least start with an X-fix or get the ulceration cleared. Once the ulceration is cleared and the infection is cleared, I then think about intramedullary, intramedullary fixation if needed. Um, I think some technical pearls to think about, um, you know, the subtalar joint control is key. Uh, Mike Iannardi, um, uh, who I talked about, you know, with, uh, frequently, uh, if you, if you're considering an isolated medial column stabilization, considering controlling the subtalar joint at the same time to help keep that talus from rotating off of the, uh, calcaneus may be helpful. I think another pearl is you want to make sure you clear the infection, uh, rule it out if you're not sure if there's an ulcer or a talus, and then think about getting bone biopsies or treating infection and then coming back for, um, the complex reconstruction. Um, when you're thinking about the midfoot and the hindfoot, you need to get into the tail or neck to get that good bone. Um, I don't think you need to prep every joint along the way, but I do think you need to find the, the, the center of the deformity and use that area to make your osteotomy or your realignment. Um, and, uh, Babu Reddy, who's out of Dallas, who works with Jacob Zide from earlier, uh, uh, is a former mentor. And, you know, he talked about with me that beams are easier to use because the anatomic shape of the foot, you're sort of aiming for that common spot in the talus. Um, and I think it makes it, um, uh, you know, a way to think about it, uh, of reducing the foot. And so another technical pearl is thinking about this hybrid fixation, adding an external fixator over your internal fixation. We need more studies to determine the efficacy of this and when it's appropriate. And so going back to those cases, uh, with that 55 year old with a Charcot midfoot, definitely able to realign, uh, with a couple of these bolts and beams, uh, feel like we got a good result. Uh, and, and I'm hopeful that, you know, this will hold up long-term for that second case. Um, you know, took the patient to the operating room, uh, got the patient sort of realigned through that, the, the center of that deformity, uh, and then pass one of these newer, um, uh, nails, uh, to try to hold it in position. Um, but I do worry, you know, we didn't control the subtalar joint here. Uh, can it break and possibly be a problem later, uh, seeing already possibly some collapse on this x-ray. Uh, finally, just looking at the 75 year old with the Charcot ankle, uh, we're able to take them, uh, get them realigned, uh, and get them to fuse, uh, and get a nice result, uh, through a lateral approach. So, um, thanks for the opportunity to share some of my thoughts on this, uh, and I look forward to the questions. Terrific. Uh, thank you, Jason. Excellent talk. Yeah. Great. Uh, that's, I think I remember all the way back when I, in 1999, I did my fellowship 98 to 99 and Dr. Simarco was the younger Simarco. You guys know the, you know, you guys know the younger Simarco, Jim, but I was his dad that, um, was already at that time. We were doing intramedullary screws back in 1998 for, uh, Charcot's that were uncontrolled. And I remember coming to, um, coming to, uh, Asheville and I said to my partner, who was five or six years, my senior and Dr. Bailey knows him because, uh, we, he, he helped train him at Emory, but, um, and I, and he said, and I said, Oh, I'm going to, what do you say? What are you doing? I said, I'm going to operate on this Charcot foot. It's falling apart. He was like, what? He was like, we, we don't operate on Charcot feet, you know? And, and so, but this concept of controlling the, the uncontrolled, you know, once they, once they go to that ulcer, boy, it's a lot tougher. And so if you see them progressively collapsing, anything we can do to try to control that midfoot and plates and screws require bigger incisions sometimes, and that can be a problem as well. So terrific talk. And I think it continues to evolve and we continue to make, make it better for the patients. So that's a good introduction to Dr. Younger, who's being a stalwart. He's the last one on the list, but, uh, we put him there cause he's over in, uh, the UK right now. And he was getting his assignments for the British open next week, where he's going to be one of the, uh, hall monitors over there. Uh, and so, uh, so he's going to be over there shushing everybody. Uh, and, uh, and so, but he had some things to do today, but we appreciate him being here and he's going to actually talk to us a little bit about maybe some different methods to, uh, think about how we can fix this in a, uh, in a minimally invasive fashion. Thank you. Um, can you see my screen? Yes, we can. Well, thank you everybody for putting on this fantastic course. Again, thank you, um, Errol Kelly, Pete, for all your energy and hard work in making this happen. Plus the AOFAS staff, you know, this is just an exceptional course. So I'm going to talk about MIS Charcot correction. So big deformities and small incisions. Um, I'm going to, so just explain why we might go here. Um, so I, here's my conflict of interest. I do have some things here. Um, I will state that I have absolutely no royalties whatsoever with the Acumed fibula nail. Um, and, uh, I will feature here. Um, but I am a proponent of it. Um, so I'm going to talk about biology. I'm going to talk about wounds in patients with diabetes and why they might fail to heal. Um, basically the principle is if you don't make a wound, you won't have a wound issue. So I'm kind of simplistic. Um, then I'm going to talk about how you're going to achieve these surgical goals, um, in Charcot cases using percutaneous techniques. Um, so failure of the healing cascade, what's going on here? Well, non-union rates are higher in patients with diabetes with tibial fractures that's, uh, demonstrated in previous studies. And, uh, Sheldon Lynn, uh, and Mickey Pinzer have been great at explaining why that might be the case. Um, so he showed that the fracture callus is lower in controls, uh, uh, with patients, uh, compared with rats with diabetes. Um, and it basically, the fracture callus had less DNA indicating a loss of cellular response. Mickey and Sheldon correct, collected a whole bunch of, uh, patients that had diabetic Charcot fractures and they put the bone in and they did a LISA analysis and showed that they had less growth factors. Um, so basically, you know, as the, uh, sugar levels, uh, you know, the average sugar level goes up, you get a failure of proliferation of the osteoblasts and fibroblasts and the growth factors are impaired, uh, uh, beta, uh, fibroblastic growth factor, TGF beta and PDGF are all inhibited and lower in patients with diabetes. Um, there's also another sort of theory that Mickey Pinzer sort of mentioned more recently, and that is that, uh, when patients have poorly controlled diabetes, uh, the red cells give off free radicals and those free radicals are very damaging to the blood vessel wall. So the smaller the blood vessel, the more contact that the red cells have with the wall and the more likely you are to get damaged. So all micro vessels get damaged. So that's obviously we know about the kidney. We know about the toes. That's why the toes are black when the pulses are strong, but, um, it, um, and why it damages nerves, but it also damages the brain. And so when you're talking to these patients, you've got to educate them better because they're not going to remember what you're talking to them about. So what you're going to see in orthopedics is an increased rate of fracture and an increased rate of non-union. So both the bone is more likely to break and when it breaks, it's less likely to heal. And so that is shown in both the spine and the ankle. So when you see these patients and you say, why did they break? Hopefully you understand why. So, um, sometimes they break with no pain. Sometimes they just break, uh, at a much lower threshold than you'd have expected. So bone healing, uh, impairment was first noted in patients with diabetes in 1972. And they were also shown to have a longer rate of fracture healing. If you're looking through this table, what's impressive in this is that the biggest, um, um, P value here. Now, if you sort of multiple regression analysis is the way that you tease this out and try and work out what are the main factors and not concomitant factors as risk factors. And if you look here, the odds ratio getting into wound problems, uh, with infection within an open fracture is, um, three, almost four times higher in patient with diabetes. Now, diabetes is not a binary endpoint. The worse your diabetes, the worst chance you have of getting into trouble. And the best index of that is an HbA1c. So if you want to know how bad your patient is measuring HbA1c, the other is ask them about end organ disease. So those are the things to look for, but, you know, I mean, there's obviously combinations. So if your patient's got diabetes as male and a smoker, you're in big trouble. Um, so think carefully when these patients come in. Wound healing is impaired. That's been shown in cardiac surgery. Synotomy wounds fail to heal. And if you improve the sugar control preoperatively, the wounds are more likely to heal. So that's why if you can punt on these patients and get better sugar control, you're going to get a better result. Failure of wound healing is the Achilles heel of foot and ankle surgery. These are the things we see. These are the things that make us anxious, uh, in the clinic. And these are the things that causes the most amount of grief. These are just some of my grief wounds, um, that have caused me trouble and anxiety and just a really bad follow-up clinic. And this just shows some of the healing issues in patients with diabetes, the ulcers they form, the abnormality they get, and this is so unique to diabetes. And you've got to then think, why is this unique to diabetes? What's going on here that makes these patients different than all the other patients you treat? And understanding what's going on and the fact the skin doesn't heal and the bone doesn't heal will really help you out in understanding how you should avoid these incisions. So this is both the pathology and it is the complication. The pathology, obviously getting the ulcer in the first place. And I would challenge anyone on this, on this webinar to go and walk a hole in the bottom of their foot. You're not going to be able to do it, but all these patients can easily do it. And that's because their skin doesn't have the ability to heal, but we can make what's on the left look like what's on the right. And if we reduce the incisions, we can actually treat these patients successfully. So this was one of the earlier cases that I did with a trimal where I did percutaneous posterior mal, percutaneous medial mal and used a fibular nail. And we published on this a combination of a series from Edinburgh and Vancouver. And we showed in 26 patients, we had, sorry, 24 patients. We had one wound healing complication, the case you're going to see a bit later in this talk. So I get, unfortunately, a bit of a reputation of fixing these. This is one of our trauma colleagues who said, Alastair, can you please see this patient on an urgent basis? She's six weeks after a fracture. She's 69 years old. She has diabetes. She came in two weeks after the injury. She walked in it for two weeks and she had minimal discomfort. So, you know, is it shock? Oh, is it a fracture? Is it a fracture with shock? Oh, who knows? But she was disabled. And so he said, can you please see her? So I did urgently and she'd already developed a medial malleolar ulcer. She actually had a cardiac arrest in the cab on the way to the clinic. So I kind of sent her from the clinic to the hospital. And this is what she looks like. So this is started off as a fracture, you know, shock, diabetes, fracture, you know, is it a fracture in a patient with diabetes? Is it a shock or fracture? Who knows? Well, she got the retrograde rod nail. I put an extra fixation in these. I do this arthroscopic this one. I was trying to dorsiflex her. So I aimed the nail a little bit to the anterior cortex. She fractured there, but she still went on to heal. And I add a couple of full threads, you know, based on the sort of beaming concepts. And it's just going to give you better control of rotation. So I just throw in a couple of full thread screws as well. Here's another case. It's a patient that in 2018 looked like this. In 2020, he came to me and said, you know, like these guys aren't treating me right in this hospital I've been going to. I want my ankle fixed so I can go play tennis, you know. So this is a little education session, show them the x-ray, say, you're not going to be playing tennis on this. You don't have an ankle anymore. And if you're lucky, I might salvage it with a fusion. So arthroscopic ankle and subtalar fusions, minimal incisions, minimal wound healing problems, maintain the biology, and you get the fusion. So he's been back to see me recently. He's not playing tennis, but he still has a leg. This is a 59-year-old male, type 1 diabetes. He's an architect, well-educated guy. A1c was 7. He was on dialysis and he had slipped and fell. So is this an ankle fracture in a patient with diabetes or is this Charcot? Still couldn't really tell. This is what it looks like on the 3DCT. Obviously, the calcified vessels are a bit worrying. And then you look at the back of this distal tibia and you go, yeah, maybe Charcot, maybe a fracture. What do I do with this? Well, maybe I should have fused it right away. I didn't know for sure when I saw him pre-op. So I did this and I fixed it on both sides. And when I scoped him, the ankle was pretty soft. The cartilage at the back kind of trampolined up and lacked any bone support. So I kind of like went the course. This is his post-op CT, a bit worrying. At this point, his Achilles tendon was intact. Then the next thing that happens, he feels a pop in his heel. Now he's got a Charcot avulsion of his Achilles tendon. Now he's got nothing to hold his ankle in, so it starts popping at the back. So he ends up with the TTC nail as typical with the SPECT CT. He doesn't have a lot of action going on here because the cells aren't doing much. So he gets a retrograde rod fusion done arthroscopically. So everything on him was done arthroscopic. And he was the one patient who got a wound complication with his rod. He's also the one patient that went on to fusion. But this kept him mobile until he passed away with other complications and diabetes about two years later. There's another patient, a 76-year-old with a medial ulcer on the medicine floor. He's on antibiotics. This is what his x-rays looked like in 2005. This is what he looked like in 2013 with a sinus. So he went to the OR, debridement, arthroscopic fusion, and insertion of antibiotic loaded calcium pellets and successful fusion. And I know he achieved that because he came in this last year with his other foot in trouble and on dialysis. And I said, well, time to take your other leg off. And he decided to go to palliative care. So, you know, he got like 10 years out of this. So you can get away with a single stage if you keep the soft tissue envelope intact. This is another case, patient with diabetic Charcot, more advanced. And did the scope subtalar fusion, did the scope ankle fusion, removed the cartilage, retrograde rod, couple of additional full thread screws to hold it more rigid. The final construct looks like this. And he went on to heal. Another case is a patient in spring of 2014. She was in a peripheral hospital. September, she's beginning to collapse. She's got a job as a forklift truck driver. You can see this sort of almost avascular collapse of her met heads. Continued to be watched December, 2014. July, 2015, she looks like this. Then she ulcerates October, 2015, and then April, 2016. So she got this. So she was told that she needed an amputation. She found her way to Vancouver and she ended up with a midfoot fusion and then lo and behold, her ankle gets into trouble. So sometimes you fix one part of their foot and something else goes off. And sometimes you fix that foot and the other foot goes off. So migrating Charcot can be a problem. The only thing you can do to control it is education and good sugar control. So she ended up with a retrograde nail. She did get that infected. She got a nail exchange with antibiotic beads. She developed an abscess later. Partial fusion, but she continued to work through all of this. And then she got this abscess. It took everything out, more antibiotic pellets. She's now healed and she continues to work as a forklift truck driver. So you can keep these people at work and her concern was with an amputation, she wouldn't be allowed to do a job anymore. This is another patient with a midfoot Charcot. And so he had a percutaneous removal of plantar callosity and a lateral column shortening through the calcaneicuboid joint. I couldn't really work out how to get good fixation in or where my beams would go. We did a percutaneous lengthening or release of the tail and the vicular joint. Insertion of calcium sulfate with tobramycin beads. And it's just a simple X-fix on the lateral side to close it and removal later. There's another patient with a diabetic Liz Frank type injury that we dealt with by taking the Shannon burr and the wedge burr, followed the line of the joints, removed enough of the bone to sublux those joints back in and then fired some beams in. We don't have the stuff you guys have south of the border. These are actually screws from the 5'5 Synthes knee set. But anyway, it went up the pipe, the full thread. I use full thread screws in this because then you can grab as much bone as you can and that held together. This is another case where we did a percutaneous cuboid osteotomy. And this is really good to do percutaneously. You know, it used to be that with these ulcers on the lateral board of the foot, then if you're gonna do something simple, if you're gonna take off that lateral bone, big long incision to get your saw in, now you just make a little stab incision. You get your wedge burr in, you burr everything down, and you get a disc of bone you can then gradually remove. And so you've got a minimal incision and then a much lower risk of wound complication. So this is what it looked like before excision. You can see the gas and the soft tissue. So in this type of case, I'll take a pituitary ronger and drop in the calcium phosphate tablets, sorry, calcium sulfate tablets with the antibiotics in it. And this is what it looks like later once the resection has been done. So you can see how there's no longer prominence to the cuboid. This is another patient who has a percutaneous, a collapse of a lisfranc with poorly controlled diabetes. A1C was 9.6, and he also had a kidney transplant. This gentleman was an actor, and his question was, can I continue to do stunts? So, you know, education for him was to tell him that this foot is not compatible with doing stunts. So the first thing I did was deal with his infected third toe after we'd educated him for a while. I got his sugars under control and did a flexotonotomy and a phalangeal osteotomy. After a while, if you go almost a year later, we went back and we did midfoot fusions done with the scope. So we got to his first, second, and third TMT joints to breathe in more cartilage, went to his NC joint to breathe in more cartilage, and then created a fusion. And the hardest thing with these percutaneous fusions isn't getting the cartilage out, it's getting the screws in. It's just hard to get the right angles, the right starting point. And although you can get your beams in the right point to the distal end, it's a bit hard to get them in the right point of the proximal end. So anyway, this is where he ended up. His arch was better. He was straighter. We removed the hardware and he developed a non-union at the TMT level, or his NC joint was solid. He then underwent a claw toe correction and a aching osteotomy, his great toes rubbing on his second and causing, making his skin at risk. So, you know, he's done reasonably well. His foot is chewable. It has no further ulceration. His sugar control is better, and he remains implied in a different role, and no longer doing stunts. So what's the evidence? Well, you know, it's minimal. And I, you know, like a systematic review is a bit like when I go out to the yard and I clean up my dog's mess and I stick it in a big pile, it's still a big pile of dog's mess. It's not good research. And so we really need to get good research to put this all together. So my plea for everybody isn't to do systematic reviews or small case series. It's to figure out how we can do some decent research with some decent funding to really sort out what are the correct answers. And the hard part of this isn't doing decent research, it's getting decent funding. And I'm afraid what we do still is politically not attractive compared with all the other competing interests for grant cash. So we have to keep trying. So this is the outcomes of the primary tibiotaler calcaneal nailing for complicated diabetic ankle fractures, like one of those cases we showed. 27 cases of them salvage rate, 96%. Hospital stay of six days. Fracture union rate was 88%. The complication rate was 18%. So that's pretty good when we consider the case series that we're dealing with. And I'm not encouraging anybody to take an initial ankle like I showed this. So some of them you could see were clear Charcot ankle fractures. Some were clear, not Charcot ankle fractures and some were in between. And I would encourage you to if they're sort of in between to try and fix them percutaneously and learn the techniques. And when it's clear that that's not gonna work then do a retrograde rod. This is one of the original beaming paper essentially was Jim San Marco back in 2010 and lots has come along since, but again, really lacking any good statistical power. So in summary, when you're treating these try and improve the sugar control. Plan surgery without incisions. That mean a percutaneous operation doesn't mean a bad operation. So all of a sudden it's made into a good operation because you did it percutaneously. You got to think of your goals and you have to achieve them. So it means getting good fixation. It means getting good debridement, means getting good correction and then fixating it and not using percutaneous as an excuse to do bad surgery. They may develop other fractures. They may get hardware failure. You need to be patient. You need to spend a lot of time educating these patients. You should expect complication, but complications will be less frequent and less severe if you can do it percutaneously. So anyway, thank you everybody for listening. And I guess back to our moderator. Thank you very much, Alistair. Great talk. We've got a few cases to go through. Let me see if there's any questions from the audience, new questions that are out there. I don't think so. There was one question I think Alistair answered and then I'll just kind of read them out from that way that at least everybody gets a look at them. One is about, is there any concern with using fixed angle devices or locking plates for surgical reconstruction due to lack of compression and subsequent lack of bony healing? Dr. Younger's answer, which I think is appropriate, is that biology is much more important than the fixation technique itself. Obviously you have to have adequate fixation with whatever you're doing, but plates are more of a concern because of the amount of soft tissue stripping, bone blood supply and increasing incision size. But in general, my experience is the same, not all of these patients fuse, but if you can get them into a stable plantigrade position and then sometimes a stable non-union is satisfactory enough. If they have to use a crow boot or an AFO brace, that's better than amputation. Any idea of insurance? I don't know. Somebody asked about insurance and double operative brace after a crow boot. I don't know. That's probably best handled by the local prosthetist that knows that information. In an ankle Charcot case, if your patient happens to have a fibrous non-union or a fibrous union instead of bony union, will you stop there? Are you going to continue to pursue bony union? Do you accept a fibrous union? I personally accept them. Any difference on the faculty standpoint? Yeah, the only reason I would not accept it is if they start to collapse and you start to see, again, a change in their position and alignment that's going to threaten their ability to wear reasonable shoe wear. I think one thing, Pete, though, just a quick comment on that. I think people, when they see a non-union, think that you've got to open it all up again. And I don't know if the rest of the panel have had this experience, but when you open up a non-union and you're looking at the bone services, you kind of go, okay, what do I do now? And you kind of wave a curette at it and think you've done some good, and then you close it all up again. In fact, that incision hasn't really done anything except let you have a look at the non-union site. Hopefully it was read correctly the first time around. And it allows you to do some bone biopsies. So I've tended to deal with the non-unions peccataneously as well. So I'll get in there, take a sample. You can usually make a small incision, get a pejorative ranger or a jam-sheeting needle, take your biopsies, make a slightly bigger hole to put in your bone graft substitute, and then change the mechanics of your fixation. So if you didn't have, look at the x-rays, see if there's different angles, you can get a couple of full-thread screws around there to change the mechanics of the fixation. And sometimes I'll use two stab incisions, proximal and distal, slide a plate in and put screws in too if I feel that plate fixation is what's needed. But I try and leave the non-union site intact and not strip it down unless it's a situation where you think that the cartilage has been left behind. So that's typically how I deal with the non-union. So if you got it and it's a problem, it doesn't need to be opened up again. I also- Yeah, I will do that in some cases as well. Go ahead. From a biology perspective, treating it with an intramedullary device is gonna create that slurry when you drill or clean out, especially if you're gonna pass a long screw or even one of these nail devices, even midfoot or the ankle, that slurry you're gonna create is gonna go right to the non-union site and that's often gonna help heal. Yeah. And you can certainly also add, I've even had a few cases where I'll place almost like parallel drill holes, almost like if you took the cylindrical kind of, if you think of the star total ankle, you know, those cylindrical kind of holes in the distal tibia, I'll take a large drill bit, maybe a 6.5 millimeter drill bit and go on either side of the nail and just drill parallel drill holes through the non-union site and then use either bone graft, plus or minus, some sort of in the U.S. augment, which would be on label for hindfoot fusions or other types of, you know, I call them bone graft accelerants, whatever, potentiators, whatever we wanna call them to try to buy orthobiologics to try and stimulate some healing across that area and agree, Alistair, trying to minimize the amount of soft tissue stripping. And I will say, Jason, you pointed out that one study about the screw with the nail that Duke put out. I actually started doing that several years ago on my own, just because I, you know, if you think about it, you know, a nail is not always the most stable device. It's a load sharing device, not a stability device. And I do think some of these patients lack stability and it does a great job of supporting it down the central canal so that they can at least put some weight on the foot and they're not gonna collapse and the bending moment is better. But at the same time, it still sometimes needs a little bit extra. It's a little different than that patient who has two or three really good bone surfaces. They've got a calcaneus, a talus, and a tibia, somebody who's got a post-traumatic scenario and you're really, really locking those together and they've got great bone quality. Adding some additional screws, you know, Alistair's probably the king of that in terms of nickel. There are no nickel allergy patients in Canada under Alistair's care. But I will say that, you know, having been exposed to Alistair now and become good friends, his philosophical process and technical process of stabilizing and stability being highly critical to producing fusion. And that I think is something that we don't always appreciate. And by using sometimes nails or I'll oftentimes supplement my midfoot nails, you know, with additional screws as well. So I put a beam or a nail up the first ray into the talus and then I supplement that with additional kind of miss a nail screws that kind of obliquely go across the midfoot at various different directions to try to increase the stability of that area. Even though the beam is helping with the bending stresses and taking the stress off the bending component, it's still got a little bit of play in that area. So- There's two things to think about there. Just one is don't mix your metals. You know, it's hard to, I mean, technically speaking, if you've got stainless steel and titanium, you might be okay if the screws don't touch. I think you might get into trouble if the screws do. And again, you're dealing with a situation where things are likely to go wrong. And so I'd encourage people not to mix their metals. The other thing is that Sheldon Lynn has shown that heavy metal leaching might be a stimulator of bone healing. And so discussion about heavy metals and bone healing. So, you know, you're potentially more likely to get that from titanium. And one of the reasons why titanium may bond to bone better. So, you know, there's a few reasons to probably stick to just titanium in these fractures. And if you're, you know, if you start with something, if you start with titanium, you probably get more options as well. But just be careful not to mix your metals. There's one more question here. Dr. Younger from, did the patient, you presented a patient who lost their entire fifth ray. Did that patient develop a varus deformity in the midfoot and forefoot? And if so, how was it treated? When I have to take out a fifth ray, and it's all of it, then I tend to, you know, like originally I sort of said, okay, well, peroneus bravis can't be reattached. In fact, you can sort of reattach it. So I'll use an absorbable stitch in that case. So I'll use like a number one vicryl and put the peroneus bravis back onto the lateral board of the foot. I'll also do heel cord lengthening. Sometimes I will cut the tip post and not transfer it. And sometimes I'll do a tip post transfer if I think that the dissection is worth it. And finally, in some cases, I might do a lateralizing calcaneal osteotomy. So there's a number of things you can do with a patient with a fifth ray excision that will allow you to offload that area. So with those techniques, I've been better, but it's a really important thing to think about. And a lot of the time, these amputations are done, you know, by general surgeons or vascular surgeons, at least in our neighborhood. And they think of it just as a dead piece of meat. They don't think of it as a weight-bearing organ. And so, you know, the peroneus bravis is often left to fly. So that's my thoughts on that. You know, if the foot hasn't been thought of as weight-bearing, then these soft tissue elements get ignored. But if it is, or if you get it later, those are the things you can do. The first thing, obviously, is to get infection eradication and get wound healing. But you can take tip post, you can harvest it on the medial side through a two centimeter incision. You can pick it up on the posterior side of the leg with a two centimeter incision. You can pass it around the back using a pituitary ronger on the bone, bring it out in the peroneal compartment, and then bring it down and bring it to the fifth ray area. So with four, you know, two centimeter long incisions, you can take tip post and put it into the lateral border of the foot. I wouldn't do it until they've got good sugar control, and I wouldn't do it until they've got infection eradication. Those are some of the things you can do to deal with that varus alignment. Yeah, good point. And I've had some experience as well with some of these patients, you know, especially if they collapse through their navicular cuneiform complex, that cuneiform rides upward and they get a supination deformity of their foot. And so even after you fix them, sometimes they still have the tendency, and I've actually done split anterior tibialis tendon transfers as well. So I've taken that anterior tib and I've tried to weaken that medial side supination pull, and I've transferred it over laterally, and that's rebalanced some of the forces that wanna pull that foot into a supinated position, which leads to that pressure on the lateral side. And that's been very effective, not only in Charcot's, but also some of the patients who, for instance, may even have a high transmet or a transmet type amputation, and I've done anterior tib transfers in those patients, and that's been very effective at rebalancing some of those forces across the forefoot area. All right, we've got about 10 minutes or so. We can go to a couple of cases. Let me pull up my PowerPoint here. And- Mine's already been talked about, Pete, so you probably need to avoid that one. Yes, yes, I saw that. Yeah, I saw that, I saw that. So I'll do that one. Let me pull it up here. Hopefully it'll work. Let's see if it works. All right, let's see. Can you see that whole screen or not? Not a whole screen. All right, hold on a second. We'll do it again. It's like it has to go through this process. Still no luck. No, you're good. I'm good there. We can see it. Good, okay. All right, so this is I think a case from Jason. You wanna talk about this case? This is a rural diabetic. He's a farmer. He's been walking on this and he's just, you know, his daughter's like he's getting this ulcer over his medial mouth. And you know, how do you address this? This is just such a significant amount of deformity. It's the only time I've ever seen a lateral X-ray show me an axial of the calcaneus. And so I thought this would be one to get the group's consensus on sort of how they would address this. Do we try more non-op management? Can you control this in a crow? And then if you don't, you know, how do you fix it surgically? Kelly, what do you think on this one? You said he does have an ulcer already? Intermittent medial-based ulcer over that medial mouth. It's got that beefy red sort of, you know, granulation tissue. It goes away, he's good. Then it comes back. I finally got him to heal. And so this is obviously him at the time of surgery. I think if he's stuck in that position, it's gonna be tough to manage him with a crow or a cast as much as I would not want to operate on him. I feel like we'd be not far down the road before we'd have to. My initial thought is probably a telectomy and a hind foot nail and just shorten him because I don't think you're gonna get him corrected to straight with the soft tissue envelope, leaving, trying to reduce that t-list. That's just first, you know, trigger. Sure. Yeah, Alistair. I get a CT and I get a 3D reconstruction and see what you got to work with. There's often more bone than you think. And then I would be using a, I'd be doing a scope. You know, the beauty of a scope is the, you know, the shocker bone kind of scoops out and then you can work out what's still there and what is still there remains vascularized. And then I'd use a retrograde rod nail with a couple of screws alongside and some stimulation. So typically I'd use platelet-derived growth factor. I'd only use a frame if that ulcer was persistent and I couldn't get it to heal. Yeah, I'm like those dogs in Jason's video. I'm like sitting on the side. I hate frames and being in private practice, you know, taking care of those. I can do them, but taking care of them isn't just an absolute unbelievably royal process. And so I agree. I think, you know, although I certainly would have a low threshold to do a telectomy if once I got in there and if I found it, I found that if you do just an aggressive Achilles lengthening or, you know, just basically do a tenotomy of the Achilles, you could do a tenotomy of the peroneal tendons in this particular instance as well. And just kind of work the contracture laterally. Usually I can get this back underneath the tibia. On occasion I can't, but usually I can. And one of the other ways you can do that as well is osteotomize the medium allelis. And that kind of loosens things up a little bit as well. And you can kind of just shift the whole thing over and translate, you know, if you need a little bit extra. And I think Chris Miller taught me that. So you can do that. And so I think those are good. So, all right, so what'd you do? So even though I'm one of those dogs too, I ended up putting him in a frame. I just didn't think I could get enough correction. And I thought it would be sort of ironic to place that, but I mean, you can see how much deformity he had. So I went laterally and he had so much loss anteriorly that I just wasn't sure I could pass a nail. And so I prepped for a frame, we put him in a frame. And I think this is one of the cases why I don't do frames anymore. He'd come back, he'd have like dirt from his farm all over his X-Fix. His daughter was like, he's out in the field with his X-Fix on, walking on it. I mean, it's just like a, you know, a South Georgia guy who, you know, but you know, it got him to heal and you can see his x-rays at the last x-ray. He's three years out and he's great and he loves it. He's back on the farm beating on it, but it's just one of those ones, like the x-rays are just like, don't look great, but he got a reasonable result. Maybe you should get more of your patients to walk in the dirt with their frames on. Maybe there's some healing power in the dirt. No, it's amazing. But I think it does emphasize what Alistair said. You know, I call it, these patients have neuropathy and their peripheral, you know, the diabetes affects their peripheral nerves. Well, it also affects their central nerves, right? So they have neuropathy of the brain as well, right? And even some of these patients who are highly educated attorneys, doctors, you know, accountants, people who were very, very high functioning individuals who have diabetes with neuropathy, they just don't think as they really, some of the brain. So- I don't know if the rest of the panel have had it, but I've had a few surgical colleagues with diabetes and shock complications. And I, you know, I kind of, one of them, I said, you know, don't you know better to keep your sugars under good control? And his response was, I couldn't afford to go hypoglycemic at the OR table. So he ran his sugars high so he could work, you know? So just a little, you know, and then once you're always running your sugars high, you can't run them low. So it's a bit of a challenging situation sometimes with our own surgical colleagues. On Jim Simarco, once again, you know, I learned so many things from Jim, but one of the things he used to tell me is whenever something happens like that, a patient comes in walking on their frame, walking, whatever, he said, never get upset. He said, because all you have to do, your job is to give people the best possible medical advice. He said, what they do, they're doing, they will always act in their own self-interest. He said, you may not know what their self-interest is, but like that surgeon there, right? His self-interest at the time was he needed to keep his blood sugars up because he needed to stay in his job. And so you may not understand what the person's individual self-interest is, and you can certainly try to find out and always, you know, if you will be, I guess there was the recent Ted Lasso quote, you know, be, what is it? Be curious, not judgmental, right? Be curious, not judgmental with these patients because I don't think any of them have a wish to do poorly, but they just don't think well at times. And they have other things that may be motivating them that you're unaware of. So trying to understand your patients better in regards to that will make you a better surgeon and a better doctor. This is the one now that was showed, oh no, this is the one that's the other one that I talked about. I'm gonna skip that one and go to the past Alistair here. So we have time for, I think, one more. All right, so this was a patient that, is one of my patients, 45-year-old female, diabetes, two-month history of redness, swelling, warmth, was diagnosed with gout, of course. You know, comes to see me, she's got this progressively worsening deformity. She's got this bump that's kind of over the medial side and her x-rays are dramatically worse than her clinical appearance, right? But she's kind of not doing so well and she comes in and she says to me, well, there's this, you know, but she says to me, you know, this is really causing a problem for you where she's gonna get pressure areas, you know, she gets occasional small lesions. And even though it's not the biggest deformity in the world, it's causing her a problem. So I talked to her about exostectomy versus fusion. And obviously you saw the picture, I chose to kind of fuse her. And there were a couple of reasons I chose this case to present was, one would be, I guess, you know, if you did this, Jason, I think you made a point about going up into the talus, right? Because if you don't go up into the talus, what happens? I mean, I think you're just, you're collapsing again. It's gonna break at the NC joint. The neck, you know, is the strongest bone that we can get to. Yeah, you just have a higher risk. And so in this lady, I did not go all the way into the talus. Now I got away with it, but you'll see she collapsed a little bit. But more interestingly, the reason I brought this case was because, I got a pretty reasonable correction there. I did it MIS. So like Alistair said, this was the first one I ever did MIS. And the reason I did that was because I thought that the deformity was reasonable enough that I could try to do it that way. It wasn't like I was tackling the most difficult Charcot I'd ever faced before. And I don't do all of them MIS, but certainly some of them, I feel like I can get a satisfactory correction. You can get minimal incision, solid fixation. You can see, although there's a lot of them, they're all small. And I was able to get pretty good virtual alignment. And probably the only thing I wish I'd have done, like I said, was extended her up a little further because she had a little bit of additional collapse at her TN joint. Fortunately, she did okay and survived. And I didn't end up having to do anything additional. And she's in a regular shoe with custom orthotics at this point. I'd see her for other tissues occasionally as well. And so, but this also, but then here she is at seven months post-op. And so she's done reasonably well, but I always, I got a little concerned. She started to show just a little bit of flare there. And then this was a patient kind of different scenario, bigger collapse. Also there's the ulceration, right? Which I went ahead and did minimally invasive correction on this patient as well, where you morselize everything. And you just kind of, it takes a while. You just have to beat it all up. And I use the Liz Frank guide in this situation, along with a long bolt device and beam. I don't know which one it is, Jason, you can tell me. And several different screws across that area. And here she was with her correction, pretty good arch alignment and that. And she went on to do quite well with that. But I think, what I wanted to show was, definitely, you need to get up into that talus bone. I think they do better with that. And then if we go back, if I fire away through, hold on a second. Some of these, back up to here. And Jason made the point of, I've really gone much more toward, now these are the constructs I use most of the time. This kind of three-dimensional construct. Really, I get that subtalar joint. I've just found, I agree, that really getting that subtalar joint controlled has helped tremendously in having this midfoot component not break down. And so I couldn't reach all the way. One comment there, Pete, about your fixation, is I'd always go full thread, non-variable pitch. Right. Because that'll give you the most amount of fixation. So in that subtalar joint, you've got fixation all the way through the bone, all the way through the subchondral bone, and then all the way up into the talus. If you use a partial thread screw, you're relying on compression, and these patients don't have much to compress. And if the compression fails, you've got not much holding them. And so all of these, if you can put a full thread, non-variable pitch screw in, that's what I go for. I completely agree. Again, I've converted to the younger camp over the years, and I really do a lot more fully threaded screws in these patients. And you can see where I added some additional screws across the midfoot complex there, despite the fact that I had the beam in there. I don't, I in general, don't do second and third and fourth beams necessarily. I do more perk screws. I've just struggled to get those beams up the shaft and through the area and not break them and things like that. So certainly that's a technique you can use, but I haven't done that. So those are the cases that I had to show. We're at two minutes to six. So I wanna just clean up here and just say, number one, don't forget about your CME. I assume, I think Elena will probably send a, there'll be emails that'll go out and tell you how to do that. It's on your site there. You can do it right after you finish here, though I know it's been a long day. I wanna thank everybody who's hung in there for the last three days and today, especially a long day. I wanna thank the staff there. I wanna thank my faculty. I wanna thank Kelly and Errol, just a great job helping all the moderators and everybody and the attendees who have been here. Don't forget there are the on-demand sessions as well as all of these sessions. All of these sessions are gonna be on the PRC that you can go and watch them over again, if you wanna hear the talks again and the discussion. In addition, you'll have the on-demand sessions there that you can listen to the talks on how it's rigidous as well as trauma. And then I guess it's good we're finishing on time. It's pretty impressive after three days and each day we were able to finish on time. That's a credit to the faculty and the moderators that we were able to get everything done and done in an efficient fashion. We hope that you've learned a lot in this course and I look forward to seeing all of you in Quebec City for the annual meeting here in September. So if you haven't signed up, go to the AOFAS website and you can sign up for the annual meeting there. And we look forward to the feedback you'll get. You will get an online evaluation form. So please do your best to give us feedback as far as what we can do to make these courses better because we really wanna tailor the information to what you can use in your everyday practice to take care of these complex foot and ankle patients. So that's all I have, Errol and Kelly, anything? No, just thanks to everyone, especially the people who stuck it out till the end. You're on mute, Errol, you're on mute. Wanted to say thanks to everyone who helped out and our distinguished faculty, Kelly and Pete. Love you, man. Great job. Yeah, it was terrific, terrific being together and I'm glad we were able to get all these faculty members together. They did a fantastic job. So everybody take care. Have a wonderful last year Saturday night and the rest of your weekend. And we look forward to seeing you in a couple of months in Quebec. Take care. Thanks everyone. Have a good night. Night all.

diabetes

foot complications

ulcer

fusion procedure

Charcot neuroarthropathy

deformity

ulcers

non-surgical management

osteomyelitis

severe deformities

minimally invasive techniques

blood glucose control