On behalf of the AOFAS, I want to welcome you to the advanced foot and ankle course. Tonight kicks off three days of strategies to tackle the toughest cases. Thank you to the course chairs, Dr. Earl Bailey, Dr. Christopher Miller, and Dr. Glenn Shih for putting together such a fantastic course. Before we get started, I wanted to share a few housekeeping items. All faculty will share their disclosures during their individual presentations, and you can also find them within the virtual platform under speaker and then disclosures. This course offers a total of 11.25 AMA PRA Category 1 credits. Use the tile on the platform landing page to claim your CME at the end of the course. The broadcasts are being recorded and will be available under the on-demand recordings in about 24 hours after the broadcast. All on-demand recordings will be available in the one for your view, excuse me, for you to view in the future. To send questions to the faculty, please click on the Q&A tab in your navigation bar. If you're experiencing technical difficulties, please try closing your browser and logging back in the same way you did the first time. Lastly, we want to thank our sponsor of this course, Medline Unite. You can learn more about this company by visiting the exhibit hall on the virtual platform landing page. With that, I would like to turn over the program to Dr. Bailey to get started. Thank you. Hello. Errol Bailey here, and on behalf of AOFAS, we'd like to welcome you to the Advanced Virtual Course. We're very excited. We have close to 200 participants thus far, and we expect that to grow even more. I'd like to thank Julie, who's done a fantastic job at putting this all together, and I've had the best co-chairpersons and Glenn and Chris to help us put this together. I'd like to extend my thanks to them as well. We want this to be very open. We want to establish a camaraderie. We want you to ask questions in your question tab, and if the sessions run a little long and we don't get to your question, we will make sure that one of the faculty members gets back to you. We want all of our speakers to be up and ready to go, such that when their time is up, they can just roll right in and present their talk. We have one change in the program. Our first speaker, Dr. Doty, is caught on an airplane and can't do his talk, and so what we're going to do is just move everyone up. We're going to start with Glenn Shee, and then we'll follow with Jason Barreto, and then Jeannie Hugh is also going to change her slot and follow at the end, and then we will have a few cases at the end of this session to continue this case presentation type of format. So Glenn, you're up. Thanks, Dr. Bailey, and let me bring up my PowerPoint here. Can everybody see my slides? I think so. So my name is Glenn Shee, and I am an associate professor here at the Mayo Clinic in Florida. My topic today is to speak of is why does the top of my foot hurt? This is a dilemma for both patients and physicians alike. I have no financial disclosures, but I do want to disclose one thing. I don't want to be known as the weird nerve guy. We obviously have some straightforward learning objectives in this case. This talk is not going to be about statistics. It's not going to be about data overload. However, we will be talking about some anatomy that's relevant to painful midfoot, but before we do that, I want to focus on something that's important in the understanding of this talk. Essentially, the lower leg acts as a lever, type two lever. The fulcrum is located over the metatarsal heads. The body's load comes down through the plank with the Achilles exerting much of its contraction upon the heel, putting tremendous amount of pressure on the dorsal half of the midfoot joints. However, we also know that the midfoot anatomy is extremely complex. There is not one or two items that are pain generators. In fact, there seems to be more and more each time I operate through this area. This photo is aging myself now. This was probably closing in on almost 10 years. It's towards the end of my fellowship and learning from the greats of our society. I felt tremendous amount of pride as well as, I guess, oops, tremendous amount of pride as well as, I guess, confidence coming into my first job at Mayo Clinic in Jacksonville. But what was waiting for me was a 35-year-old woman with three years worth of dorsal foot pain. On the x-rays, it only showed perhaps mild degenerative joint disease of some midfoot joints, but the MRI was essentially normal. She tells me a story. It's a story that I can relate to. She was reading a book on her iPad with her child in her lap, and somehow she lost control of the iPad, and it fell directly on top of her foot. And she's illustrating here with her phone how it happened. So the edge of the iPad landed directly on her foot, and ever since, she had uncontrolled dorsal midfoot pain. She grabs a hold of my shirt in the clinic room and asked me to believe her, and she was actually a normal person. If I can think of a way to convince something that you're normal, that would not be the way to do it in a clinical setting. But regardless, I can see why it's frustrating. She has seen over 10 physicians in the past. She carries a huge list of diagnosis, anywhere from contusion to ligamentous tear to arthritis, all the way to psychiatric problems. Only one MRI, when she had a few months after the initial injury, showed maybe some clue that there was some soft tissue contusion on the dorsal mass of the foot. Now I work at a place that was founded by surgeons. These guys were confident. These guys were famous. I was none of those. My first week of work felt exactly like my first week of internship, confused. But I had one thing in common with the guys who founded the Mayo Clinic, is that I'm actually into learning. If I can summarize my favorite pastime, this guy is probably the spirit gift. When I didn't find any answers, I asked some of the elder generation to see if they have any idea. My dad actually clued me in that they have been denervating the wrist since the 1980s. It seems to be helping at least a subpopulation who cannot tolerate major surgery. Well, if we can assume that we came from the same hypothetical ancestor, then there has to be some similarities between our feet and our hands. So looking more into this, all the cartoons that I seem to come across show one similarity, one straight line down to the first web space, then the bifurcation where he innervates the first web space. That's the role of the deep perineal nerve. And it's not just in our cartoons. It's also in the drawings and illustrations across multiple different specialties. And this one is from the plastic surgery journals. So that takes us back to the basics. This is our simulation lab at the Mayo Clinic in Florida. It allows us to perform dissections many times with students and residents to learn more about anatomy. Once you get them interested, now you have a research team. What we found is that indeed, the deep perineal nerve does not just innervate the skin in the first web space. In fact, it gives off multiple branches, branches that go into the dorsum aspect of the foot into the capsules overlying the midfoot. When we look at which joints these branches went to, pretty consistently, they went to the second and third tarsometarsal joints, less so the first and fourth, and very rarely to the lateral joints. We published this in 2019. So now I have some ammunition. I call this person back. I have something for him, for her. Some anatomy evidence, but some surgeons, I told her, will view this as experimental. What I offered her was a consideration for a denervation procedure with deep perineal nerve neurectomy procedure. And I asked her, well, what other options do you really have at this point? We're reaching fourth, fifth year now. So I performed the procedure for her. And for the first time in several years, she no longer have that sharp pain on the top of her foot. And she wants me to be an expert in CRPS. That's not my intent initially, but really that made me think, is there another path to get to the same place? So what we're trying to treat is patients with pain and reduce their pain so they become more functional. It's very simple. Let's take a look at this case that also illustrates why this is important. This is a 17-year-old woman who came to see me for a third opinion, has been under the excellent care of several local orthopedic surgeons. She's a ballerina. She told me that when she was doing a kick, the top of her foot landed onto a bar that caused some bruising initially, and then subsequently followed by severe dorsal midfoot pain. And again, she carries a very similar list of diagnosis. Look at it. Contusion, stress fracture, capsular injury, early arthritis. And the one thing I really want to remove from her list is CRPS and pain syndrome in a 17-year-old. When she showed me the pictures of the variations of her foot, I can definitely see why some of these diagnosis exist. Her x-rays were unremarkable. Again, the one MRI image that shows some swelling in the soft tissues. So I thought that this was an injury possibly to the nerve. So I gave her an injection of the superficial perineal nerve. It gave essentially mixed results. She didn't feel too much improvement of her pain. But three cc's of lidocaine mixed with bupivacaine gave her up to 24 hours of pain-free state. Of course, when the pain did come back, I asked her to draw for me where the pain is now. And this is where she puts it. So I offered her a neuralysis procedure. Let me see what's actually in there. So of course, what I found was large amount of dense scarring wrapping up the deep perineal nerve. So I performed a neuralysis procedure. And then I thought about it. What have I done here? Effectively, I performed a partial denervation. I removed the little teeny branches, teeny tiny branches that went into the dorsal capsules of the midfoot. And I did preserve the first web space sensation. But effectively, I performed a partial denervation here. So she did come back for her follow-up at one month. I'll take that. Unlike almost none. So she's about 90% improved after that procedure. The truth is, not everyone's going to be happy with this. And in fact, you will have unhappy patients. I have several, if not many. Sometimes successful surgeries, in my opinion, successful surgeries result in unhappy patients as well. So can we use what we learned in the anatomy lab and apply it more broadly? Take this case. This is a 64-year-old woman who had over eight years worth of left midfoot pain. With selective injection, it was located to the second tarsometarsal joint. So I took her to the operating room and performed a second tarsometarsal joint fusion. Is it really time to celebrate? Because it looks good to me. But she hates it. She said that, I know I'm fused. And I read the report that radiologists think I'm fused. And in fact, I saw several opinions in our city that they said I'm fused. But I'm still in pain. So I got a CT scan just to be sure. Of course, the second tarsometarsal joint is fused. She does have adjacent joint arthritis now with moderate severity. There was no infection in her labs. I performed diagnostic injection of adjacent joints, which did take away some of her pain. So now what? So she can either live with the pain. She can consider adjacent joint arthrodesis procedures. Is there really another option for her? So this is the cycle that we are looking at. So patients come to see us as Worth Peak surgeons. We find a mechanical problem. We take them to surgery. And they can get better, but sometimes there's other things going on and they can get worse. And they go through the cycle again with pain management, different versions, whether it's physical therapy, desensitization, non-surgical management, or just the pain service. And then ultimately, they circle back and we find something else to do for these patients. So how do we stop this cycle? Remember that case because that person shares a very similar fate with this person. This is a 61-year-old woman who was actually an emergency room nurse at our hospital. So after a late night shift, she was going home in the early morning hours and she lost control of her car and she was involved in a motor vehicle crash. And so the ambulance took her back, straight back to the ER that she left. And this is the injury film on the left. Because of the damage, the continuation and delamination of the cartilage, I decided to proceed with a primary arthrodesis. And after nine months of healing, the patient describes to all of her friends, to me and my colleagues and my wife sometimes, that her foot feels like the left lower picture, any one of them, knife, pin, stabbing, pain. So now what? Okay. So, so now you have a nonspecific dorsal midfoot pain. Is it really due to adjacent joint disease? Is it neuritis? Is she developing some CRPS type of symptoms? Well, again, I got a CT scan. The union was achieved. Diagnostic injection of adjacent joints showed only partial relief of her pain and a deep perineal nerve injection gave her 95% relief, and she wants to know what to do next. Of course, this is the same cycle. What should we do? What should we do as orthopedic surgeons to stop this from progressing? Of course, for me, for these two patients, they both went, underwent a deep perineal nerve neurectomy procedure. This is the time to celebrate, in my opinion, because one year after this procedure for the first patient, her pain dropped down to one to two, at best, out of 10. She was able to return to work almost immediately after that procedure, and she now walks for exercise. That's what she wanted to do in the beginning. What about this patient? This is our nurse from the emergency room. I performed the procedure for her, and one year after that, she tells me that her pain is better, but it's not perfect, and her life is just okay, and I'll take that as well. Applying to the third case, this is a 72-year-old man. He comes to me with a history of 10 years worth of left foot pain, and really, he tells me I'm actually here for a second opinion. He lives alone, and he needs to walk for his ADLs, and the only thing that he can remember about his left foot surgery is that he doesn't want to do it again. He doesn't want the fusion again, if that's what it takes. Looking at his x-rays, I can see what is happening. He had what looks like a flat foot reconstruction, and now he's developing adjacent joint arthritis. So if we're going to do a fusion, which joints should we fuse? This one, that, or maybe that? Is there a limit? Is there a stop to this, or should we do nothing at all because the patient doesn't want any fusion and just hold our hands up and surrender? So for these very complex mid-foot cases, we really want to know, is there another way? So I choose to consider a deep renerve neurectomy. So typically, I draw all my landmarks, and I find the joint line. My incision is about five to six centimeters proximal to the joint line. I bluntly identify the superficial perineal nerve, and that's protected and retracted all the way through the case. I find the extensor house's longest tendon, and usually at this level, you're at the musculotendous junction. You can see right there. The interval is taken between the EHL and the tibialis anterior. I use a Galpi retractor. Once I find the deep neurovasculature, I use a freer to separate the nerve away from the vessels, and then a scalpel to excise approximately two and hopefully three centimeter of the nerve. Very carefully, I do evaluate the nerve after I take it out to make sure that it has vesicles in it and is not any vascular tissue. I typically do not perform this with a tourniquet. Well, it's not that hard to convince a patient to undergo a much easier recovery and still have some pain relief, and it's definitely much harder to convince another surgeon to buy into this concept, and the hardest person to convince whether or not this is a good idea was actually myself. Arun Kumar is one of our orthopedic residents, and we looked at some early outcomes of dorsal denervation of the midfoot for chronic midfoot pain secondary to arthritis. This was selected to be presented as a podium presentation at the AOS 2020. This is what I was hoping it would look like, but it was canceled. We still have some good data, so I want to share it here. If you look at that data, when patients started out, they had on average 7.4 on a pain scale and it dropped all the way down to 1.4 at six months, with the biggest drop within the first three months, which makes sense because if you're denervating something, they should have less pain almost immediately. This is how I feel when I published that abstract. What if I'm wrong? What if I'm making people worse, creating problems in the long term? We have seen this before in our society, but as orthopedic surgeons, then you'll be forever associated with something that didn't work very well. And then of course, I start to wonder, all those patients I've done this procedure on, do they regret it? What about their satisfaction? How satisfied are they now? And also one way to measure, I guess, would they repeat the surgery knowing what they've gone through or recommend it to a loved one? And what limitations do they have? One of our orthopedic medical students, Jose, who is going to be an incoming intern, did study this. Almost three years of a follow-up, we have 48 patients. About 80% of people were satisfied and 83% approximately were recommended to a friend. So we thought that this could be a reasonable alternative to orthodesis in management of dorsal midfoot pain, secondary to arthritis. And this is one of our first patients. It's a 69-year-old woman who was recently widowed when she saw me. She had two years worth of right midfoot pain. She tells me that, hey, I got two large dogs. I'm one of the leaders in our church and I drive. I drive meals on wheels and that's not going to stop. So can you help me? So because of all of that, she elected to proceed with the denervation option, the neurectomy, deep perineal nerve neurectomy. And I recently saw her for her five-year follow-up. But it's not for everyone for her all of her pain was gone, even at five years, but it's not for everyone we did have several patients with neuromas. We had several patients with incomplete reduction of pain unsatisfied that had to be converted to arthrodesis, and one case of infection. And I think it's because sometimes, especially the first cases, my incision was too distal, there's highly the high variable of the different levels where the deep neural nerve is, and also between people. There's high variability at the same level, this study, particularly was done at the Medical College of Wisconsin, looking at the location of the deep neural nerve at the same level in relationship to the artery. Even when you get a stump neuroma, there is a way to treat it. We know this from our hand surgery colleagues, and also our foot colleagues that presented a way of burying the nerve end into the bone. If you haven't read this article from 2002, I highly recommend that you take a look at it. It's a very interesting and simple technique. So midfoot, it's extremely complex, in my opinion, finding a source of pain, I rely often on injections, and also there are options, including the options that I presented to you in this talk, but to accept those you have to have an open mind. Thank you. Thank you, Glenn, that was excellent. We do have a few questions, and we'll address those after the other two talks if that's okay with everyone. Great job. Jason, I think you're up next. Awesome. Let me try to share my screen and get started. So I just want to thank everyone for participating and thank the organizers for asking me to talk. I'm going to give a talk about midfoot fusions, you know, getting them to heal, but really just trying to get an excellent result, like Glenn talked about having that patient come back a year later and being happy with the result. I do have some disclosures. I'm a consultant for Stryker, DJO, and C-Spine. I do get royalties from DJO and I'm an editorial board member for FAI and FAO. So we're going to present a couple cases. I'm going to think about some key problems I think with midfoot fusion patients, talking about getting an accurate diagnosis, talk about non-unions, think about nerve issues and pain. What are the wound challenges with this type of surgery? Think about some possible solutions and then review those cases at the end. So this is a patient I took care of recently. She's a 78 year old female, has somewhat of a rocker bottom deformity in her foot. She got bad OA across her midfoot, no trauma, but gets a persistent callous and pain and needed to do something. Second case is a sort of different type of midfoot OA. She's got a large bunion, but she's got pain at her big toe as well. And so how do you address the pain at her MTP joint? Do you do a TMT fusion with your midfoot fusion or do you address in an older patient with an MTP type fusion? Third case is not as much deformity, but again, you know, she, she has pain across her midfoot, OA at her midfoot. She has this dorsal bunion a little bit. And so do you address that? Do you not address that? There's no pain at her MTP joint. And then just the fourth case, she's got midfoot and MTP pain without deformity, more of an in situ sort of arthritis. And so how do we address this? And so let's think about the epidemiology a little bit. Midfoot OA is getting more and more common. 12% of patients over the age of 50 had symptoms of midfoot OA. It increases with age and it's more common with females. It also is more common with patients who are obese and they're more likely to be diabetic. And so this is going to be an increasing problem that we're going to have to continue to manage. And so this was one of the older articles talking about treatment of midfoot OA. This is an Anderson and Bohe study. They looked at 95 patients and 104 feet back in 2011. They had an 8% non-union rate, but they also had a pretty high re-operation rate, 25% hardware removal, 11 other patients had re-operations. So can we do better than this? And I'm going to talk about a bunch of studies, but I don't know that anyone has done better. But what are some of the common issues associated with midfoot arthritis? It's difficult to diagnose. Non-unions again are common. And I think there's four reasons non-unions are common. One, it's joint prep and anatomic factors we're going to talk about. There are patient factors that play a big role that you have to manage. You have to figure out what fixation works for you and you may have to think about graft. And then the last thing we're going to talk about is how do you deal with persistent pain? And so getting a diagnosis is always difficult. When thinking about midfoot OA, you want to think about, you know, where the midfoot arthritis is coming from. It could be post-traumatic like a previous Liz Frank. For primary midfoot OA without previous trauma, Meyerson and Schoen wrote this article describing four types. Basically in situ where the patient doesn't have deformity, patient with a bunion who overloads likely their second metatarsal that leads to them having some of those issues. Oh, sorry. Developing a rocker bottom deformity like that patient I showed earlier, or somebody who's related to a severe pes planus deformity. And so the other thing I want to think about and talk about is this naviculo cuneiform joint. I think it's underappreciated in our patients. I don't know when you need to add that into a fusion, but I do know that there's definitely patients who it still bothers. Other pathologies need to be thought about. Tibant tendonitis is one of those. Be wary of the corticosteroid injection for midfoot OA given blindly. I know I've seen at least two patients in my practice got referred into me for a Tibant tendon rupture after an injection and think about neuritis. And we'll talk about Glenn's study as well and how we address that. So first thing, key differentiators on physical exam to identify the OA. Piano key sign is an interesting one response to corticosteroids. We're going to show an article, but I patients have to do the finger test. Point to me where your pain is. Point to the spot. They almost always point to their bone spur along their midfoot. If they have medial pain or their pain isn't across their midfoot, I don't know that a midfoot fusion is going to be the right answer for them and so something to think about. So what's the piano key test? You push down on the metatarsal neck and usually get pain across the midfoot. I found this to be a pretty good differentiating exam finding for patients with midfoot OA. This is a nice article that describes it. For me, steroid injections are really a great diagnostic tool, but I think similar to what Glenn talked about, they're a good tool to manage patients who don't want surgery. This study demonstrated significant improvement in pain and function at four months and for non-obese patients that got up to a year of pain. I think it's a valuable tool, but I almost always have it done under ultrasound with one of my partners who are the non-op sports medicine at our group just to make sure we don't inject the Tibant tendon sheath. We're going to have another talk about the lateral column. All I can say about the 4-5 joint is it's difficult to assess and how does it play a role. This is one of the few studies that's out there, but in this larger study, they only had six patients with normal sensation and normal anatomy. So when do you include it in the fusion mass? I don't know is the answer, but I think it's something to think about. I like to debride the bone spur at the fourth TMT joint when I'm doing a second and third TMT fusion. I think this is an important thing to think about. We're all really good at prepping the ankle joint or prepping the subtalar joint or doing an MTP fusion, but I think a midfoot fusion is much harder to get to because we're working down in a hole and it's hard to see both sides and we always worry about taking too much bone. But this is a nice little study we're working on where on the right side, they use the curette. On the left side, they use more aggressive. And you can see with just the curette, you're not always getting through that subchondral bone. And so, you know, getting plantar is also challenging. Other things to think about is can we really compress these joints? There's other ligaments that are stopping us. And then if we're not going to compress as much, how do we fill that gap? Is it autograft? Is it allograft? And this is just showing, again, that slide we showed before. On the right side, using your curette only, we didn't get down through that calcified cartilage. On the left side, getting down through it much more aggressively, which I think is really important to get to this left side to try to get that to heal for patients. So I always wonder if true compression is possible. We have these deep transverse ligaments, all these muscles. No studies have ever shown if it's really blocking us, if you release these. But I always wonder about how much compression we really can get. And so it always makes me nervous in this case because of these other constraints. Next thing to think about, you know, after thinking about joint prep are patient factors. You know, we know that increasing age contributes to slower healing and we know that midfoot OA is more common in older females. We know that with age, you have to think about how can you optimize their healing? How do you optimize their blood flow? How do you optimize getting bone healing in that area? That type of thing. Smokers, you just can't do it. I won't operate on midfoot fusion on a smoker. They have to stop smoking for at least six weeks and have to have a negative nicotine. And I think this study really proves it. You know, the odds ratio for a nonunion went up, you know, five times greater in smokers than even in ex-smokers and non-smokers combined. So we've talked about the joint prep. We've talked about patient factors. What can we do at the fusion site to make it better? You know, you know, are plates and screws matter? Do we need newer techniques? Is nitinol the answer? Is intramedullary the answer? And does bone graft improve results, autograft versus allograft? What does the data show us? So in thinking about this approach, I like to do a dorsal sort of over the lateral aspect when I'm doing a two and three in isolation. I like to do this because I can get down and elevate the bundle. And I don't have to worry as much about the branch of the bundle that goes into the one, two web space. I think you got to do this wherever you're comfortable prepping the joints and getting good access. You really want to identify the neurovascular structures. Always let the tourniquet down prior to closure. Hematomas are a disaster. I even consider using for those patients who are oozy and I can't find a bleeder, adding gel foam with ramen to optimize. Adding TXA is something to think about. I don't think there's any data in midfoot fusions, but something to reduce hematomas is always important. So what about those constructs? When I started in practice, it was screws alone. That's how I learned in Dallas, you know, an isolated three, five screw across the joint in the lag technique. Always put the third tarsal metatarsal screw in the oblique view. So you make your straight across that joint. But is this really enough fixation? I think for some patients, yes, but for some patients, it probably isn't. What about plates and screws together? You know, this is a nice study looking at the combination of a compression screw and a locked plate. They had significant improvement in all their patients with at least two joints fused. But plates and screws were associated with a lower nonunion rate than cross screws alone. So it's something to think about. That same group did an additional biomechanical study, excuse me, where they showed that the plate and the lag, the plate and screw construct were biomechanically superior. So it's just something to think about. Plating systems. We can have all these new hybrid type plating systems that are out there that have compression and lock screws. Again, they don't have any improved rate since that original study from 2011, about an 8% nonunion rate. Overall complication rate was 17%. This is more of a study of Charcot patients, but just discussing intramedullary devices versus plating. There was no significance in biomechanical strength in this model. So I'm not sure alone. This is a reason to go to intramedullary fixation. Is Nitenol the answer? Another study, looking at Nitenol staple with and without a compression screw. They had 69 patients with 149 joints available for review. Again, only about a 90% healing rate, and they really didn't find any difference between their constructs. So what is the answer? I think no product is going to give you 100% union. You need to use what you're comfortable with. I've switched to 5-pole plates that I pre-bend. I fixate in a cuneiform and compress through the plate. But you want to think about when you're doing your fixation, do not dorsiflex. So I pre-bend these plates. You can lead to transfer metastatalgia, similar to what you get with a dorsal bunion with a lapidus, if you elevate them up. So just something to think about. When should you bone graft these? This was a survey done by Dr. Baumauer. They basically stated for patients who had a previous nonunion who are smokers or diabetics, I'm getting to the point with this type of surgery to at least consider some type of allograft to fill in that gap. Often, though, I'll even go into the calc and get true autograft. The volume of graft is important. This was a study. This is the original Augment study that they did a subgroup analysis. Christy Giovanni did this nice study. And basically, they were predictive. If there's enough graft material at your fusion site at nine weeks, this was predictive of healing. So you've got to fill the space. So if you create a space when you're doing your second or third TMT, any of those other joints in your midfoot, something has to fill that space. Either you have to compress the bones together so they're touching, or you have to fill it in with something, whether it's a bone graft substitute, whether it's true bone graft for the patient. But something has to fill that space if you want to ensure you're going to get healing. And then there's even a study on this. This is a study by that same group up at Harvard. They looked at 188 patients with 189 joints. They had 11% non-union rate. They showed that isolated plate fixation smoking and non-anatomic alignment were risk factors for non-union, but bone grafting was protective against non-union. And so this, along with the other work, has really led me that at a minimum put some type of allograft in there, like a demineralized bone matrix, to make sure that the osteoblasts have something to work across because they're not going to jump that space if you don't fill it in. Another interesting study that came out recently, biodegradable screws. They had no non-unions, but they didn't have a comparison group. This is a study for the future. Maybe this is the best of both worlds if a biodegradable screw can provide that sort of a cross, filling in the gap a little bit. I'm not sure this is the answer completely, but it's certainly something to think about in the future. I think Glenn's study is really interesting. Do we need to denervate the midfoot to get successful results? Like he talked about, 80% successful, but 10% of patients still wish they had an arthrodesis. My question for Glenn, and I'm going to ask him today, is should we consider denervating the midfoot when we do our fusion procedures? Something to think about. So the key points, make sure you get an accurate diagnosis. You want to make sure you know those key exam findings. Utilize your diagnostic tests. What hardware should you use? Choose what you're comfortable with and what you're confident with, and that'll let you sleep at night. Consider more rather than less. Newer materials and techniques are not as important as appropriate prep and filling the gap. So doing a good job prepping the joint is more important than whatever plate or screw or device you're going to use. I have a low threshold to graft, allograft versus autograft is surgeon preference. What is the future of the midfoot? Do we add biologics at some point? Or do we think about denervating? I'm not really sure. Let's talk about those cases. So that 78-year-old female, persistent callous, we took her to the operating room. We addressed her alignment a little bit. Probably could do a little bit better to get Mary's angle back, but just did a plate and screw construct across one and just screws at two and three. That patient with a large bunion, how do you address a bunion? Do you do a combination, midfoot fusion or MTP fusion? She elected to have an MTP fusion. I added this home run type screw. I do think it makes your construct more rigid if you're going to use screws alone across the midfoot. This is a patient with no MTP pain, but isolated two, three TMT pain. Just a screw construct, did excellent. Really pleased with her result. You can tell, though, I took bone graft from her heel to try to optimize. Lastly, is the 77-year-old with MTP and midfoot pain. She had a little bit of hallux rigidus. She elected to proceed with an MTP fusion. I tried to use a newer technique. I was like, oh, I read that paper on night and all staples and cross screws, and let's see if I can make it work. And, of course, she gets a nonunion. You can see here on CAD scan, the third joint didn't heal. So I had to take her back and bone graft her again, and finally was able to get her to heal with a compression plate. I thank everyone for listening, and I'd be happy to answer any questions later. Thanks. Thank you, Jason. We're going to have some questions for you, I'm sure. Jeannie, are you ready to go? Are you there? Dr. Hu? Yes, I'm here. Sorry about that. All right. There we go. Okay. Let's see if I can do this. All right. Can you guys see my screen? Here we go. Not yet. There you go. All right. Okay, thank you all for attending this, and to Glenn and Dr. Bailey for the invitation to speak. So I'm going to talk about the lateral column because it's often, you know, kind of a redheaded stepchild, although very important in the midfoot, and so we'll discuss why. All right. I don't have any disclosures. We're just going to, this is a quick talk, so I'll go, you know, into some pathoanatomy just real briefly, and then really spend some time on some cases. So as you guys know, you know, there are three columns in the midfoot, medial, middle, and the lateral, and the lateral column, it's so important because of the increased motion has, relative to the medial and middle midfeet. And there have been studies, biomechanical studies that show, that have shown, you know, the different degrees in the sagittal plane, and rough averages are listed here. So you've got the lateral column of the midfoot, you've got your fourth and fifth metatarsals, the cuboid, and the calcaneus, and the different joints that are involved and that provide that extra range of motion in the midfoot, you know, or the fourth and fifth metatarsal joints and the calcaneus cuboid joints. And because of that extra motion, that's what allows us to accommodate uneven surfaces. Sometimes you'll hear it's the shock absorber of the foot. And, and so very important when considering definitive treatment for trauma, traumatic injuries to the lateral column of the foot. This is, was, there have been multiple anatomic studies and recently looking at the facets of the fourth and fifth tarsal metatarsal articulations. The cuboid bone is very important as a cornerstone of the lateral column, it bridges the metatarsals to the anterior process of the calcaneus. And so it's important in, as far as its role in providing length to the lateral column. And also, because it does articulate with both sides is, it's going to be important in the motion at that, about the lateral column. And, you know, various studies, looking at the motion about the tarsal metatarsal and calcaneus cuboid joints. And this study is probably the most referenced in terms of when we look at the lateral TMT joints. And you can see on this graph how compared to, you know, the medial column has some motion, the middle column having not really any, and then laterally significantly more motion relatively to the other columns. These are additional studies that have shown that have supported that finding. So, let's talk about different injuries in the lateral column. So, as I, you know, talked about, it's made up of the metatarsals and the cuboid and the anterior calcaneus. And so, the spectrum of injuries are going to expand from tarsal metatarsal joint, fracture dislocations, which can be in association with your Lisfranc injuries. You can have just fractures to the cuboid or fracture dislocations about the cuboid. Then we all know that the nutcracker injury that is referenced for cuboid fractures based on the most common mechanism of injury and the resultant shortening of that lateral column that you can see with such injuries. Moving further or more approximately, you can see calcaneo-cuboid fracture dislocations. I throw these studies up just to point out that you can see the literature on these injuries is very much case reports, case series, not much more than level four evidence as far as outcomes and when talking about different treatment modalities. Moving on, this was a great paper on cuboid dislocations associated with Liz Frank injuries. Then another series of papers that touches on a unique injury where you can see basically failure through not only the calcaneo-cuboid joints but also the navicular cuneiform joints. It's funny because each of these papers say it's a rare injury, but it's been talked about since historically it's been seen on numerous occasions. Then finally, the isolated fractures to the anterior process of the calcaneus. How do we treat these? I want to just touch on principles of treatment when we're talking about the lateral column. We want to primarily restore lateral column length. The reason for that is if you get shortening, you can get this abducto planus deformity in the foot. The reference is greater than three millimeters of shortening would push you to do something operative to improve that. Also as expected, you want to restore articular congruity, so less than two millimeters of step off at the articular surfaces. Restore the stability of the Lisfranc and Chopard joints, even as a support to the medial side of the foot. Then finally, when doing this, we're going to do it with rigid fixation but without compromising range of motion at the TMT and CC joints as best possible. Your options are varied because we have a very heterogeneous group of injury patterns. Ranges from K-bar fixation, screw fixation, external fixation, internal bridge plate fixation, and then something to think about is the use of bone graft as an augment to your fixation. We'll go through a few example cases. This is a young Navy corpsman who sustained an isolated injury to her foot that presented 10 days out from injury. She was otherwise healthy and this was closed. Her soft tissues were appropriate at the time that she saw us. You can see here that something does not look right about the calcaneus and so to get a better depiction of this injury and some preoperative planning, there was a CT scan that was obtained. This shows us the extent of her fracture. She meets operative indication for intervention based on articular incongruity and the loss of length. Because it was isolated to the anterior process, I fixed this with just ORIF, essentially. The cuboid was fine and so that was fairly straightforward for her. Moving on to other papers on operative fixation of these injuries, this is just discussing when you have concomitant Lisfranc injury and injury to the lateral tarsal and metatarsal joints, what kind of fracture fixation pattern are you going to use, again, the lateral column you want to maintain motion so you're going to avoid primary arthrodesis and then even ORIF is not really advocated in order to preserve the articular surfaces at those joints so K-wire fixation is an option and so this paper talks about that. This was an example of where there was instability at the tarsal and metatarsal joints on the lateral column as well as throughout her entire midfoot. This was a motor vehicle accident in a sedentary woman who she was otherwise healthy, nonsmoker. These were her injury films. We know she's going to need surgery but for preoperative planning, I got a CT scan. Three of these x-rays, these radiographs in here because this is how she presented and then in the ER, she was splinted, of course, for soft tissue rest and unfortunately her medial column instability was accentuated by that but it just goes to show that the instability can be hidden and so certainly stress exam intraoperatively is important if not already done as in this example while she's awake. We, of course, did not want to leave her there. We got a CT scan. The image that's important to look at here is just that sagittal view where you can see some step off at the cuboid and so with her, my focus was on her medial column and trying to get that stabilized. I did elect, given her age and the energy of her injury, elected to do a primary arthrodesis of her medial column and then once I got stability of her metatarsals and her middle column, I was able to build to that as far as stabilizing her lateral column. Because she was shortened at the cuboid fracture, what I did was use K-wires, 1,6 K-wires to basically pull her metatarsal out to length and then pass those transversely to the adjacent metatarsals. An option here, and I did not do this in this patient, but in retrospect, filling the void in the cuboid where the fracture was impacted would have been wise to help maintain that length when these wires came out. So I just show this case just to show you that so postoperatively, it looks like she might be coming back a little bit, shortening a little bit, but these are her three-month post-op films and she's still in her recovery, so we'll see how she does, but I fear that she might fall back a little bit, shorten a little bit there at the cuboid fifth metatarsal joint, but we'll see. So that injury was more isolated to the tarsal-metatarsal joint there. There's been description of bridging plates that help you gain length and distraction with internal fixation and first described in 1984, also referred to as biologic planing. It's a nice alternative to external fixation because you don't have that extensive fracture stripping, or I'm sorry, it's better than opening it and fixing the fracture and trying to address a combination and so the benefit. So it benefits you from that, not having to do fracture stripping, but also better than an external fixator because you don't have to worry about pin sites and potential infection there. So this is a nice option when you have, again, severely combinated fractures, if you have significant shortening of the lateral column, and typically you're going to span from the calcaneus, the anterior process of the calcaneus, or a little more proximally to the fourth metatarsal base, and I usually would do the fourth as opposed to the fifth, just given the risk of a Jones fracture on the fifth. Sometimes these patients can have concomitant, you know, fourth metatarsal fractures, and so you kind of, you may have to get creative with this, but the whole point is just to span what usually is, you know, a comminuted cuboid fracture dislocation. And so this is an example of a young man, he's in a bad motorcycle accident, polytrauma, and this was among his many injuries, and he presented like this. So clearly, you know, something's going on throughout his entire midfoot. And so the good trauma, or my good trauma team partners took him to the OR initially and actually put on this nice external fixator to, you know, get him out to length in anticipation for his future surgery, for some soft tissue rest, and pinned the dislocated cuneiform so that it wasn't compromising or being a threat to his skin. And then after, once his soft tissues cooled down, I was able to take him back and he was very unstable throughout the medial, middle, and lateral columns. So I elected to span his medial column as well as his lateral column there to try to get length on both sides. If you can remember from the injury films, he was pretty much pancake smashed medially and laterally, so. And then this was him at six months, I have not yet seen him since, so he's out there walking around with these plates. My intention is to remove these at six to nine months and then let him be on his way. So both the medial plate and the lateral plate. This is a case of my good partner, Dr. Bettegrew, who, when she was over at Fort Campbell where she's taking care of a lot of our active duty infantry soldiers and combat arms guys, this was a patient she saw, a 22-year-old gentleman. I think it was a training injury, and so these were his injury films. And so obviously he's got some metatarsal base fractures, which should always kind of get your spidey senses up in terms of some sort of midfoot instability injury, Liz Frank injury. And so, you know, the rest of the midfoot needs to be interrogated. A CT scan was obtained to further, you know, characterize his injury. And so what was interesting on this one that she shared with me was that you could see the cuboid, you know, the cuboid has got quite a good amount of displacement and impaction that, you know, I didn't really appreciate on the injury films. So again, going back, you know, you could look at those films and say, oh, cuboid doesn't look that bad, but sure enough, you know, on CT, he's got that impaction. So she took them to the OR, and I like what she did here in putting, using that whole, that idea of spanning, you know, a bridge plate to span the joints and then put some bone graft after correcting that impaction distally. And so because the plan was to take the hardware out, we have the fortune of having a post-operative CT, which shows that, you know, she did a great job here. And so cuboid's out to link, looks nice and healed. And so that was removed and he's nice and stable there. So moving on, other options for fixation, you know, there was a recent study that was done where the group looked at K-wire versus transarticular screw fixation for the lateral column and they, you know, of course it was, you know, just a retrospective case series, but they did show that the, if you look at the second box there, that the disuse osteopenia and the post-operative pain was less in the screw patients, as opposed to the K-wire patients. So something to think about, and these patients did undergo hardware removal, but they left those in, you know, a little bit longer as opposed to the K-wire patients. This is another, just, you know, to let you know that these, some different techniques are being used out there. Not again, not necessarily standard of care, but this is, you know, has been shown in a series of five patients using kind of a suture anchor fixation with fiber tape or braided suture across the joint. Now these patients were, this was a series of patients who failed non-operative management and they had, this was not a high energy population, high energy injury population. These patients were, you know, these were subtle injuries, but had failed, I think the average time to surgery, yeah, it was nine months and, you know, the typical mechanism was an inversion sprain, but they all had responded to, you know, diagnostic injection. And so they targeted the pain to be at that joint and imaging supported subluxation at the fourth TMT joints. And so they showed, you know, with a mean follow-up of a little over a year that these patients were able to get back to activities in about four and a half months and they had no complications out there. And then not too long ago, there was an interesting study that, you know, I've actually thought about this in my own practices, you know, because there are often times when you'll have a terrible medial column injury and you'll stabilize that. And then the lateral column, you know, is stable with that and I don't, I end up not having to put in any hardware. So this group did a nice job looking at their series of Lisfranc, you know, injuries, midfoot injuries, and of the 113 injuries that had, that involved the lateral column, only 13 of them underwent K-wire fixation. And even following, you know, a final follow-up, they didn't see any loss of lateral column alignment in those patients. And so, you know, that actually goes in alignment with, there are some recent, there's some studies that looked at the plantar lateral ligaments and that show that from the second to the, you know, fifth, the long plantar ligaments are in continuity. So if you stabilize that medial side, you may not, and there's no disruption in between. Oftentimes you don't have to really do anything to the lateral tarsal, metatarsal joints. Okay. So I just went through this little bit in here, as far as the sequelae from, that can happen with injuries to the lateral column, namely post-traumatic arthritis. And, you know, as I said, you know, and as has been dogma, fusing, primarily fusing the lateral column is, you know, not recommended. So many studies here looking at fusion of the lateral column in a post-traumatic, you know, situation now in a Charcot population, you know, that's different if you have a rock or bomb deforming, those kinds of things, different, but in this post-traumatic scenario or acute trauma scenario, you know, the recommendation is not to fuse these joints. Reason being is, you know, the risk of nonunion, stress fracture from the added, you know, stiffness to the column, you know, overloading of the lateral column, metatarsalgia, hardware failure, and, you know, adjacent joint arthritis and, you know, and resultant inability to accommodate the ground. So exacerbating all those things. So, the, just to go, you know, run through options for salvaging, you know, post traumatic arthritis and, you know, the patient especially you know if they had their injury at a young age. They're in their, you know, midlife and they're, they've got, you know, bone on bone arthritis there are painful. There are some salvage options. These. I will say the literature and the, you know, the evidence backing up these things are scarce, and we have, we don't have a lot, any long term, you know, real good long term follow up but. But there are, you know, reports of these things. These options being used so there's tendon interposition arthroplasty ceramics here interposition arthroplasty resection arthroplasty and even arthroscopic debridement. So we'll just run through these real quick. These are just some. I want you to finish those up for us real quick so that we can get to. We have. Yeah, so this is just, yeah, given you guys can see on there the screen. Some good results but again no not no long term follow up same thing with the ceramic arthroplasty the spherical balls. Longest follow up meantime was 34 months. And then this was a resection arthroplasty. If you get the idea it's just, you know, removing segment of that bone dorsally. And again, this was only six patients. And then finally, these are some snippets from the arthroscopic management of TMT fourth and fifth TMT arthritis, small series, not, you know, kind of information but are kind of information but good results, more to follow there. So, in summary, lateral column injuries, often you know occur, not in isolation. There's a potpourri of injuries, spanning from the TMT to the, you know, anterior prostate calcaneus and cuboid treatment goals restore link without compromising motion. You know, consider standing with temporary internal or external fixation. Shortening of the lateral column will lead to an abducto cleanest deformity. Fusing lateral column can risk metatarsalgia and lateral foot overload and motion sparing salvage options are limited and, you know, the evidence is also that way. So thanks for your time. Those are all fantastic. We do have a couple of questions. Glenn, can you see yours, or maybe we should just repeat those out for the, for the audience. Yeah. You want to take over would you like for me to do it. I'm happy to, to read them off and then see, see the ones are addressed to me, and knock them out real quick. The first question is from Eric. Basically he's asking, do I typically just do a diagnostic injection or do I do a trial steroid injection before surgery. I assume the questions, talking about the diagnostic injection of the deep inner before surgery. I assume that's the case. I don't put any steroids. In the injection, it's purely a diagnostic test. There are some evidence to show that steroids before a total knee arthroplasty predisposes them to research will infect a risk factor for surgical infection. Within the three months period. So these patients are coming in, they just want to diagnose this first. So I do put place a fast acting and a long acting anesthetic in there, so the patient can walk around the hospital or in their house, walk their dog, so they can have an experience and usually I have them, because people forget, usually I have them report to me the following day and how much pain relief they got from the injection. I have used steroids. Before, trying to treat one of my stumped aromas. I do that I do that under ultrasound. It seems to be an anecdotally at best 5050 shot in relieving stumped aromas. Next question comes from anonymous. Do you have any issues with neuroma, yes, and issues with CRPS after transactional nerve. I have luckily not had any CRPS cases after this but theoretically you can get CRPS from a cast. So I suppose it's always possible, but but not necessarily experienced in this case, and also if you look at the literature on, again, from our hand colleagues that CRPS is not exactly one of the highest risks from that procedure AI and PIN denervations. So hopefully it doesn't affect the foot, all that much otherwise I'll be in trouble for the next 10 years. Going down the line. Also from a anonymous attendee. Do you think that the deep inner direct me can predispose a person to sharko joint. That was actually one of my biggest fears, initially when I started this process. But if you look at what we do know what we do know is that we don't see charcoal joint formation in the wrist, even after 20 years. What we do see is advancement of arthritis that probably would have naturally advanced. Okay. That patient I presented he she was one of many. She has some progression of her arthritis in the midfoot, as we expect natural history of arthritis to progress over time. Okay. But we don't necessarily see the typical charcoal destruction. So I think if you look at charcoal pathology, right, whether you're a neuro vascular theory, supporter, or a micro trauma neuro traumatic theory supporter, neither of which are that much supported by removing a single nerve, when the plantar sensation of the tibial nerve is preserved and large amount of dorsal sensation is preserved by the superficial perineal nerve. Right. And also again, charcoal has more than just neuropathy of a single nerve, it has to do with autonomic neuropathy and perineal react reactions as well. And also, I would argue that we have tons of patients out there with foot drop traumatic perineal injuries. They're walking around with AFO fully weight bearing on their foot, and we don't see large amount of charcoal in those patients. Right. So for all those reasons, I do keep a close eye on them, I do keep an eye, I do keep an eye on them with x rays, I awarded them for five year intervals to keep an eye on how they're doing, but I have not seen those existing and then there's several other questions that just came up from Brian he says, is the is your diagnostic injection to the deep inner done with ultrasound guidance. While you can do it with ultrasound guidance, but I do it without one, and typically I find I go to the area approximately six centimeters proximal to the ankle joint. direction, I use a 25 gauge, one and a quarter inch needle, so very thin. And I go, I go from the anterior lateral side, down to the tibia, and I pull back, and I insufflate, and usually that hits it. So I don't do it the ultrasound guidance, although some people, some of my colleagues do use ultrasound. And there's another one actually, when you're doing. Yeah, so so so these are two of the same. Do I use ultrasound. No, I don't personally, but, but you can, and my colleague does use ultrasound for his injections for diagnostic purposes. Thank you. We also have one other. A few other questions. One is to the panel. How do you treat isolated base of the fifth metatarsal pain. When patients come in, and the x rays are normal MRI seems to be normal, yet they continue to complain of pain in that area. So I have patients often a cavus patient who's overloading. I, you know, you got to figure out if the hind foot is supple. If you can offload it with orthotics first metatarsal cut out those types of things. Otherwise it's sort of offloading with, you know, padding and that kind of stuff until you can get a better isolation if this is a stress fracture versus just, you know, a callous overload management. But the first thing I think of is a cavus foot. Janie, any comment. A component of metatarsus adductus. Their hind foot might be normal but they have this metatarsus adductus that they can cause that. And again, just like Dr. Barrett who is saying is offloading would be my first, first bet. It's interesting that his MRI is normal. Right. That pain. So, no stress fracture yet. Sometimes to the panelists. I'll find these people have a fifth metatarsal cuboid synovitis. And I'll do a selective injection into that joint blindly, but you can pretty much. There's a lot of motion at the fifth metatarsal base so you can kind of put your finger on that joint and really feel where you are. Put a little injection in there and if they hurt, I will add a little steroid to that area. Yeah. A couple of our athletic trainers, especially with tech, and some of the other high level sports teams talk about, you know, manipulating the cuboid after injury and getting it where it feels like it's stuck for patients. I send them to the therapist and the therapist seemed to be able to do excellent. We've also done, you know, some PRP in that area too when they've had a sprain of that four or five TMT cuboid joint because it's not something you can fix but it's something that gets inflamed and irritated. Like you said, there was the, there's a group in Dallas. doing the, this arthroscopy of the four or five, you know, TMT joint, and they described doing like a license of adhesions and, yeah, cleaning, cleaning up, cleaning up the joints with some good relief and patients I think you know as a last resort if you have, especially if they're responding to injections that might be something to consider. Thank you, Jason I have one for you as well. Sure. I do a fair amount of midfoot fusions. And it's very difficult to determine which joints to actually fuse. Yep. I do selective injections and I don't know how accurate. Those are, and I'll get in there and the first and second TMT. Clearly, something needs to be done and I look at the third and I go, ah, I don't know, because I don't really want to create another joint that has to be fused if I don't have to because of potential complications. You know, what, what do you do clinically when you're in there and you're looking, trying to make that decision I think I think it's interesting right I think it's a lot the discussion before with the patient right. If you're like I can be super aggressive and, you know, increase our rate of complications with a second incision, and, you know, increase our rate, but maybe never have to go back again, or we can pick the most painful joints, one incision, but hey if this other joint gets painful later to go through it again and let that patient decide and then once I get in there, you know, it's it for me if I'm going to open up one and two, I'm definitely going to at least really look at three because I'm probably making a second incision to get over there because I don't think I can get really well to the lateral side of two from that dorsal incision, without really dissecting out the bundle really well and I just don't like doing that. I much prefer to get down to bone and keep the bundle in the soft tissue and not make it mad, so I don't get any inflammation around it and maybe, maybe avoid neuritis, but I want to ask when passing on to him. Is he going to denervate his fusions in the future. Because that was the biggest thing I was wondering when I read his article preparing for today. Should I cut the deep perineal nerve every time I see it. No way man. So, so I want to, I want to answer arrows question first for me. I tried to go after the obviously the most arthritic one on x ray also that one that responds to the injection. Even when there is some arthritis in the third TMT once you fuse the second, it acts like a split, almost for the third, so they symptomatically feel better. And also, I don't know how you do it to avoid the neurovascular bundle but every time I operate through that area it seems to be right in the way of my fusion. So what I do is I actually perform in elevation, and I perform almost like a neural license and guess what happens to those little fibers I go to the third, they're gone. So when they're gone, their third naturally feels a little bit better as well. So, so the answer is, if I'm doing a midfoot fusion, I am not taking out the deep perineal nerve, because that that is a pocket of aces, because if something happens later, and they're still having pain, and they're out of joints to fuse. You can still say that as an option without predisposing them to early stump neuroma. It's a long thought process not proven. I've loved your study and I just recently I've had some patients where I've done that injection. And, you know, you see people who've been making the circuits around and seeing four or five people and I gave I just yesterday I gave somebody injection and like all his pain went away. I'm going to give your thing a try. I was up front I was like I can send you down to Jacksonville, but he preferred to stay up in Boston so we'll see how it goes. No, no, I prefer they stay in Boston, because, because the whole idea of this this is this is that one slide you remember, with all the finger pointing. That's my biggest fear before I thought about really hard. And I talked to my dad, you know my I even talked to my wife she's a physician assistant but but she listens, I'm sure you all do as well talk to your spouse. And my biggest fear is, I don't want my name to be associated with something like metal on metal hips, because I remember those guys at a was talking about metal metal hips is best things in sliced bread. Right. So, so I thought about really hard whether or not I want to keep this to myself, or, or letting, letting it public, letting it go. Um, so so I started with the anatomy paper, and you know what the hit this his. This is a truncated slide obviously because we have a 15 minute limit, but, but that paper was rejected, and I had, I had to, you know, convinced at the time it was David Thorderson that hey you know I before I submit it to another journal. I just want to take another look at this because there is some value to this eventually, and and only with that anatomic study I was able to a little bit more confidently offered to the first few brave patients who essentially at the end of the road. And so with them as as the subjects, they give me a little bit more confidence in offering to more and more people. And so far, you know, if you look at the result, 80% of people are reasonably satisfied that essentially is the outcome of any neuroma or procedure, whether it's Morris neuroma, the wrist, or, or anything else that we do in the human body right so so I think I think that's where we're at. I still have to, I still want to keep these patients in my file. I would love to, to see what happens at 10 years, and if I'm still working in 15 years. One more question just for me, are you burying the neuroma in the tibia, when you take it out or do you just let it fly. Yeah, so, so I don't. I, I cut a segment out. It is already in a deep area it's not superficial right it's already the deep period buried underneath the muscle soft tissues on top of on top of the bone. So in the cases where neuromas stump neuromas formed and they were symptomatic. Okay, I assume that all of them will have some sort of stump neuroma, by definition, if you look at under pathology, but those symptomatic ones. I did bury them, and then that paper I showed you Dr. Jones technique was excellent. You basically drill two holes next to each other. And then, and then you put the stump neuroma, you treat you freshen it up truncated, and you put it right next to one hole and use a Frazier tip, but the other hole is basically using physics to suck that stump into the bone, pretty deep, and then missing doesn't seem to come out. So Glenn. If you've got a patient with hardware in the midfoot and pain and non union. Are you ever just removing the hardware and burying and cutting the nerve there and burying it deep. The, the traditional conservative orthopedic surgeon in me will freak out if I said I would just remove the hardware in a non union and just take out a nerve. So, so I think, you know, that's a case by case basis I have to really think hard about what's going on with the patient where the pain is coming from. If there is a truly a mechanical problem, and you're just trying to cover, cover it up, you know whether whether the hardware is shooting through the skin you know like what's going on there because sometimes what I have done is people don't want the fusion removed, and then, and have a deep inner rectum, it's kind of like a la carte and I've done that before, because they really can't wear shoes. They have arthritis, the deep perineal nerve injection works, but their skin is so irritated from wearing shoes. So I have done almost like a midfoot highlight to me procedure, removing the nerve and allowing the patient to weigh very immediately because a lot of my patients in Florida, as you've seen in the cases. They're older, sometimes they live alone. They have to take care of animals, they have community activities and pickleball and such taking time off it's just not really an option. And one final question for each panelist for bad fourth and fifth metatarsal cuboid arthritis isolated. What is your go to. It's an interposition, is it osteoctomy. What is your go to thing for that problem, because I don't have one. I don't, I don't know what I'm going to do half the time I get in there. I inject them and I sent them to Jason Barrett telling Atlanta. I've read it on my, I tell you over the years, I've talked patients out of surgery more times I've talked them into it because I tell them, I don't know what I'm going to do. I know we can try these little metallic things or try an interposition, but most of the time, I just go in and to breed it. They do often feel better with a dorsal debridement though and I just wonder if because there's so much motion there that if you let them get a little more dorsiflexion through those joints for uneven ground they'll feel better, but there's just no good answer. I have to say I actually haven't seen much of it but that that would be my go to is, well first injections and then, and then a resection arthroplasty and that's it. You know, no interposition or anything. Chris. Yeah, I'll do a resection. I haven't seen it too often but I'll do a resection and I'll put some dermal matrix or something in there, or a tendon graft and, but I think if you do that. I've always also fused the second and third, because I think that if you don't have a really solid middle column, I worry it'll sort of fall laterally so I've done it in the setting of pan metatarsal arthritis, pan TMP arthritis. Okay, that's great. We're on time. And we're going to move to symposium to Glenn Glenn's taking over again.

midfoot fusions

challenges

diagnosis

joint preparation

patient factors

fixation techniques

bone grafting

lateral column injuries

motion restoration

ORIF

risks

offloading

treatment options