Thanks for everyone who stuck with us towards the very last session. This is the 1.30 central time session on progressive collapsing foot deformity, and this really is an update on what that is. That will be started with Dr. Conti, followed by treating a failed flat foot by Dr. Irwin. So our first speaker is Dr. Conti, who is an assistant professor of orthopedic surgery at HSS. His topic will be, what is this and why do I care regarding the progressive collapsing flat foot deformity? Dr. Conti? Thanks, Glenn. Can you see my screen? Yes. You're good to go. All right. Okay. So I'm going to talk about progressive collapsing foot deformity. What is this and why do I care? These are my disclosures. So I'm going to start with what is progressive collapsing foot deformity, and the name has been updated over the last several years, so why did we update the name? And then I'm going to talk about how I'm preoperatively planning for my cases. I have two cases that I'd like to present today, and then just some new thoughts and new research that's been coming out. So initially, we called the disease posterior tibial tendon dysfunction, and then adult-acquired flat foot dysfunction or deformity, and those names didn't really encompass all of the deformities that go into the foot when a patient has a collapsing foot. And so talking to patients, it can be confusing when the patient says, I've had a flat foot all of my life, why is it bothering me now? And we know from recent data using weight-bearing CT scans and MRIs that it's not always the posterior tibial tendon that's involved. It's both a bony and a ligamentous problem. So a consensus group came together and they proposed changing the name of the disease to progressive collapsing foot deformity, acknowledging that at one point, once patients begin to have significant pain in their foot, it's typically a progressive natural history. And what's happening to the foot is that the arch is collapsing over time. And so in addition to changing the name, they proposed changing the classification system. So Johnson and Strom in 1989 came up initially with this classification system based on the posterior tibial tendon. And so stage one was based on just tenderness along the posterior tibial tendon, stage two was a flexible foot, and stage three was a more rigid foot. But this classification really only applies to when the posterior tibial tendon is involved. But we know now that it can be that the posterior tibial tendon is not always involved in this pathology. It can be the interosseous ligament or just the bony anatomy that causes pain during a flat foot. So the new progressive collapsing foot deformity classification, instead of describing it based on the posterior tibial tendon, they wanted to describe each individual deformity that we see in a progressive collapsing foot deformity and then decide whether they're flexible and rigid. And I think the idea behind this consensus classification was that if you could better identify each of the individual deformities and then identify if they're flexible or rigid, it may go on to help us understand to standardize treatment for these patients. So class A is a hindfoot valgus deformity, class B is a midfoot forefoot abduction deformity, and class C is a forefoot varus or medial column instability. And so those were fairly classic deformities that people had thought of. Then they went on to describe peritailor subluxation dislocation, which is significant subluxation at the subtailor joint. And we know that from more recent studies on weight-bearing CAT scan, that middle facet subluxation can happen as the calcaneus kind of slides out from underneath the talus and the talus plantar flexes and inverts. And then also when the deformity becomes even more severe, you can get subfibular impingement. So that became part of the classification system as well as ankle instability. And so using the new name and the new classification system, I wanted to talk a little bit about how I'm preoperatively planning my cases and what tools I'm using to do that to better identify the deformities that my patients have. So I found that identifying deformities on weight-bearing plane radiographs alone can be challenging. And so this is a study looking at weight-bearing CT scan and how potentially weight-bearing CT scan has changed how people think about the deformity and which deformities are involved. And so if we look on the bottom are the classes of deformities, and then the blue is just plane radiographs and the red are weight-bearing CT scans. And in cases of midfoot abduction, forefoot varus, and peritalar subluxation, weight-bearing CAT scan may change management. And so I think weight-bearing CAT scan is giving us more information about the deformities that these patients have and potentially the opportunity to better investigate how patients look preoperatively and then how we correct them postoperatively and what their outcomes are as we continue to learn more about this disease. And this study out of Mercy Hospital also changed my thinking because, and what they found was that on weight-bearing CAT scans, they found that about 38% of patients had sinus tarsi impingement in the subtalar joint, and then about 35% had subfibular impingement here. And so potentially these are indicators of more severe disease and maybe these are indicators that the subtalar joint is unstable. So when I'm preoperatively planning for patients, and I know this isn't available everywhere, so it's controversial, I think, to say that you need this, but I just found it to be extremely helpful in understanding my patient's deformity, understanding where I need to fix. And these are obviously very drastic examples of different deformities that you can see on weight-bearing CAT scan that maybe aren't as readily visible on weight-bearing radiographs. But here you can see the sinus tarsi impingement where there's impingement in the angle of You can see that the fibula may abut both the talus or the calcaneus in severe disease. And then in patients with severe subluxation at the subtalar joint, that may also demonstrate instability at the subtalar joint, and it's been written on over the last few years, looking at how much subluxation at the middle facet is suggestive of a flat foot and then potentially a painful flat foot. And then what I've also found, and that other study, when I was going through the literature to put together this talk, that study that I presented at the beginning, looking at weight-bearing CT scans to look at the deformity, what I've also found is that true talonevicular abduction is really difficult to determine on plain radiographs alone. And when I was looking at this patient, she didn't seem to have a lot of forefoot or midfoot abduction, but I couldn't tell how much talonevicular uncoverage was at the joint. So does the articular surface of the talus really end down here, or does it end here? And so it's really challenging. So this is just the slice that I used on the weight-bearing CT scan, kind of at the midpoint of the talonevicular joint, and I think it better demonstrated that the end of the articular surface is sort of in this area, so there's really not that much uncoverage at the talonevicular joint, so I avoided doing a lateral column lengthening or a larger medial column procedure. So now I just wanted to go through some cases and just talk about how I preoperatively plan and then intraoperative decision-making. So my first case is a 53-year-old woman who had three years of medial ankle pain. Her pain was localized primarily to the medial ankle, and there was no pain laterally. Her heels inverted on double heel rise, and she was unable to perform a single heel rise on the right. I still use this test to determine the flexibility. I also manually test the subtalar joint to look for flexibility as a double check to make sure that I'm going to correct a flexible deformity. The tenderness over the posterior tibial tendon, she didn't have first-rate hypermobility on examination, which is obviously clinically very controversial and even radiographically hard to determine first-rate hypermobility, but in my hands, she didn't have first-rate hypermobility. She had a gastrocnemius contracture. And these were preoperative radiographs, and she did have on both exam and radiographically a bunion. It didn't hurt. How it's not this deformity didn't bother her, was asymptomatic, had no severe plantar gapping at the first metatarsal joint. When we went to her MRI, she has really severe thickening of the posterior tibial tendon, mild edema within the angle of Cassane, but nothing else remarkable. And then, again, I'm getting a weight-bearing CAT scan, and on the sagittal view, I'm scrolling through and I'm looking at, is there plantar gapping or evidence of hypermobility at the first tarsal metatarsal joint? She did have a spur over the dorsal talus, but that wasn't symptomatic. Then I'm looking and scrolling through and looking at the sinus tarsi and looking for impingement in that location, the posterior facet of the, as well as the posterior facet of the talus. On the coronals, I found that you can get a good sense, obviously, of the valgus nature of the posterior facet. If they're in significant valgus, she was not. Also, you can look at the medial facet subluxation. She has very minimal medial facet subluxation on these radiographs. And you can also really get a nice sense because we always get Saltsman views or Hindfoot Lyman views in the office, but I found that just measuring the inferior point of the calcaneus here and comparing that to the center of the tibia, that distance gives me a better judge of the real Hindfoot moment arm and how much in valgus they are. And then again, you can use the axial CT scan to evaluate talinevicular abduction, which she did not have significant talinevicular abduction. So for me, in this case, I started with my gastrocnemius recession. I was going to do BMAC because I had a feeling I was going to do, or I knew I was going to do a cotton osteotomy since she did not have first-ray hypermobility. I didn't think her asymptomatic bunion needed to be treated with the first tarsometatarsal fusion. I did my FDL transfer, which I find the FDL really, I go all the way to the knot of Henry and then use a biotinodesis screw through the navicular, and I perform my medializing calcaneal osteotomy. I think what we found radiographically, and I think as we get to weight-bearing CT scans, some of this can be further validated, is that you want to avoid overcorrection in the flexible progressive collapsing foot deformity. And so I try to avoid doing a large cotton or a large lateral column lengthening, and I want to get the heel aligned. So if you're going to overcorrect one thing, you want to put this into a little bit of radiographic varus or clinically neutral heel when you slide the heel. And so I did my heel slide and slid her heel over. I sort of preoperatively measured how much I was going to slide the heel, and this is about eight millimeters I thought would get her kind of centered under the tibia. And then I did my cotton osteotomy. I started with my medial approach, and then I tie the biotinodesis screw at the very end of the case after everything. And so here were her final fluoroscopic images, and then she's three months postoperatively, and her cotton osteotomy is healing in her, and her heel looks like it's in better alignment, but potentially not overcorrected, and maybe I could have corrected her hair more. And so my takeaways from this case were that asymptomatic bunions don't need to be treated with a first tarsometatarsal joint fusion. I mean, she's very short follow-up, so I guess that will remain to be seen, but I think putting a cotton also probably stabilizes the medial ray and decreases hypermobility at the first tarsometatarsal joint. So I don't think, I think with patients with mild hypermobility at that joint, they don't necessarily need a first tarsometatarsal joint fusion, and then you really want to avoid overcorrection of the practice of collapsing foot deformity. This is my second case. This was a 60-year-old woman who had one year of medial pain and then began developing severe lateral ankle pain. She had two corticosteroid injections to the sinus tarsae by an outside provider, which gave her good pain relief. She had a BMI of 38, significant pest planus with hindfoot valgus. Her heel did not invert with a double heel rise, and again, she had no first ray hypermobility. So these are her preoperative radiographs demonstrating severe talonavicular uncoverage, collapsing through the arch. There's sinus tarsae impingement you can see on this radiograph, and really severe hindfoot valgus. Her posterior tibial tendon actually, you know, didn't look terrible, but certainly she had impingement in the sinus tarsae, and so we can see that on this CT scan. There's the sinus tarsae impingement. She also, I mean, you could argue has arthritis within the subtalar joint, severe collapse of the arch, no real first ray hypermobility on her. Again, you can get a better sense of her hindfoot valgus here and really how valgus her subtalar joint is and how valgus her heel is. And then finally, we can use the axial view to look at her uncoverage and how severe that is. So for me, this is a double or triple arthrodesis. I think there's controversy about which one, and I won't talk about that, but I performed a double for her, did a BMAC, a gastrointestinal session, and then I always consent patients for possible medializing calcaneal osteotomy and a possible cotton. And so for her, I think it's really important to be able to fuse the subtalar joint in the appropriate alignment, and then if you need to move the heel over after you try to fuse the subtalar joint, you do a medializing calcaneal osteotomy. You don't want to try to crank the subtalar joint over into varus and then try to fuse the subtalar joint when it's not aligned in order to get the heel over. So I found more and more that I need to move the heel over in order to appropriately align my subtalar joint. So I almost always perform a medializing calcaneal osteotomy in the setting of a subtalar fusion in order to get the hind foot over, and then I get the talar navicular joint where I want to, but because of her severe collapse through her medial column, I like to further stabilize her first ray by performing a cotton osteotomy, get a first ray down. She didn't really have hypermobility at the first tarsometatarsal joint, although I think that would be a reasonable option in this patient as well. So the takeaways from this are that, you know, I think a double arthrodesis that's well-aligned and that may require a cotton osteotomy or a medializing calcaneal osteotomy as part of subtalar fusion is a really good option for patients with severe deformity or subfibular or sinus tarsal impingement, and so just always be ready to perform a medializing calcaneal osteotomy or cotton osteotomy in those situations. And then just in the last minute, I want to talk about this because I, there's been a lot of talk about it, but not a lot of data. And so in the flexible deformity, I know that there are some people who are adding a brevis to longus transfer, and it wasn't something that I had, that we had talked about a lot when I was a resident, but more in fellowship, I heard about this procedure, and across the country I think people are adding it at the end of their flat foot reconstructions in order to take away a deforming force on the foot as well as plantar flex the first ray. And so this is the only real data on this procedure, and it was performed in 12 patients, and they demonstrated good radiographic improvement, but obviously in a flat foot deformity, it can be really challenging to know how much of the deformity is coming through the concomitant procedures you're performing versus the soft tissue procedure. And so we've started here at HSS, we have a simulated flat foot model, and we've had an opportunity to look at adding a brevis to longus transfer, and so the way that we did it in this study and the way that it was described was at the level of the perineal tubercle to take that down, and then you cut the brevis, you let the distal part of the brevis fly, and then you advance the brevis tendon approximately one centimeter, and then suture it to the longest tendon. And so what we found in our flat foot cadaveric study is that you do get increased plantar flexion. We had it through the tail intervicular joint just in our model, I think that there's not very much hypermobility through the first tarsomenotarsal joint in the cadaveric specimen, so you don't really get a lot of plantar flexion through the TMT joint, but because there's more motion of the tail intervicular joint, we were able to demonstrate you get increased plantar flexion and potentially stabilization of the first ray, as well as decreasing the abduction deformity at the tail intervicular joint as well. So I think this is really early data. I think that a lot of people have spoken about it and are interested in it. I think that there's some early cadaveric data and then some early patient report outcomes that suggest that it may be a good concomitant procedure to add at the end of your cases. It's fairly quick and kind of low morbidity. So thank you very much for the opportunity to present and be happy to answer any questions. Yes, thank you, Dr. Conte. That was a very good summary of the new description of progressive flat foot deformity. If you all, for the attendees that are still with us, please type in your questions. We'll address them shortly after the next and final talk. This is a talk by Dr. Todd Irwin, who is an orthopedic expert at OrthoCarolina, and he's going to discuss those flat foot reconstructions that have failed. So his topic will be treating the failed flat foot reconstruction. Dr. Irwin? Thank you, Glenn and Errol and Chris, appreciate being here today. Let me just find my talk here. Can you guys see that? Yes. Okay. Okay. So again, thank you very much. Appreciate the opportunity to talk to you guys and to follow Matt Conte. It's fun to do this with everyone and see if we can get going here. Okay. Here are my disclosures, nothing pertinent to this talk. So Matt gave a great overview of PCFD, and I have incorporated this newer classification system into my practice. When Matt was a fellow with us in Charlotte, we had a lot of good conversations about this. I know Matt was able to be in the room for a lot of these discussions with the consensus group. And so I can just kind of imagine Matt being there and actually speaking his mind and standing up with all the giants in our field and say, no, this is the way it has to be. And so because of that now when he talks about flat feet, you know, this is this is what he looks like he's pretty cool and he's like I can do this. So, anyway, because this is revision talk we're not going to not a lot of literature out there on this. Just revisions in general but I do think with the PCFD you know Matt went into a lot of these concepts and so I think when you're thinking about revisions you have to remember the components this is what I think about when I do a primary case and I think you got to think about it with revisions also. So you have your gastric tightness you have your PTT insufficiency and spring ligament disruptions you have your hind foot valgus and foot abduction and medial column collapse and forefoot varus and peri-taylor sub-taylor subluxation and even that the deltoid instability so the. I think those things are obviously all important, and then. Hang on, sorry. Okay. I also kind of was able to start thinking about this talk with asked to give it a revision like oh this is easy this would be a, this would be a two slide, you know, two slide talk just double triple. Okay, you're going to revise a PCFD double triple but I think it's a little bit more nuanced than that so I had the opportunity to contribute a chapter to this, this textbook and it was revision the failed flat foot reconstruction a few years ago. So I did think about this some and and I also would refer you to September 2017 17 the foot and ankle clinics issue really has a lot of good articles in it review articles on flat foot, and there's some revision articles in there and a lot of these are in my references so if you're looking for more information I took a lot from this just in my practice. In my chapter I kind of came up with this. This algorithm and so one sec. So, you know, the first thing is just looking at, you know, is the, is there deformity what's the alignment and so the first thing is, is it acceptable alignment or is it, is there a residual deformity and so if you go down and say okay, this is an acceptable alignment well then what is the causes of your pain I'm not going to go through this whole thing it's, it's a little bit involved but I think it helped me kind of think about these revision cases, cases. So if the cause of the pain is DJ D or non union then you address that. What if it is residual deformity so if it's residual deformity is it under corrected or over corrected, the next slide will show over corrected but if it's under corrected you say okay what's the location is the forefoot mid foot is it behind part of the ankle, and then you go from there and, you know, again, we don't have to go into each of these but with each location you say, you know, again, what's the deformity are we going to do joint sparing and we're going to do joint sacrificing. So these are all kind of procedures that we know how to do flat foot reconstructions with, but you just have to kind of go through the algorithm to help you with your revision case for an over correction. Again, same idea, what's the location forefoot mid foot high foot ankle. And in the end, this is pretty much just a cable various reconstruction at that point. Moving on so I'm going to talk about some cases I don't have an overcorrected case in this is mostly some other things but we're going to hopefully hit a lot of those things on that algorithm. So first case was a 68 year old female she had two years status post poster to attended to breed and advancement with the first team to fusion This was done at an outside hospital. At this point she had zero out of five poster to 10 and function, she had an asymmetric pes plano valgus here her radiograph so for each of these cases I'm going to talk about what was the potential reason for failure and then what you know how do you address the revision and what should you think about this case I thought it was more inadequate medial tissue soft tissue stabilization or poster to 10 and was diseased, probably was an underpowered initial surgery she didn't have a good hind valgus correction. Maybe they didn't correct the medial column enough. So, in terms of the algorithm this was a residual deformity case that was under corrected. So, my approach for revision and this was to do an FDL transfer and DCO a lateral column lengthening and a cotton osteotomy through the previous first TMT fusion, as well as a TL. So, interoperatively, I was happy with the case, probably maybe give her a little too much calcineal pitch there with inferior inferiority of the tuberosity but I was pretty happy interoperatively. So this is what she looked like at year and a half she had improved Taylor vehicular coverage. It's kind of funny looking but importantly she was doing well, but you see this lateral column lengthening and she had a non union there with a broken screw. Thankfully she was asymptomatic and she didn't need revision surgery. But this leads us leads me to my next case. This is a six foot 11 former NBA basketball player who is 66 years old. He had progressive arch loss medium lateral hind foot pain. And if you look at these x rays I think you can definitely see Taylor vehicular on coverage and abduction lateral not too bad but then you look at his other side comparison view and you can see he's got relative cable cable various on his normal side so pretty more, more significant substantial flat foot on this side. So this is my plug to get comparison views on all these cases I think it's very, very helpful. You also have to always look at the ankle so that's one of my other take home points always got to look at the ankle and these flat foot cases. And you can see the ankle in this case looks good no dog is tilt but you can see the foot is really flat underneath it as well. So we do get the MRI and you can see his poster to 10 minutes is pretty much gone so again this is still just a primary So my surgery was a gastroc recession and FDL transfer MDCO lateral column lengthening first TMT fusion and as Matt just pointed out a longest brevis transfer. So I was very happy with the correction, however, at six months post up you can see again, good correction. Another lateral column lengthening non union. Great so I'm doing over to so far on my lateral column lengthenings. So here's our weight bearing CT scan. As we go through you can see the non union coming in right about there and we can see in the sagittal view. The lateral column lengthening non union again right there and if I can control this a little bit. I studied this a lot because I didn't know what I was going to have to do to revise it is there enough bone stock to really revise it or am I going to have to fuse the joint. So, potential reasons for failure here. Am I not fixing my lateral column lengthening it's enough I think it's a very fair argument. I typically have only done one screw, however, you know if you put a plate on the lateral side I think you can get involved with your perineal tendon so I think there's some things to think about there but probably wasn't fixed well enough. What about graft resorption, I've typically used allograft soaked in BMAC for this would a metal wedge be better. Well I think it's debatable and we'll see some other cases going forward. So in this case with the algorithm. This was an acceptable alignment I thought, but it was a non union. So what are we going to do. I think you have to think about bone stock what's the status of the CC joint. Are we going to be able to revise that on union or fuse it. And then we just have to maintain our correction. This is a case I actually did with Matt. I remember us talking about it a lot, not really being sure what we're going to be able to do once we got in there. Thankfully, there was enough bone stock to revise it we use proximal tibia bone graft and some biologic, and then we improved our fixation so couple of screws night and all staple. And luckily he did quite well and fused it up and was doing very well and here's his clinical alignment like this is either six months or a year out after the surgery, so that was a win after a hard case. So, very similar case, 54 year old male this is several years ago now. He had a previous reconstruction done with an FDL transfer MDCO lateral column lengthening initially with allograft. And then per the report he had a non union of that allograft and then that was revised for trabecular metal wedge this is all again done somewhere else and he came in with persistent lateral column pain and swelling. So you can see his x rays here pretty good acceptable alignment lateral column looks funny metal wedges in there a couple old broken screws from the first surgery I believe. And here are some select cuts of a CT scan. So this one's a little bit different you can see on that sagittal view that he's got that metal wedge it's kind of flexed down there's a fracture into the interior process broken screw right there. So in my opinion this CC joint is not salvageable, but he's got this metal wedge in and how are we going to address, address this whole, this whole lateral column. So potential reasons for failure in this case as well as other considerations to think about I kind of mentioned them already. You know what, where was the initial lateral column lengthening was it was it posterior enough or proximal enough was it too close to the joint. And now what about our bone stock, how are we going to address this whole, this whole issue with the metal wedge the allograft etc. So I think he's acceptable alignment in this but in this case he had DJD of a CC joint. So the first revision was we I felt we had to resect the entire interior process including the metal wedge which you can see there. This leaves us a huge bone void. So we had to do a calcanea cuboid joint bone block distraction or not really distraction but just a bone block arthrodesis. And in this case we use a vascularized medial femoral condyle autographed with one of my hand surgeon colleagues. So we put this in we did have to use a little allograft as well to help kind of fill in fill in the defect. And this is what he looked like a year out with his x rays and then a select CT scan which honestly looks okay I think his screws were all his, his hardware was intact, he held up I think he's bridging across it. Not a tremendous fusion but he was doing reasonably well considering this. This is another option very similar case this is from one of my partners Dr. Joe Carol Jones. Very similar metal wedge issue, and he addressed it with a autographed wedge so where he he took a wedge from the superior tuberosity placed it into the calcanea cuboid joint as autograft backfilled that area with with allograft, and then did a in addition for stability so I think this is another great option and you can see here he's got a very nice looking post op CT scan with a good fusion. I think probably the game changer here, these are all done you know several years ago, and I think with the advent of 3d printing and custom cages and wedges and things like that I think that might be a better option today but again these are a couple of different options in these, these cases. Okay, next case 71 year old female. She was 11 years now status post flatfoot reconstruction, which was a gastroc FDL transfer MDCO and again a lateral column lengthening this was done by one of my senior partners. And she said you talked to her about you know what happened the time of surgery said well for a couple of years but she had a relatively quick recurrence cosmetically she felt like her foot collapse pretty quick. And now she's been complaining of lateral high foot pain for several years and she just kind of been grinning and bearing it because she was kind of gun shy about doing anything else just because the initial recovery was so difficult. So these are the x rays initially on the left six months post up on the right, and very good correction very skilled surgeon I think, you know, it looks great. However, at 11 years post up this is what she looks like now. So you can see that she recurred through her tail and vicular joint, the lateral view doesn't look too bad but she's got significant abduction. Most importantly, we still get the ankle x ray so she doesn't have any valve is going through the ankle but it's important to make sure we always look at that. Here are her clinical fit pictures and you can see asymmetric test panel valves on the right compared to the left. Here's her standing CT scan, and you can see here maybe I can speed this up a little bit. Here's her tailor joint which now she's got significant DJD of her sub tailor joint. There's the metal wedge doesn't look bad looks like it was placed well but who knows if that's impinging a little bit, maybe a little bit of sub fibular impingement right there. But overall pretty good alignment. Here's the sagittal view. And again, you can see the sub tailor DJD right there, maybe a little bit of calcaneo cuboid joint DJD as well. So, that's her, her situation. There's potential reasons for failure in her, maybe she collapsed through her sub tailor joint and real sort of had a rotational type collapse. Maybe there was something going on with the medial column or spring ligament. Maybe there's subsidence through that metal wedge. So in my opinion for the algorithm in this case she had residual deformity and it was under corrected. So, for me in this case I hit the easy button. I'm going to say this is a double triple she's 71 years old I think that's the way to go for this case, however, she's got that metal wedge in there so again if you're going to do a triple and what are you going to do with that lateral column. This is an intro up video, and you can see as we start to move the foot a little bit. That is the cuboid right there the CC joint is distal to this so she had good incorporation approximately of her metal wedge, but no real incorporation distally so I think probably the answer in this is that she subsided through her metal wedge. And that's probably why she, she failed. So in this case I did a double where I did a realignment subtalar arthrodesis with the tail and avicular arthrodesis didn't exhaust stuck to me of that anterior process and attend to Achilles lengthening, but it just kind And figured, I am kind of a double versus a, I am more of a double person than a triple person in general. And so again we can debate that some other time. But, you know, there's not much motion at that CC joint once you get the other two joints fused and she actually did quite well at two and a half years post op she came to see me again for an unrelated issue and her x rays looked quite good. So last case here, a little bit different. This is an 86 year old male, he was 10 years status posted a triple arthrodesis for a flat foot. And now he came in with lateral hind foot pain and progressive deformity. This is what he looked like clinically with again asymmetric pes plano valgus on the right. So you can see he's still pretty abducted through his tail and avicular joint, maybe there are some under correction there. But again, importantly, we get his bilateral ankle films. Now this case he's got valgus instability on his right side. So that's probably one of the major causes of the subfibular impingement type pain. Here's a CT scan just a couple of shots. And again, valgus instability with ankle DJD subfibular impingement, as well as collapse through his medial column, and the vicular cuneiform joint. So, potential reasons for failure in this case, I do think is what was probably under corrected. This may be led to a progressive deltoid insufficiency and just a super difficult case as Liz Cody showed earlier with some of her valgus ankles. So again, this fit in the category of residual deformity that was under corrected but this one involved the ankle joint so pretty tough case. So I think when you think about revising this, you could go straight to an ankle fusion however he's got a triple underneath that that leads to a pan tailor which is not ideal, definitely need to correct the foot one way or another, and then you have to start thinking well am I going to do this in one stage or two stage. So, we did this in one stage I think two stages is very reasonable. Partly this was because of his age and his sort of appetite for doing one surgery versus, you know, staged, you know, to surgery So we did a total ankle arthroplasty to address his valgus ankle DJD. We did an MDCO underneath his triple. We added an NC fusion to bring the medial column down and we did a tendo Achilles length. I think you could definitely argue that with the tail and vicular uncoverage maybe we maybe didn't address that. I think if I would do a two stage procedure I'd probably do some of this with a revision triple and maybe take a wedge out of his medial side, and then come back and do the total ankle later. But again with the one stage this is what we felt comfortable doing all at once. And he did quite well from this little bit of August tilt there as you can see, but he did relatively well and you know tough case for older gentlemen. So in summary, I think for revision cases PCFD similar to your primary surgery remember the components, address the issue if you can. The easy buttons always going to be your double or triple arthrodesis but I don't think everyone needs this so kind of everyone's a little bit different. You can consider the algorithm to help your decision making and, and obviously we have to fix the foot but don't forget the ankle I think I mentioned that many times and that's always very very important. And again, if you need to swear don't, don't be afraid to swear and people who know me know I like to do that. So, these are my references thanks again for everyone's listening and for being the last talk of this three day course, it's great course. Thanks. Well thank you very much for that excellent talk to the attendees we will try to address as many of the questions as we can. First the end saving maybe a minute for the chief to have some closing remarks. So the first question come from Jeremy, I guess it's a question regarding the easy button. Can you please describe your order of approach. And when you let's consider adding a medial displacement calcaneal osteotomy. Sure. I can take that. Let's see. So I, I disagree with Matt a little bit I don't add as the the media column as much at least in my primary subtalar fusions I think you can address a lot of that through your rotation of the subtalar joint. Now, in a revision such setting, it could be a little bit different and so I have done some medial displacements underneath subtalar fusions I think sometimes if they have something like a coalition. It's very stiff that the anatomy is different. I think that's when I consider more of an NBCO underneath the subtalar fusion. I think if you can still get good D rotation through the subtalar joint. A lot of times you don't need to do it but I do agree with Matt that if you can't get all your correction and you check your hind foot alignment after your subtalar fusion. If it's still displaced if you're concerned about it then adding it, you know, being ready to add it and before you put all your hardware and is important. Hopefully I answered the question. And the next question comes from Dr Buchanan. So, so any of the joint sparing procedures seem to alleviate the sinus Tarsy or subtabular impingement for you and which one will be your go to. I can take, I can take this one. I mean, I think the sinus Tarsy impingement is a little bit up for debate. I think you know it's extra it's not in the posterior facet of the subtalar joint potentially rotating your talus back on top of your calcaneus. During your procedure could potentially prevent pain in that, you know, in the sinus Tarsy. I think when you get the subtabular impingement, there's enough valgus tilt and enough instability at the subtalar joint where, you know, that's to me and I think a good indication for at least an isolated subtalar arthrodesis. And then I think, you know, it's very controversial whether or not you need to do a, whether or not you do a subtalar arthrodesis for sinus Tarsy impingement, but I would certainly consider it. And then, depending on the age of the patient, the activity level, what I was trying to achieve, I think, you know, then I would then I would consider not maybe not doing it, but I have a low threshold to fuse those patients, even with sinus Tarsy impingement. Glenn, I think you're muted. Did we lose Glenn? I think he's just muted. This is me. I'm sorry. I was muted. Um, 68 year old man. And this is my first I'm doing this. Uh, this is a 60 year old man with a history of RA. Um, and, uh, obviously no prior treatment for his RA presented with this, uh, deformity and, and clearly it is quite severe. So we obtained some ankle, uh, x-rays, uh, like Dr. Irwin has recommended. But I would argue that perhaps we need to investigate further in these cases, because usually, uh, when you see windswept legs, um, I'm a little concerned what's happening up and above. So, so since, since a total ankle replacement usually takes about 250 steps, we can always, um, consider, uh, doing something about that guy. So, uh, next best surgical steps. Would you say we will agree that the knee should be addressed before the foot for our panelists? Yeah, I would, I would a hundred percent agree with that. Um, I think it's a great, great point. I think I've been harping on this for a long time. We don't look at the knees enough and, and people come in and they have pants on and you got to, you always got to look at them standing and you always got to look at their knees. So I would 100% before I touched that ankle, try to get the knee, knee surgeon to fix his knee. Yeah. Well, sometimes, uh, when you just came out of fellowship, you still remembered how to do a knee replacement. That was the last one I've done. Um, it turns out well. Um, but, but his foot is still, um, extremely, um, uh, deformed. Uh, now, but at least we have symmetric deformity. Um, so, so, so that, that was, that was my, my one point that I wanted to share. Then that's all is, uh, is that, you know, sometimes we have the residents, uh, when they're on the foot rotation, they zoom directly towards the foot and the toes, and they totally missed the missed the major deformity that the patient's coming in with. Um, so I do, I didn't want to show that. Um, I think we have one more minute, uh, left. Dr. Bailey, would you like to give some final remarks to this, uh, this web web course? Uh, sure. Um, this session is, has been fantastic as has been this entire day. And in fact, the entire course. And, uh, I'd like to thank everyone who, who spoke today. And also I'd like to thank again, Glenn and Chris, uh, as we put this together many months ago, trying to figure out what would be interesting, uh, uh, to the community. So I I'd like to thank you guys. And also as I've done in the beginning, thank Julie, because Julie is absolutely fantastic. And it takes so much to put something like this together and, uh, want to, uh, give a shout out to Julian and thank her too. And then in closing, uh, Julie, you always have some final remarks, uh, from AOFAS. Yeah. I just wanted to remind all the attendees, um, that there is a document posted in the chat tab. Um, it has instructions on how to claim your CME and complete the evaluation along with the email addresses for our chairs, which they have graciously given permission to any of the attendees. If you have any further questions, they're willing to answer them. And I want to thank our chairs and all the speakers for such a great course. Everything was wonderful. And I think this is really beneficial to all of our members and attendees. Okay. Without further ado, I guess this meeting is closed. Thanks again to everyone. Have a great remainder of your weekend.

progressive collapsing foot deformity

PCFD

classification system

preoperative planning

weight-bearing CT scans

failed flat foot reconstructions

revision surgeries

management of failed reconstructions