So, this is going to be the section on sort of Charcot and neuropathic foot condition. We have a really great lineup here of speakers. I think it's sort of amusing that I was asked to moderate the MIS section and the Charcot section. It probably tells you something weird about my practice. But I've already looked at all these slides, and they're amazing. I'm really looking forward to Dr. Halim's talk here. Just one sort of message to the attendees. If you have questions, please put it in the Q&A box. Don't put it in the chat, because it's harder for us to... We can't get back to you directly into the chat because of how the webinar is set up. So if it goes into the Q&A section, we'll be able to get to you. Anyways, Dr. Halim, please take it away. Dr. Milo, thank you so much, and thanks for Dr. Bailey for inviting me. It's an honor to be here, and cheers from Oklahoma. It's tornado season, so I hope we have quite a couple of days. These are my disclosures. And I'm going to be talking about the basics. So it's going to be really bullets, but we're talking about when we leave medicine and med school and try and medically manage our patients and work them up, especially if we're in a private practice. I'm in an academic institution, so I have a lot of backup. But if you're in a private practice, it really becomes a little bit bewildering. You should know that fractures in neuropathic are very common. You can see them at any stage, whether acutely, subacutely, or chronically when they present with severe deformities. They can include any part of the foot and the ankle, as you know, either alone or in combination. And can be complicated by the soft tissue compromise, which can make your life very difficult. Even if you do not electively treat charcoal in your practice, I guess Dr. Miller said it one way or the other, it will see you and it will fall in your laps. Neuropathic fractures will be an inevitable part of your practice, as well as deformities. So in my humble opinion, it is just prudent that you are comfortable formulating algorithms and implementing them to be able to salvage your patients. So just take a deep breath and try and dive into that. Most importantly, I think you should also be more comfortable ordering the basic workup. Every EKG is a double-blinded study for orthopedic surgeons. I think we can navigate through this in efficiency and sometimes even orchestrate the teams. So my tips and pearls that I've adopted throughout the last eight years as my practice has evolved into a major charcoal practice with referrals from all around Oklahoma and the neighboring states. Number one, do not wait to optimize your patient and, you know, keep them hovering around in Lala's land until they are optimized, because this is not going to happen. Get started optimizing them post-op from the pre-op visit. So be aggressive, admit them, get them into the hospital, and establish an interdisciplinary team. This is something that I definitely tell everybody. If you're in an academic institution, you're going to have those pillars. I call it the hexapod. So you really have to have an internal medicine who should be amenable to admitting the patient and not telling you that I'm going to just be consulting on him, because that's going to turn your life into a big misery. A cardiovascular medicine attending, an infectious disease doctor, a plastic surgeon if you have soft tissue compromise, an orthotist and a prosthetist, and a case management and a nutritionist. If you do not have established relationships with all these six interdisciplinary services, you are not going to be able to manage these patients effectively. Basics, clinical exam, again, in the clinic, always check the neurovascular status. We know that the Charcot foot is a hyperperfused foot. We've been always taught that. However, microvascular disease does exist. And I can tell you that I've operated numerous times on Charcot where my tourniquet time was at a minimum. And after the surgery, they had delayed recovery and capillary refill, and it was a nightmare. And we had to anticoagulate them aggressively. So you have to check. Cardiovascular disease is not going to be detectable, but macrovascular disease definitely is. So get the ABIs, check the pulses if they're not palpable, get ABIs, send them for a cardiovascular medicine consult for an uninvasive studies. We all know them, the TCPO2s. And if, again, they're going to be abnormal, get them worked up with a CT angiogram and a cath lab, and eventually a vascular bypass surgery before you operate on them. Because you don't want that to be a problem. Again, remember, microvascular disease does exist. I've had it in a couple of patients, and I can see we have examples to show you. So definitely keep your tourniquet to the minimum. If you can operate without a tourniquet and you're comfortable doing that, then my advice would be to do that. Always check the neurovascular status. I always say the Nile is not a river in my home country, Egypt. It's in the heads of all these chiropractic or neuropathic patients who really tell you, oh, I'm fine. I don't have any loss in sensation. But then you pull out your Simms-Weinstein monofilament from the pocket, and you test them, and lo and behold, they're definitely neuropathic, with almost 40 to 95% of these patients having some sort of neuropathy or the other. So I carry around these Simms-Weinstein filaments in my pocket. They're available on Amazon or any other website by the dozen, and they're super cheap. Always ask and check for hemoglobin A1C. If they don't know it, get one. The previous consensus was that you don't want to operate on a patient with less than 8% of A1C. However, the recent study by our good friend, Dr. Drew Kruper, and his colleagues showed that the cutoff recently has changed to 7.5, and that was for better results with reduction on postoperative infection, following elective ankle surgery, sorry, forefoot surgery in neuropathics. You'll be amazed, but again, always check vitamin D. This is a very good study that showed that almost 47, almost half our patients, neuropathic patients are deficient in vitamin D, and 36.8 of them are insufficient. So a vitamin D workup is definitely going to be part of your basic workup. For me, I always check the comprehensive metabolic panel and renal function test. Another excellent study by Dr. Hines showed that diabetic kidney disease is associated with increased complications following operative management of ankle fractures. Another study by our mentors in special surgery from the limb lengthening and deformity correction showed while fusions in neuropathics can be as successful as 85 to 90%, yet patients with renal compromise and on renal dialysis have lower results of up to 60 and 65%. I always check the serum albumin, total serum protein, and if they're low, I try and get them a nutritional consult, because again, that affects healing. This is a study that showed that the predictive factors and amputation levels for reamputations were albumin levels, smoking, hypertension, and duration of diabetes. So definitely the nutritional status of the patient matters. I don't think you don't want to, if you're admitting them and you're going to try and give them albumin, it's not going to be really effective. It's going to give them a very short boost because of the short half lifetime of albumin IV, but definitely long-term nutritional status and controlling their diet is very important. If I do have any history of smoking or tobacco use, I get serum nicotine and cotinine level. Cotinine is the byproduct of nicotine, and it lasts longer in the bloodstream. And it's, for me, it's even a more elevated levels are more indications for me to hold back. If we, again, the foot may look completely supple, the skin is intact, but I always ask for a history of infection or healed ulcer, because if they are positive, I will get an inflammatory panel with ESR and CRP and CBC. And again, we all know that the diabetic neuropathic patient can present acutely with Charcot that can mimic infection with these cardinal clinical signs that I do not need to state to you. The most important of which is a high premium improving with elevation. Again, the white blood cell count can be elevated in an acute Charcot because of other infections, other than osteo. So that's a lot of time, a derailer that can throw you off. When it comes to imaging, a lot of times we send them and we get an MRI, an MRI by itself is not sufficient. I'm sure you know that by now you have to get an MRI with contrast on these patients. Fracture edema can become a confounding factor. So if you have an acute fracture, I wouldn't advise getting an MRI, but it can differentiate an abscess from soft tissue swelling. It is the most sensitive in diagnosing soft tissue and osteomyelitis. The limitations is difficulty in differentiating infection from acute Charcot arthropathy. Is that true? I can challenge that and say not really. Very quickly. This is a 66 year old neuropathic patient that I got consulted on a couple of days ago in the hospital. He had history of cellulitis four months ago treated with IV antibiotics presented again with the swollen left foot. I'm sorry, I don't have pictures of his other side, but this one was definitely swollen. Slightly hyperionic. The internal medicine team admitted him and diagnosed him as having acute osteo and the ID doctor wanted me to go in and do a biopsy. I examined him and really didn't strike me as an osteomyelitic foot. So I went ahead and ordered this MRI and this is his MRI. And I looked at it and immediately I told him this is an acute Charcot, it is not osteo I can swear by it despite his ESR and CRP being sky high. And this is the report from the radiologist who conferred my diagnosis. I didn't even wait for the radiology report, but it says Mark Charcot arthropathic changes. And this is the typical pattern you're going to see. Again, look for always this diffused lightening up subchondral cysts and sclerosis of the joints. And this is a very good paper that shows the differences between neuropathic arthropathy and osteomyelitis on MRI with contrast. So again, the distribution in neuropath is going to be tarsal, metarsal and MTP joints, like I showed on my slide, whereas with osteo it's going to be around the ankle, calcaneus, distal and metatarsal MTP joints. The bone marrow pattern is not really going to throw diffused bone edema. And I think the MRIs I showed did have diffused bone edema. But cellulitis on soft tissue edema in the neuropathic foot is going to be more common than abscesses and sinus tracts and skin ulcers in osteo. And then this is the key for me, subchondral cysts and intraarticular bodies, as opposed to the synovitis with disappearance of the subchondral cysts in osteo. So these are cardinal signs to look for in MRI with contrast. If you are comfortable reading them, they're really going to guide your path. When it comes to indium-labeled bone scan, I know a lot of studies did not show that it was specific. In fact, it is part of my practice right now. If there is metal, and we see a lot of these patients with previous surgeries. So an MRI, even with a metal artifact reduction, is not going to be helpful with contrast. So I order bone scans. It's ordered mainly for deformities, but I can argue that in acute fractures with suspicion of infection and metal and previous hardware, it can become very valuable. Remember the Charcot in the indium-labeled bone scan, the Charcot foot or the neuropathic foot or an ankle is going to be cold in the bone phase. So we have two phases in any bone scan, the blood pool phase and the bone phase. Anything is going to be hot in the blood pool phase. So the Charcot is a very well-perfused foot. So on the blood pool phase, it's going to be hot, but in the bone phase, it's going to be cold. In osteo, the indium-labeled bone scan, the white blood cells are going to be tagged and it's going to be hot in both phases. So both the blood pool phase and the bone phase, and that's how you differentiate it. And again, these are studies, and you'll have the slides available that show again with dual isotope scanning, sensitivity is almost 93% and a specificity of 83. And the indium-labeled white blood cell scan can reliably determine the size and extent of osteomyelitis. And this is another study literally iterating the same. CT, with or without 3D reconstruction, again, integral part, while the MRI looks at the soft tissue, for me, the CT looks at the bone. I'm sure there's going to be weed-bearing CT studies rolling out, but as of now, it's not part of my routine practice. It assesses the bone quality, it can, you know, I then detect the occult and adjacent fractures and the comminution extent with concomitant arthritis. Finally, is there a role for PrEP and CT scans? I believe yes, however, it's very cumbersome for us to obtain in the US right now with a painful peer-to-peer review, but in patients in which, again, you don't have an access to a bone scanner, I think if you have a PET-CT, it will show you a lot, and these are papers now that are showing the evolution of use of PET-CT in bone remodeling in diabetic patients with neuropathy and detecting the difference between neuropathy and osteomyelitis. Operative pearls, again, you should know that ankle and foot fractures in diabetics can provoke neuropathic changes. So although the patient might not present with a neuropathic foot, but you should know that a fracture can precipitate these changes and cause them down the road. So I would urge you to operate ASAP, and this is something I'm sure Dr. Miller is going to hit on, to avoid soft tissue compromise and development of neuropathy. Finally, a couple of tips and drills I've adopted from clinical years, an indication for me in an ankle fracture to adopt a primary fusion, again, dorsiflexion, weakness in foot drop or deep sensory loss, comminution, and believe me, a contralateral below-knee amputation. I've found that patients who have had below-knee amputations on the contralateral side and present with an acute neuropathic fracture, if I don't fuse them, they end up walking on it early because they can't favor their prosthesis all the way, and they end up breaking their ankle. And I've had it a couple of times where for me, having a contralateral BKA is a relative indication for me to do an acute primary fusion on these. And finally, I would urge you to think about that you are always fighting a poor biology and a poor host, to use the kitchen sink, use autologous bone graft. My go-to is proximal tibia, viable allogenous bone graft if you have access to it, definitely biologics, and we've hit on it yesterday. In my practice, if there's any history of infection, antibiotic-loaded calcium sulfate beads go into the formula, think that these neuropathic always have polymicrobial infection, so gentamicin or tobramycin for gram-negative, and these are the doses, and one gram of Vank for gram-positive, mostly resistant bacteria. You should tell your plastic surgeons if you have compromised soft tissue that calcium sulfate beads are going to cause yellowish discharge and can mislead into a misdiagnosis of ongoing infection, so careful interpretation of the wound status is needed on patients with these antibiotic-coated beads. My last slide, again, post-operatively, remember, put them on calcium and vitamin D. I use external bone stimulator on every neuropathic patient. There have been multiple studies on post-electromagnetic field stimulators versus low-intensity pulsed ultrasound, and I think the lipase has been shown to give better results, likely in the literature. While awaiting your intraoperative cultures in infected patients before ordering ID consult and a PICC line, don't wait for the ID guys to come and, you know, show at the hospital or the two sets of blood cultures before ordering the pick line. And while you're waiting on your plastic surgeons to cover your defects, make sure you pre order a CT and you just make sure that if they're going to do any flats that your flaps that you're covered, get case management involved on day one to attend for home health or rehab placement and finally brace for impact and be ready to treat your own complications. So in conclusion, I think neuropathic fractures are going to be an integral part of any foot and ankle surgeons practice. Remember clinically check your neurovascular status. Pre-op labs that you routinely order that we've hit on. And finally, all imaging mentalities. And after all, just know that everything is not going to be quiet on the Western front and you're going to be facing a lot of complications that you should be brave enough to treat and sorry for going 15 seconds overboard. Thank you. That was awesome. I think, as I get this up I think one of the most impressive things I've seen from hearing you talk several times now is just how much of a team you've been able to create down there. I think for anybody contemplating this type of stuff you really got to look at what you've done and try to replicate it. So I'm going to, I'm going to transition here and this is my talk here about treating the neuropathic ankle fracture. So I'm going to talk a little bit about what I'm going to be talking about today. And I'm going to talk a little bit about what I'm going to be talking about today. And all of the stuff that I'm going to just talked about applies, except here it's in the acute setting and so you can't necessarily wait to do everything in terms of workup, but certainly you can get some of it started. And I want to talk about how I handle these and hopefully give you guys a sense of some ideas of what you can do for your own patient population moving forward. So first of all, you know, fractures in neuropathic population, not the same as Charcot. So I'm going to talk about some of the, some of the treatment options here through the cases. So, as I was saying, if you're, you know, brace for impact I said, you know, stormy seas ahead. So if you're going to get into this type of work, you're gonna, you're gonna have some rough weather coming up your way. So, and, you know, why do people not deal with this because these are some of, for me, some of my most rewarding patients because you can deal with it. But they don't make it easy on you. This is one of my board collection cases, it can ruin a clinic day if you have a more elective practice and you're not really set up to do this so and you start asking yourself, how do I, how am I going to handle this. When am I going to take care of this and, you know, I need to get time at the main hospital now. Where can I do it and does it really have to be me or can I send it somewhere else. This is my first endeavor on a neuropathic ankle fracture. So as a 42 year old woman, type one diabetes I think and she was sick, she had a in the past, a one seat up into the 10s and 12s. Now five five but she had a renal pancreas transplant. She had a four foot ulcers and Hallux amputation, and really severe peripheral vascular disease which the, our vascular surgeon said there was really no option. Because of how diffuse it was. Initially, this was her picture she came in to see our trauma team, and they looked at this and said she's way too sick for surgery. So we're going to treat it closed, and unfortunately she came back. A few weeks later looking like this which is not a surprise to anybody who deals with this on a routine basis. But now we have a real problem so we have an ulcer, clearly not going to last here. So now they say okay well Chris is your turn. So I'm pretty fresh out training. My first year, ready to go. And I'm not sure I would do this now but I think doing some sort of fusion is the right way I was nervous about putting a frame on somebody with as many medical issues as she did. And so I did a TTC fusion fortunately the deep cultures were negative. And I thought I'd done great. Even the nail look good had a little smiley face. But two weeks later she came back looking like this. And so she had basically just necrosed all the skin for about a centimeter or two and it just got worse from here. And so, couple weeks later she ends up with a below knee amputation. Not what I wanted, but she got back to work she was walking prosthesis. So, happy. Three years later actually I looked this up as I was preparing this talk so I was thinking about her. And I found out that she had passed away about three years after my surgery. And this is one of the points I want to make is that, especially in this population, the mortality rate after BK is extremely high. If you have a BK plus diabetes and renal disease, it's in this study 90% at five years so these people are medically complex, but there may be a real role for limb salvage because these numbers here are worse than metastatic cancers. Okay, so where am I seven years later. They just keep on coming. We keep seeing more and more of them. Diabetes is not going away so here's what I've learned and here's what I think about them. So here are the three cases I was going to talk about so this was the first one 72 year old. Anyone seen the low to mid sevens chronic kidney disease, and had been seen elsewhere in a local setting, they tried to treat her closed. She's active she lives with her husband she has support. And so one option can you even treat these clothes. For me, I'm very tenuous very nervous about treating these clothes I think they really need to have a truly stable fracture pattern. You need to check their skin all the time, and you're gonna have a prolonged weight bearing non weight bearing period. So, the benefit no surgery, the downside. Gas disease loss of reduction, all of this. And when we look at unstable fracture patterns in the diabetic neuropathic population this was a nice study here of 28 patients 20 treated close eight with or F and the complications are actually much higher in the group treated non operatively. In this case, 75% of the non op treatment had complication, and of the people that had a surgery after non up, all of them had a complication so we may be thinking that we can avoid complication with non up, that's not necessarily the case. So here's a table from that study and you can see, loss of reduction was very common progression to charcoal wound complications, and that's in the non operative group that's because of the ulcers or subsequent surgery and having complications there. So, not new, we know this from Dr. Sean and McCormick in the 90s they also showed very high rates of non operative complications and non operatively treated group. And what lovey's study here said was that they found unacceptably high rates of complication with non operative treatment. So how about just or F, fixing it like a regular ankle fracture. I think here again, especially in neuropathy, we have very high rates of failure or wound complications so multiple studies showing that in the patients with neuropathy, you know, 11 out of 12 had wound complications for developed charcoal. Next one half of them develop complications and on and on so even just or F by itself may not be the best option. So, how about just like a lateral plate. Right. So, now we start talking okay, can we supplement the RF can we make it more robust. So several studies have looked at adding some sort of fixation so I'm a fan of the sort of TTC Steinman pin after fixation you can add an x fix. So there's a lot of different techniques that you can use. When you start adding more fixation. And one of the sort of themes here is that more is more. Now we start seeing lower rates of complications still high right 20 25% complication in this group, including infections or below knee amputation, but of the others, you know, the remaining were able to be pain free and, you know, ulcer free as in their walking. So this I think is a great one and a little less in the neuropathic literature here but we see more studies of the sort of fibula pro tibia fixation where you're using the tibia as a medial plate to really increase your stability and stiffness of the construct in osteoporosis or elderly patients and so this is another good way to increase the rigidity of your construct and help avoid some of the complication we see with the neuropathic population. So here's back to my case here clearly an unstable fracture diabetes neuropathy I'm not going to treat this clothes, I'm not going to treat it just with RF in this case, I chose to use locking fixation I use three syndesmonic screws and I actually put a medial plate on as well. I haven't seen this written about but I have seen, despite this being a laterally unstable fracture pattern with neuropathy and charcoal sometimes you see medial instability, if you just put a couple screws in there so if I do have a medial mal I'll often put a plate on these patients to act as a medial buttress, even though from sort of classical thinking, this is a laterally unstable fracture pattern. And she fortunately went on to heal and do quite nicely. Here's my second case. So this was a patient who our trauma team tried to fix because of the significant displacement. And you can see her multiple medical issues here. But they only fix laterally. Now they put some more syndesmonic screws in. And I think to in their defense, the medial skin was probably not great. But unfortunately, four weeks later, you can see she's already starting to slide and go laterally. So I think this was a case of really inadequate fixation in a patient who is just going to be walking on it. Right. So she was walking early inadequate medial stability, and we know that in with or if alone high complication rates. And now not only that, but we have a wound issue as well. So what am I going to do now. Revision fusions internal external fixation lots of options. Obviously, if I can avoid amputation. I want to give them the high mortality rate. So this was another study that I liked 17 patients who had RF and then failed in a neuropathic population. You can see the reasons for failure here. So what did they do three of them went on to RF eight went on to X fix and six went on to a primary fusion. In this case, TTC They had a limb salvage rate of 82% of the three that had amputations, they all had infection at that initial presentation. And then the other ones either had a formerly fused ankle or clinically fuse where they had no motion. So no patient who saved their leg saved a functioning ankle. Also, a lot of additional surgeries in this group. So amputation at least six additional surgeries or median six additional surgeries limb salvage three and a half. And so what do we do for my patient here. So I can't save a functional ankle. Why try and I go straight to a fusion construct pretty much universally for these patients. So here's my patient. We have a possible infection. I'm going to go for an X fix and I tried to get her to fuse three and a half months later, it looked good. I took the X fix off. Unfortunately, she's now slipping into malalignment I took her back shortened her put a plate on the back because we're still working on healing the lateral wound. Looks good. Unfortunately, she was walking on it. And now she felt a crack and I had a stress riser with my pin site being too close to my plate fixation, but fortunately cultures were negative. So now I took her back for a TTC fusion and successful limb salvage. And I'll just put a plugin that for these patients. I think you need to go along with the nail and I think Mickey pins are showed us that multiple times here. So then I'm going to this can be my last case here. So I call this the work. So this was a lady very compromised neuropathic ankle fracture already had charcoal in the foot. This is what she looked like. Here's her midfoot alignment. You can see the charcoal in the midfoot here. Again, not a great revascularization option according to my vascular surgeons. And so what are we going to try and do. So here, my surgical plan is going to start with the TTC fusion. However, now if I don't do anything about the midfoot, I'm going to leave her in calcaneus and we know that a neuropath with calcaneus, that's going to be a recipe for a heel ulcer and a very poor outcome. So now I'm not only correcting her hind foot, I now have to take a wedge out of her midfoot, bring that down to create a plantigrade foot and then beam it. And the great thing about putting this talk together after I've already done the surgeries, I can make it look exactly like I did in real life. And so this is what we did here. And she's about six weeks out. So I don't have long term on her, but I thought it was an interesting case to show you. And a little plug for MIS and Phil Kaiser's case coming up is that I did all this with a percutaneous approach. So this was her post-op x-rays here. So in summary, don't avoid surgery if it's needed. I think non-operative is often more risky than surgery in many cases. Not that you're going to get away with just one surgery in this population, as you've seen here. I think more is more. Augment your fixation with an X-Fix, multiple screws, Steinman pins, go to fusions early and use it often. And then don't forget to look for that hidden deformity as our limb alignment people would call that foot deformity there. So final thoughts here. Don't be afraid of these cases, but do know what your hospital can handle. So if you don't have OMGAD's resources, you might want to not do this if your hospital can't handle the medical issues. I thoroughly believe that any surgeon on this webinar can do these cases though. And I think they're your best cases, your best teachers, both in terms of your technical skills and just your overall compassion for the patients. So have a plan. Diabetes is not going away. It's getting more common. Neuropathy will be more common. And as you're treating ankle fractures, don't forget to look for this because if you don't see it, it will definitely see you. So that's the end. Thank you very much. Okay, so next up is Dr. Ghaly here and she will be talking to us about internal and external fixation. So thank you very much and looking forward to it. Don't forget to unmute yourself, Sarah. There we go. Am I unmuted now? I got you. All right, great. Thank you so much for having me. My two talks now in professional career have been the fat flatfoot and now it is followed by Charcot. So as I transition to a practice in Wisconsin, I'm a little afraid what that's going to leave coming my way, but thank you to the organizers for having me. I'm here to talk about Charcot neuroarthropathy and my decision-making for when to do internal versus external fixation. You can see my disclosures on the slide. I'm a consultant for Ardelcon, but nothing is relevant to this talk. Unofficial disclosures, whenever possible, I do prefer internal fixation and my algorithms continue to evolve with experience in my patients. No two patients are the same. I'm still learning and as I've done the preparation for this talk and read the literature, I have to self-admit my results are not as good as theirs. So I look forward to the panelists teaching me and I look forward to the continued teaching that my patients provide me. The roadmap for this talk is that I'm going to present three representative Charcot angles. We're going to discuss my algorithm for deciding when to internally versus externally fixate and then we're going to come back to those cases to look at the limb. So to introduce you to a couple of my South Louisiana patients, we have first a 62 year old male who came to see me like my first week in practice. He had a recurrent fist met base ulcer. His A1c was 7. His MRI suggested that kind of that little avulsion fracture was associated with osteomyelitis. He lives alone and he has low health care literacy, low support. Case 2 is a 50 year old male who had a fracture dislocation about an hour away from me in 2020. He's not diabetic but he has end-stage renal disease from some sort of energy drink protein thing in the 90s. He's on dialysis and he went through two attempted ORS and a TTC outside and came to see me. And the last is this 49 year old male who came to see my partner. His A1c was 11. His wound looked like that in the office and his social history is notable for he works at a chemical plant. He's married with two kids and is the main provider for his family. Okay, this is a busy slide. I'm going to move past it very quickly but I want to highlight that kind of I break my algorithm for this decision-making into kind of four groups of when they have an intact soft tissue, when they have an active wound or ulcer, when they have active infection, which I differentiate, and then when I plan a telectomy. First of all, before we get into any of those subgroups, don't forget your indications that, you know, not every Sherco needs surgery. Those are kind of my indications if it's unstable, if it's infected, if it's non-braceable, some say non-shoeable, and then that they have pending recurrent or non-healing ulcers. Don't forget your other tools, total contact casting, Achilles lengthening, some of those. But moving into kind of each subgroup. So for the intact soft tissue, you have all kind of options available in my opinion. Fix it how you feel most comfortable. There's literature that shows beams, bolts may be stronger than a plate, hind foot nail may be stiffer than a blade plate, but then when you look at outcomes, there's really limited literature on whatever construct you use. One study that I did came across saying that X-Fix works better than InFix, and that foot has better outcomes than ankle. But I think, again, do what you feel most comfortable with. Patients. I generously use Biologics as we kind of talked about. These patients are poor hosts, so I use Autograph from the calf or the tibia, I use osteoinductors, and then I'll use void fillers as needed when there's a lot of bone loss. And then in general, for any of my Charcot patients, after they come out of the boot, I brace them for at least six months to kind of help with that consolidation and to help avoid another Charcot process. Next, when they have an active wound or ulcer, we know from the group where I did my fellowship in Charlotte, that if you operate on someone with internal fixation who has an active ulcer, you have increased rates of deep infection following their surgery. My preference, knowing this, is I try to get wounds to heal first so that I can go from a wound algorithm to a soft tissue algorithm. I like it because a lot of these patients that come with wounds, I question their compliance. A lot of them are not medically optimized. And then for me and my hands, I'm just more comfortable and my union rates are higher with internal fixation. So this brings us to my first patient. 62-year-old guy, Charcot of the ankle with gross instability and a rigid deformity. His A1C suggests he's close to optimized, but he's got this FIFMET osteomyelitis. He lives alone. I'm concerned about his support. I'm concerned about understanding of non-weight-bearing, compliance, all those things. So what I chose to do with him was admit him to the hospital. I did an IND and FIFMET-based excision. The margins were negative. I got my infectious disease colleagues to help me treat him. And then I helped get him... I didn't help, social work. Again, going along with the team. Got him admitted to an LTAC. So he had good support while he was healing this wound and can get regular wound care. The wound healed and we came back and did a TTC fusion with an intramedullary device. He was healed and ulcer-free in a shoe for about a year and then came back and saw me with a red swollen foot. You know, differential for me was, is this Charcot? Is this infection? Is this just a non-union? Got lab. They were unremarkable, but his A1C had climbed to 11 at that point. We talked about BKA versus salvage. And the decision we made was to change the biomechanics with a bigger nail and a little bit different construct. His deep cultures were negative. I used an MIS wedge burr for this to do my joint prep. Really didn't want to make big open incisions on a guy with an A1C of 11. And this is what we achieved. What I learned is revision Charcot surgery, as we all know, it's already hard surgery. It's harder when it's revision. The tissues don't move and bone loss is often a problem. And then trying to get compression across that bone loss is hard because the soft tissues don't move. He's now two years out. I actually just saw him this week for a social visit because he heard I'm leaving South Louisiana and wanted to come give a hug. Really sweet guy. And he wears normal shoes and sneakers for his ABLs, but he does wear his Arizona gauntlet for Mardi Gras and Jazz Fest. All right. Next group is those with active infection. Leaning on your colleagues for medical co-management. Try to treat the infection first if possible. So I like to do INDs and let the soft tissues calm down if I can. It also helps me with my colleagues because I'm the only person in the region that does this. So I can counsel colleagues on, hey, wash it out, put in a splint. I'll get it on my schedule. So I'm not constantly derailing my day, my life to take care of these people. The exception to that is if it's unstable, then you need to do something acutely. Principles for this is I use X-fixes 100% of the time. I avoid allograft. And I'm really getting more and more aggressive with my counseling of these patients about the guarded prognosis for them because currently in my practice, my reoperation rate, my complication rate is about 100% for this group. So okay. That brings me to my next case. This is a 50-year-old guy who's not diabetic, but he's on dialysis. He had extensive surgical history and was referred to me for a second opinion from one of my sports medicine colleagues who works with him because he's a football coach. He came to see me with a swollen foot, but all his incisions were healed at the time. The hardware was palpable underneath his heel. Labs were kind of equivocal. I think labs in the end-stage renal disease patient populations are impossible to interpret. And while the workup was ongoing for what we're going to do next, he calls my office and said my foot is draining. And so we told him to go to the ER and he had bloody purulent drainage coming out of his lateral ankle. So we got a CT. There is so much missing bone. And so what we did for the first stage was we IMV'd, took out everything, washed it out, curetted all the bone holes, and put a just simple antibiotic nail over a rod and put an external fixer on him. Cultures were diphtheroids. Again, this is why you have colleagues to help you with this stuff. And he completed six weeks of IV antibiotics. He was healed. And then we came back and used a reamer sort of device in the tibia to get a lot of bone graft. And then fixation was a problem. I was like I wanted to get some compression across this because he had so much bone loss, but where to put it. And so I used some large cannulated screws and then obviously kept him in the external fixator. Frames are challenging. They're hard for patients to tolerate. He's a big dude. And so at two and a half months into the frame, he's like, you have to take this off. We got a CT scan. I was like, no, it kind of looks healed. So we took the CT off. He was stable in the OR when we removed it. And ID wanted to maintain him on PO suppression. One year post-op, he's obviously got a non-union. He had a screw back out that we removed. He's wearing a crow. He's been diagnosed with cancer. He still intermittently drains. Now he's got strep and he's maintained on antibiotic suppression. So this case has taught me a lot of lessons. It's taught me when someone's had four surgeries, don't promise to be their savior. It taught me that don't use hardware in the setting of infection. And can does not equal should. And frames are hard for patients. The other lesson takeaway, and this is kind of a call out to Dr. Miller's talk, is, you know, fix these right the first time. Use his principles when you fix these. And so I think we could all look at the initial story of this patient and note it was fraught with disaster from those initial x-rays. What does the literature tell us about infection? It's all over the place. Complication rates are high, but the literature would also suggest that Lyme salvage can and is often successful. So these two studies here show that Lyme salvage is achieved in over 80% of cases with pretty long follow-up. The thing I took away from these studies is that my patients should probably be in the frame for longer than I am keeping them there. And so that's kind of what I learned. Counseling is everything. I really am generally an optimistic person to a fault. And so these are the patients that I really try to rein that in and talk about, we're going to try. And we keep focusing on the try, and we say, you know, there's surgeries we can't plan for, there's complications we can't plan for, and we talk about the elephant in the room every time. And for patients that you don't think can handle a frame, super important to have that conversation about BKA as well with them. Last group that I talk about is the talectomy group. What are my indications for a talectomy? Subtalar dislocations when the calc is lateral and often superior to the talus and almost abiding higher than the fibula in some cases. When you have severe talar at BVN, which I diagnosed on CT scan, and then any severe peritalar deformity, as you can see with these two just kind of representative cases. Technically, I do it with dual medial and lateral incisions. It's a transfibular osteotomy. Save the fibula just in case. I've used it a couple times when I need a lot more bone. You obviously remove the talus, use lots of generous bio, and then I place a short hind foot nail, close, and then apply a pre-built frame with the distances just enough to avoid the short nail. So this brings me to my third case. 49 year old male with this lateral wound. A1C was 11, primary care, primary provider. We needed to get his A1C better in my opinion, so we did total contact casting to get the wound to heal and to give him time to get his A1C under control. We went to the OR with plans to do a talectomy and tibio-calc fusion and apply an X6. The way I was kind of taught to do this is with these chamfer cuts of the tibia to help make the square fit into the square of the subtalar joint, and I leave the TN and CC joint alone, kind of what has been termed the flipper foot, and then you apply the external fixator over the top. This gentleman's two years post-op and ulcer-free. He does wear a crow for his very physical work, and then he wears a custom shoe because the limb length discrepancy is significant in these patients. And what I have learned from these patients as I, you know, kind of go back and look at the case series that I have is they all kind of have this pseudo-arthrodesis situation, if that's even a word, and so I'm really continuing to add more and more biologics. Probably should be leaving the frames on longer. And my question for the panelists is, in your talectomy group, am I an outlier? Is this what y'all are seeing? Because I don't have a single with bridging bone across that joint, but yet I look at the papers and they show beautiful x-rays with bridging bone across the joint. And so with that, I'll transition to kind of, this is the humbling study that I read, is we found a meta-analysis of how to make decisions in this difficult papal population, is that salvage can be achieved more with x-fix. According to this meta-analysis, when they looked at x-fix versus x-fix, they consistently found that foot is more successful than ankle, and the other thing I took away from the study is that we can't be one-trick ponies unless you're incredibly facile with the frame, and so know what works in your hands, but also a willingness to be flexible and bring lots of things to the OR to have those tools that you need to be successful. And so with that, you know, when you're going to do this surgery, expect to be humble, expect to be rewarded, expect to have calls when you're on vacation at home, know how to counsel your partners to help you, and know if you want this, because you need to know it in order to do this work, and be prepared to sometimes have less successful outcomes, especially as you start when you compare yourself to the literature, but with that is also be willing to look at your results and ask yourself, how can I do better and participate in courses, these discussions, and ask your mentors for guidance. So these are my references. We just finished Jazz Fest here in New Orleans, and thank you all for having me. Sarah, thank you so much. It's going to be a real loss for your area when you leave, because those patients aren't going anywhere, but thank you for all the stuff you've done for them. If you want to take down your screen, then we'll move to Phil Kaiser, who was formerly at MGH and then left about a year ago, much to our loss in our area, and he's now out in the Bay Area and continuing his excellent work out there. So Phil, you're still muted, but looking forward to your talk on MIS and Charco. Let me just get that up for you, Chris. Good. Can you see my screen there, Chris? All right, thanks for having me on, and thanks to Dr. Bailey, Dr. Miller for having me and the panelists in this group. So I'm going to build off a lot of what Sarah and Chris have talked about already and talk about the role of MIS in Charcot, which I think really makes sense and is kind of an exciting, relatively new area and opens up a lot of options for these patients. And here are my disclosures, none are relevant to this talk. So what is MIS? Really it's not a new concept, and it includes other modalities such as arthroscopic surgery, which all of us perform, includes small incision surgery done under x-ray guidance, percutaneous procedures, and obviously MIS barosteotomy, joint prep fusion and debridement with or without fixation. And so it's a method that allows us to cause minimal trauma to the soft tissues, which is obviously inherently important in MIS surgery. We can do it through smaller incisions, and we don't need to expose surgical planes. It does rely on an excellent understanding of local anatomy, and then there's a technical component to this, getting comfortable using an MIS burr, which relies exclusively on tactile feedback and x-ray. And so these are some of the potential benefits, especially in our Charcot patients, is it reduces tissue trauma, which allows better healing, it preserves the biology, which as we know is very important, high risk of non-unions in this patient population. It can reduce surgical time, I think, in the long run when we're not exposing or making multiple long extensile exposures, less post-operative adhesions, fibrosis, scars minimized, less immediate post-operative pain. This might not matter as much in our neuropathic patients, but as we know, there are neuropathic patients that do experience a tremendous amount of pain. Minimizes tourniquet. I don't do any of the MIS work on tourniquet. So as we heard, I think it was in Dr. Miller's talk and Ongad's talk about minimizing tourniquets important for these people with macro and microvascular disease. The surgical principles are the same as open surgery. So we correct the deformity, we use robust internal and external fixation as Dr. Miller and Dr. Galli outlined, and we want to respect soft tissues and anatomy. And the indications, they're the same, but, you know, and this is level five evidence, this may allow us to intervene earlier in diabetics and vascular paths because we are decreasing the wound healing complication, which is one of the major limiting factors when we see these kind of neuropathic ankles early on, or these Charcot in patients with hemoglobin A1Cs in nines, tens, and above. And then I think, you know, the one underlying thing, these are probably the important slides that talked, and Dr. Miller gave some evidence on the mortality rate of these patients that ultimately go on to amputation, but, you know, this is hard already. So there's a lot of room for improvement in this. Complications rate, same as Dr. Galli's practice, mine are close to 100. They're all coming back to surgery, and I talked to that from the start. And you'll see in a couple of the cases, you know, taking patients back for frame removal, I'm often adding in other procedures, and they know that from the start. This is not a one and done procedure. This is multiple, man in an amputation. Mortality rates, Dr. Miller talked about, and these are real, these still apply. They're high. They're high in the first year. They're high in the first three to five years, and they're worse than most malignancies. And if you follow your patients and look them up, unfortunately, you'll see a lot of them, you know, don't just stop showing up to clinic, it's because they've passed away from their disease. And this isn't necessarily a causal thing that they have an amputation because of that, but it's correlated, and I think a lot of these people, it's difficult for them to become even low-level ambulators in a prosthesis. So I think limb salvage is an important goal, and hopefully with some of these newer techniques, a more achievable goal. I think MIS can seem a little daunting for people, too, especially when you're applying it to the kind of these bigger surgeries and tougher patients, and a good place to start is just start open. Like, do the normal procedure, have the MIS burr on the field, and use it. Use it for some joint prep, some exostectomies, things like that, I think it's a great application for. And then as you get more comfortable, you can decrease the incision side, your aperture, and move on to true MIS, and really, you know, it allows you to really be a surgeon here. I think you can be creative with how you use it, especially in Charcot, you know, you can do your osteotomies with it, joint prep, correct deformities, the options are kind of whatever you can think of. And so I want to go through a few cases and just kind of highlight some simple principles and hopefully give people some ideas when they are tackling these cases in terms of how and when they could use MIS. So this was a very simple one I did actually with another surgeon at my former practice. This was his patient, so I don't have a great follow-up on it, but he knew I was doing MIS for some joint prep and things like that, and he does a lot of arthroscopic ankle fusions and had this challenging patient, 49-year-old male, bilateral tailor AVN, Charcot ankles. He was end-stage renal, he was afib on eloquence and insulin-dependent diabetic. So tough surgical candidate, he was painful, couldn't walk. And so he asked us to kind of combine and do a joint procedure here together. So this was his CT scans, you can see the bilateral AVN, Charcot changes. And so he went ahead, did his typical arthroscopic ankle fusion, cleaned out the joint, prepped the joint, and then I came in and helped out with a MIS subtalar fusion. This is just an indicative picture of arthroscopic subtalar fusion, but just did this under radiographic guidance. I was able to prepare the joint nice. We added biologics in, both autograft and some PTGF, and then placed our TTC nail. And so you can see the incisions, and Dr. Miller had a very nice case he presented. This really cuts down on wound healing issues with these patients, which is a huge issue. There's a compliance issue with some of these patients. This patient was relatively compliant, but I think if you can minimize your incisions, the compliance is a little bit out of your hands, unless you're going to put on kind of a protective X-Fix on everyone, which has its own downsides. I think this really lets us tackle a little bit more and sleep a little bit better at night knowing that you're not going to see that big kind of lateral wound open up or start draining in clinic in the first few weeks. This was another case. This was a case of mine. There's a few parts to this. We think of, in terms of revision, is revision's bigger surgery, more open. Dr. Galley touched on it, though. That tissue, especially in Charcot patients, becomes a lot harder to work with the second time around. It's woody. It's not pliable. It doesn't move. And so this was the case that I actually revised. It was the original case of mine, but it was a female in her 60s, type 2 diabetic, now better controlled, but previously was uncontrolled. She had a cancer history, but was in remission. She had previously had chemotherapy with some induced neuropathy. Her BMI was in the 50s, and she presented with this plankton draining ulcer on the inpatient service. This was her X-ray. She had known Charcot diagnosed prior. She wore a diabetic type shoe, but this had opened up. And this was her original MRI, and you can see the AP of her foot with the deformity. This is just some representative CTs. You can see how that cuboid drops down. A good place to try MIS out is just for a cuboid exostectomy or that kind of lateral exostectomy in people with a slight rocker bottom that are developing either a plant or wound or ulcer. You can do that through a very small incision under X-ray guidance, and I've had a few at least temporary saves with that. So I took her to the operating room, just initial IND. We cleaned out the ulcer. It looked pretty clean. We closed it. I got my ID partners involved on antibiotics. And then I talked to her about next steps, and I think this is important to have a real conversation with how patients want to go. She had been ambulatory on this foot for a period of time, and obviously there's a deformity to it. But one consideration is just non-operative treatment, TTC, Cro, keep her off of it for a while, and then in a proper diabetic shoe, let her get back on her foot. There's a whole back and forth you can go between, do you do a midfoot procedure? Do you do a hindfoot procedure? My training was pretty heavily focused on doing a hindfoot with any charcoal or deformity that entered into the hindfoot area, and so I still believe in that. You try to get the calcaneus and tail set of Aquinas, get a solid fusion through the hindfoot, and at times you can leave them with kind of that flipper midfoot. So I started with an open procedure here, so I did the full TTC. She had that ulcer recently, so I elected to place a frame. We tried to get the calcaneus out of Aquinas as best we could. This was her initially in the frame. I also did osteotomies across the TMT joints to at least help with the positioning of the forefoot, but I didn't apply any formal fusion across it. This was her in the frame. Frames are a great tool, but also challenging in this patient population. You know, this is a big leg, multiple pin sites, especially once they start walking, there's a time that either the patient's going to require to take it off or the leg's going to require you to take it off, and so it's a constant balance. I do get a CT scan three to four months. I don't know if it's really useful. You know, you always kind of look at it and like maybe there's something bridging, maybe not. And we've seen a few examples like where like, hey, it looks okay on the CT, and then you get the frame off or whatever the fixation is, and these Charcot patients, they just lose it over time, and these were just a couple of videos. And, you know, critiquing, you know, this is hard to correct everything. You know, the calcaneus, yeah, maybe I got it out of a coin a bit, but still pretty flat. That cuboid's still down there, and that's sitting right under that incision, everything I cleaned out, so I think that's going to be an issue long-term. Bringing people back to get off a frame, I often touch up the foot in some way, whether it's, you know, doing an Achilles lengthening. In this case, I did do an MIS, exostectomy of the cuboid, and it felt stable in the OR. Someone else had a case. It felt stable in the OR. Like, I don't like just, you know, shake it. I like stress it. So I don't know what it is over time, maybe the load and cumulative effect of these people walking, but she did okay a month afterwards. X-rays looked reasonable. Started doing some protected weight bearing, and then two months after the frame, she comes back in way more swollen, gross instability on exam in the clinic, and she knew something was going on. And so we talked about options at this point, like other people have brought up, you know, do you revise this? Do you do internal fixation, repeat the frame, amputation? What's a reasonable option in this patient? And she elected to go continue with limb salvage. And I don't have any intraoperative pictures, but, you know, this was a nice one. It's tough to work. I had a big lateral extensile incision. That tissue was really woody and hardened, and I had already prepped the joints. And so through very small apertures, I'll show you, I'll show you her post-op pictures. We did a TTC fusion, re-prepped subtalar, re-prepped the tibiotalar joint, and this was her a couple of weeks after her revision surgery, and those small little incisions are healed. I'm not looking kind of at those big open incisions that I'm managing, leaving sutures in for four to six weeks. And so far, she had been doing well. She got out to six months, transitioning to a crow walker, you know, in terms of lifelong crow, you know, I at least get people to a year, year and a half, and the crow kind of protect all this work. I think there is still slow healing going on, and if that looks good, then eventually a diabetic shoe. This is another case, a case of midfoot Charcot, tough one, and just meant to emphasize the point, doesn't have to be like all or nothing MIS. So this is one I'll show you through kind of a mini open approach. I use MIS techniques to, to correct some of this, but this is a six-year-old female, history neuropathy, bad Charcot foot. She's had this long, long standing ulcer followed by podiatry, kind of with this offloading shoe, recurrent ulcerations. And then she came in when this ulcer worsened, I don't know if I have a picture, her leg too was just kind of this woody, non pliable tissue. And so I think, you know, working through those soft tissues can be really challenging and wasn't a candidate for BKA. This lady was just hanging on to simple ambulation in the home with a walker and her shoes. So we did an IND initially, we did the skin graft substitute, and this took a lot of time. This is weekly visits. And I was lucky I worked in kind of a joint limb salvage group with plastic surgery and myself and some other orthopedists. And eventually slowly we got this to heal with continued offloading. We let her walk eventually when she was healed on the right side there. And then I got a call from an outside hospital nearby about a year later saying the wound had opened up again and the surgery, the vascular and general surgery teams, they were recommending an amputation and she was not on board with that. So I had her transferred over to our hospital, which is nice and a privilege that you have the capacity for, like Dr. Aramgad pointed out, with vascular surgery or vascular interventionists there, ID and all the rest of the teams to help out with these cases. So we took her to the operating room, we just said, hey, let's take a look, clean up what's infected and talk from there. So we INDed, we backed, we cultured, and we discussed BKA or reconstruction options. And these were her foot x-rays. So you can see the severe deformity both in the AP and the lateral views. And so along with my plastic surgeon colleagues, we like to do kind of this mini open approach. I don't have any pictures, but I put in K wires across there and took out a pretty big wedge resection, a plantar base wedge resection, shortened the foot, improved that rocker bottom deformity. And then the plastic surgeons did a very nice local kind of soft tissue rearrangement and closure of that wound. We put her in a vac, I put a frame on her initially, it was this kind of butt style joint frame here to get some compression across the midfoot. I thought, you know, technically it's a little bit more challenging, but it was a nice option for her to get some compression across the midfoot. I still respect the fact that she was recently infected and she did OK in that. Obviously, this is a non-weight bearing frame. And so we left her in that for about three months. And then I took her back and I converted her to a more classic kind of TTC Elizabeth style frame. I still bent the wires that were in the forefoot, keep some compression across the midfoot. Thankfully, her ulcer continued to heal up, and this was her when we took her last frame off and eventually returned to walking. And you can see, you know, this is her rocker bottom deformity here. And I think we did a pretty good. This is not a normal looking foot, but we're just trying to get people ambulatory and save their foot in the long run. You know, this is being done more and more. I don't think this case is anything special, but just kind of outlines the fact that same surgical principles apply to MIS midfoot deformity correction. This was in a female in her 50s, better controlled now, but previously uncontrolled diabetic, charcoal midfoot. She was getting a plantar ulceration in the setting of this rocker bottom deformity. You can see the displacement of the TMT joints. So we elected to do an MIS procedure for her. And it's the same principles of deformity correction. You got to get these joints realigned. We clamped, we spent our time prepping all the joints across the TMTs through small incisions. I'll show you in a second here. But when we got it relatively reduced, we did our kind of typical bolts and beams construct. You know, looking back, I have a lot of bolts that break. There might be some more indications for nails and other more robust devices. But I think when in doubt, use more or use stronger internal fixation. And these were the incisions that we used for the case here. This is her still don't have long term follow up in here, but six months out doing relatively well walking. She's in a modified air cast boot and doing well at this point. And this was Chris talking more about ankle fracture, so I'll just show this case quickly, but it showed the applications and these neuropathic ankle fractures sometimes kind of co-mixed with cases of Charcot. This was a male in his 50s and he had kind of the kitchen sink of problems here. Type two diabetic. He was an avid smoker, heart failure, hep C. He was on methadone and he presented six months out with a dislocated ankle. I couldn't feel his pulses, but he's walking on the side of the foot. He was cutting his lawn. He said his ankle was just hurting more. I knew he did something about six months ago and this was his ankle. You know, he did not want to undergo a below knee amputation and I didn't want to do an open seat surgery on him. So we were left with doing something in between those two. And so I took him to the operating room and I had all the stuff and I combined techniques here. I used I did use a scope for the ankle to kind of start start the joint prep. And I worked through a very small open lateral incision to kind of free up the fibula and all the lateral soft tissues. And I used the MIS burr to prep the tibial joint, also the subtalar joint and the osteotomy. You know, this might not be perfect, but I think we got his position corrected nicely and we did it through very small incisions, which is the main thing I think long term with preventing complications in this guy. He's still despite all that, he's still one of these wounds on the lateral side, had this like drainage for like a good couple of months after that. We we managed with wound care eventually that that improved, you know, as Omgad has set up in his practice. You know, I think endocrinology might be one of the other pegs of the octagon there to kind of put on and, you know, manage these people. You know, the joints literature has pretty good evidence for for increased infection rates with with hyperglycemia post up. But this was him after surgery. Besides that one small incision that took some time to heal, he did relatively well and eventually got him walking in an air cast boot and he eventually into a regular shoe. And he was he was happy with that. So in summary, you know, I think just try it, have the burr available for these cases, even if you're going to do them open, just get comfortable with the burr in your hand, see how it works. It's not all or none. I don't think there's any prizes if you're showing cool x-rays or just small little apertures, you know, can make some open incisions and decrease it over time. And then Charcot is a great patient population to start this. And there's so much room for improvement here. The complication rates are so high. And I think this has a lot of benefits to offer these patients. Thank you. Hey, Phil, great talk and good to see you again. And for Amgad and Sarah also, you know, sometimes I look at these cases and it's just like exhausting looking at them, because I know all how hard all these things are and how much work it goes into trying to set these things up. And, you know, it's also sort of humbling to see the number of questions that we get versus the second toe people get, right? Everybody's interested in the second toe. We got like 10 questions and we have one question for us from the audience here. So if anybody has stuff, it's OK to admit here that you guys see Charcot and have some questions, but they're challenging cases. So I'll answer this one since it was directed to me. So it was Dr. Miller, do you have any tips for prepping the ankle joint thoroughly with the MIS spur? For example, where do you put your incisions and are you able to prep the entire joint percutaneously? And finally, if there is a pilon, I assume doesn't make it more challenging. So I will say that, you know, as with all MIS techniques, it really takes some practice and experience with it. And Phil and I, when he was still in Boston, we did a study together where we took a bunch of cadavers and just practiced prepping them in the cadaver lab to see if we could do it and how well we could do it. And he showed some of his pictures from that study, but it does take experience. And I think early on, I would use the scope to look in there and make sure that you have adequately prepped. And what we showed was that the percentage of the cartilage that you could get off with the MIS technique versus open was about the same for most of the joints. But you do need the hand control and you need the experience with the MIS bur. So I think you can do it. And specifically in this population, I actually find this usually easier to do it in these neuropathic ankle fractures, Charcot, because a lot of times the bone quality is so poor. So for me, it's when I'm doing it, and for these cases, I'm more worried about taking too much bone because you're almost just like blasting through the bone, it's so soft and you can get a lot of correction and take a lot of bone out before you realize it. I don't know if Phil or Amgad, if you're doing any of this, if you find the same with some of the bony debridement, but I have not had difficulty getting the bone, the joints prepped when I'm doing it with the bur. Well, I don't know what your guys' thoughts are on that. Yeah, I think you have to be really careful with the wedge burs. As you said, you can go a little off plane pretty quick. And once you do that, you almost have to catch up and redo the rest of the joints. I think you want to be, especially early on, and I still use a lot. Here's the downside of MIS is the fluoroscopy and zapping my hands for four minutes a case and things like that. After a while, I've gotten a little bit better and trusted it a little bit more. But yeah, if you start going off plane a little bit into soft bone, you got to take the other side of the joint with that. And so you can really shorten things and kind of make things a little bit more challenging on yourself. And whether it's a TTC or a midfoot, the more you shorten, and if you're one of those, or if it's one of those patients with those tough, soft tissues, the soft tissue envelope is going to prevent you from kind of actually getting those bones pushed together and actually achieving a fusion. So you want to take away as much bone as you need, but not overdo it. And I think that's one of the challenges at times. Pure question, Chris. I just started dabbling with MIS, but when I'm doing the major joints, ankle and sub-tailor, I still use a scope. I still use the small joint scope to prep. When I'm doing midfoot, I'm using the K-wire method Phil alluded to, so that my K-wires are my guide for my burn and that actually keeps me from taking a lot of shots and, you know, zapping my hand. And I can do big ankle and high foot deformities, but I'm not able to correct major midfoot deformities with MIS yet, just because of the extensive, the bone at that wedge, the bigger the wedge that you have to take out, just takes forever milling it down and squeezing it out. So I think those, and that's the question I had for Phil, is like how much midfoot deformity are you willing to take with that MIS burn and being as time-consuming as it is, as opposed to that small incision you showed on some of your cases? I mean, yeah, I don't know. I haven't, I think, yeah, maybe it takes more time to take down the joints doing it MIS just because, you know, you're doing it closed and can't use, you know, a saw or something like that that quickly, but whatever time I'm losing there, you're making up and, you know, closure and soft tissue dissection and all sorts of stuff like that. So, as Chris said, you know, it depends on the degree of Charcot, the hind foot stuff, sometimes, you know, it's pretty soft. The midfoot can be a little bit harder to work for. It's kind of a longstanding Charcot or the foot's immobile. So they're kind of like rigid there. So that can take a longer time. And, you know, the MIS talks from before, you know, you obviously have to take time with the burr. You got to cool it, same principles apply. So yeah, you got to spend a little bit more time working and then I'll make multiple incisions. I won't try to get, you know, second TMT from my first necessarily. If it's easier, just make another. So you can make it almost as many incisions as you want once you're keeping the aperture small to get your burr where you need it to go. Question in the chat here. So how does plantar flexion of the talus affect your surgical decision-making in Charcot foot? Maybe we'll give that to Sarah. It's a great question. Dr. Kaiser and I trained at the same fellowship where we were pretty extensively instructed that if you saw the talus starting to drop, I think there's been angles that have been published in literature. If you see that talus starting to drop, the declination increasing, then we were trained that you do a TTC fusion. I was still stuck with the triple for that. And so what my decision-making is, is I get a CT scan on these cases. And as long as the talus does not have cystic degeneration in it, I will still go with a more triple with extended medial column fusion in those cases using like a beam bolt type construct. The reason I do that is, I think I hate sacrificing an ankle joint that looks normal. And so if the ankle joint looks normal, the talus looks reasonably normal other than it plantar flex 40 degrees. You can do joint prep and do releases. And the joint prep is really hard to get it to correct, especially if it's a really bad valgus. But if you spend the time, you use K-wires, you use joysticks, I will have gone to a lot more open tendo-Achilles lengthening to help gain that length to also bring the calc pitch back down. And so for those patients, regardless of the talar declination, if there's talar bone, I will go with a medial column fusion. If I start to see a ton of cystic change in the talus, then I'm pivoting to either a TTC if I think there's enough bone or a talectomy with TC fusion. Chris, if I may pitch in, I'm of the same school and methodology of Sarah. I trained where TTC fusions were the go-to with the exact same methodology, but I started challenging the dogma, not just based on the CT, but also based on clinical exam. You will see these patients and you'll examine the ankle and the ankle is rigid, it's solid. It's not chiropractic, it's not going anywhere. If it's unstable clinically and it's rocking all the way around, yes, that's an indication for me to do that. But if it's stable and the ankle is moving and it's good and the CT is good, then I just exactly go for the same construct that Sarah is mentioning. But here's the key. When you have the peri-talar subluxation on the calcaneus slides from underneath the talus and the talus head dips this way, you have to do two things. Number one, in my humble opinion, number one, of course, after releasing the Achilles, you have to release and cut the perineal tendons because they are a major deforming force in your way. Not only do I go laterally, but I go medially and through the both lateral and medial incisions, I can see the sub-talar joint through and through and swing that calcaneus underneath. And once you get that calcaneus underneath the talus, the talus can swing up and pop up from that position. And then intraoperatively, I would use a K-wire through the TTC joint. So from the calcaneus through the talus to the ankle, just a K-wire, a thick one to hold everything, to hold that calcaneus in that straight position and then do the construct Sarah is mentioning with the midfoot beam and the triple. But that has been my go-to and I think I've been able to save a lot of ankles. Yeah, I totally agree. I think for me, the decision on triple versus TTC has come down to clinical. I mean, if it's grossly unstable on exam, that's one thing, but I really spend a lot of time looking at the CT, at the x-rays. If there's any instability somewhere on an x-ray in these patients, even very subtle, if you don't address it, it's not going to be subtle after your surgery. And so, as long as you're able to, when you have that rocker bottom deformity, the talus gets forced down, right? And if you can bring the foot back to where it's supposed to be, by weight bearing, you're not going to have that severe talar declination. But if you're looking, especially on the AP of the ankle, if you start seeing the talus looking like this in the mortis or whatever, I'm not going to, I don't think you're going to be able to save the ankle long-term. But that's just my thought. And again, I love the concept of pinning to, getting the hind foot and the ankle in the right position, finding a stable base and then moving everything back to it, I just think is a great technique that you got to work towards. The other thing I would add, the way Dr. Helene described it, which is fantastic, is I have started adding a laminar spreader in my medial incision. And that laminar spreader goes underneath the talar neck. And that really helps you elevate the talar neck. And then I used to do my sub-talar joint pinning first. And now I've gone to, I put that laminar spreader in, I elevate the talar head and neck as well. The talar head and neck as a unit. And then that allows you to spin the foot. And that's where I know that I can get the foot out of that externally rotated, pronated position because you can get the sub-talar joint looking right, but if you have not corrected that undercoverage of the talar head, you've already pinned your hind foot and then you can't get that correction. Because we know the talonvicular joint is all of a sudden is rigid once you have the sub-talar joint used and vice versa if you pin the talonvicular joint. And so I've really started spending more time making sure I get the talar neck elevated with the laminar spreader. I bring the foot around, pin my talonvicular joint reduced first. Then I do what Dr. Helene is describing next because I have found when I was doing my sub-talar joint first, I'd all of a sudden be like, ooh, my talonvicular joint's not right. And so it's a lot harder to correct that versus you can tweak your sub-talar joint a little more easily if you get your talonvicular joint correct first. You only need to get burnt once to do that. And exactly what that's what I do right now. Chris, I have a question for you, if you don't mind. Yeah. So you showed your rigid construct and that's an area of debate, where you have a TTC nail and midfoot beams and you have this really rigid foot and patients postoperatively, they're very happy because they have a stable foot but they have a difficult time going into shoes and they end up having these custom made shoes with a long lace up and the tongue. So what are your thoughts? And again, the folks at OrthoCarolina or Sarah and Phil trained are very big proponents of the flipper foot as opposed to the rigid, extremely rigid foot. So where do we stand on this dilemma? Are we going for a more rigid construct or are we just giving the patients a little bit of leeway so that these beams don't break down the road? Yeah, no, I like the flipper foot also. I think if with the TT, if you can get the hind foot realigned and back to the tibia, it's hard to then end up with a rocker bottom foot, right? So if I can leave the midfoot something, I will. That case, I'm not sure I'd want to do like a resection arthroplasty type thing through that. Maybe you could, but she's a tough one. She has a below knee amputation on the other side already. I want to have something that she can stand on that's going to be rigid for her and we'll see. So I like the flipper foot if you can have a little bit of a motion there. I think that's nice for the patient, but you also can't do that and leave somebody in 30 degrees of calcaneus. So that's where looking for that hidden deformity I think is going to be critical. Sarah, you had a question for the panelists. I forgot what it was in your talk. It was sort of like, are our outcomes also, not as good as some of the literature. And I just think these are really challenging cases. That was when you were saying that there, I'm a little bit of a nerd when it comes to sci-fi and stuff was why I had all the Star Wars references in there, but there's a quote from Ender's Game saying that the enemy is your best teacher or something like that. And these things just, the only teacher is going to be doing these things and learning from other people and from your mistakes and everything else. So I think I was really impressed with your cases. Thank you. I appreciate that. And it is, it's very humbling. And the x-rays, I think our MIS colleagues talk about how their x-rays, they don't look like normal x-rays. Charcot x-rays don't look like normal x-rays. And like my radiologist, I have a lot of non-union from a radiographic standpoint. And that was my other question for the panel is just asking you guys, what is your radiographic union versus like clinical union? And do you think that's worth differentiating or am I just wearing rose colored glasses right now? I will tell you that I care more about limb salvage and a braceable, shootable foot. And I've listened to Dr. Pinzer talk a lot about this stuff and his talks show a lot of midfoot non-unions also. I mean, and he's a master at this. So that's not a criticism of him at all, but I think they're tough. Amgad, did you have a, you raised your virtual hand. Yeah, I think I just, we're currently doing a systematic review on meta-analyses and I think it's really prudent for us when we're reporting our results to differentiate clinical and radiological non-union which has been under-reported in the literature. So although reaching a clinical successful plantigrade foot with a fibrous non-union could be achieved as a success, all right, I will tell you, reviewing, having done the literature review, there's a very big blur and I think we should be very prudent when reporting our outcomes to clinical versus radiological. Whether that impacts our clinical survivor rates I think is yet to be determined with longer term follow-up. But I had a question for Sarah and that might be my last question for the panelists. If you have soft tissue compromise like an ulcer or maybe phil can contribute as well and it's not probing to bone, so it's not osteo yet, what are your thoughts about putting on a ring external fixator as a shield, as a temporary stabilizers instead of topical contact casting for wound care and plastics be managing this and then after the acute sarcophagic and the soft tissue compromises heal, we go back again and do definitive. Have you tried doing that algorithm at all? I have, I have a gentleman right now who I have been following for years and we tried wound care, he had wounds. I was like, I'm not gonna fix your foot until the wounds are gone and the wounds just never healed. And so finally we're like, okay, maybe we need more stability. I really wish I had the skill set of MIS because now we've put him in a frame, I released all of his joints, his foot is now planted great and his wound is healed and now he has wounds from my surgery that are slow to heal. And so now we're doing wound care again, but his foot is more planted great because I was able to do the releases. And so I do think it's a helpful strategy. The challenge I have found is that I have yet to have a patient that will let me leave a frame on them longer than about three and a half months. And so if you know you need the frame for the second part of your case, I have had a hard time talking myself and talking to patients into a frame that is gonna start becoming a four, six month frame because you're using it for stability first and then you're probably gonna need it when you do their reconstruction. And so I think it's a fantastic idea. My plastics colleagues love it because patients don't get new ulcers from resting their leg in bad positions. But I think you have to be prudent in your patient selection because those get to be some really long frame courses for the patient. I wanna say one thing and then leave with a final thought before turning it back over to Errol. I'm glad you said you only make that mistake once for something. The other thing, if you're gonna do a frame and I tell my residences, always make sure you close your big incisions before you put the frame on. You only make that mistake once. And the plastic surgery folks they'll always wanna put the flap on before the frame goes on. They make that mistake once too. It's just so painful to close around the frame. It's painful to get the stitches out under a frame. And I wanna say, first of all, thank you. This has been a really amazing panel discussion and just super impressive with everybody's cases. So I've learned a lot. And so thank you. I wanna leave just with this one thought, but we talk a lot about this orthopedic surgical side, the stability, the deformity correction, everything like that. And one thing that I don't see talked about as much as sort of the psychosocial aspects of this, like has anybody met a patient with Charcot who is happy with their life? And I sometimes say they're all angry. They're all feel like the world has just persecuted them and turned against them because this is, they're living their life and then suddenly their foot's falling apart and they don't know why. I spent a lot of time talking about that. I think one area to look in the future is like how can we help support them from the depression and psychological aspects? And that's one area where kind of the promise depression score may be really important for identifying like how do we improve these people's livelihoods, not just their foot? And I challenge everybody on the call to think about that because we might be the only people that ever talked to them about that. And we don't have a lot of time, but even just acknowledging the suffering that they're going through can be very helpful in their healing process. You're absolutely right. And actually to your point, this is, when I see a Charcot-Baptist patient, it's a 45 minute encounter regardless. And just, it's all about setting expectations. So I talk to them, if you're looking at a limb salvage surgery, it's going to be a six month to a one year project. And I actually counsel my patients a lot about if I'm going to put on a ring external fixator about leaving it for all the way up to six months. And when you tell them that the first time and you show them the frame, if they're on board, they have the mindset of reliving with the reality that they're going to be, living with this Frankenstein cage for the next six months or so. And I've had them, I've had them do that. Of course, I tell them the earlier, if we are able to move it earlier, the better. But if you want that very first encounter, just like you mentioned, Chris, spend a good 25 minute counseling the patient, setting up expectations. I think you're setting the stage for success, not only on the physical state, but on the mental state. Well, thank you all. I'm going to turn this over to Errol now for something completely different. I think we're getting into our total ankle. And so hopefully nobody's doing total ankles in Charcot. That would be a great complication talk in the future if you are, but I'll turn this back over to you guys now. Thank you so much. Thank you, Chris. I don't do a ton of Charcot. Thank goodness that I don't have to do that. I've got younger partners who love it and I am so happy that they exist. This is an incredibly challenging era and you guys have really laid out a very strong foundation for all of those who are tuned in. So I just want to commend all of the speakers. Thank you.

Charcot neuroarthropathy

approach to treatment

case studies

soft tissue condition

wounds

ulcers

infection

talectomy

biologics

challenges

complications

panel discussion