Well, thank you so much for joining. This is the 2024 Advanced Foot and Ankle Virtual Course, Revisions, Complications, and Complex Cases. And thank you to my co-chairs, Dr. Zide and Dr. Cody. I think you've all really put a great session together. I hope all the audience enjoys it as well. And I also just want to especially thank a lot of the speakers are from outside of our AOFAS society. And so a great thank you to all of our speakers, but especially from visiting societies for taking time to educate us as well. And I will let Jacob introduce our first session here. And please remember to put any questions into the Q&A tabs. So thank you very much. And we'll be looking forward to the rest of the course. Jacob. All right. Thanks, Chris. We have a really outstanding group talking this afternoon about adolescent deformities. Everyone who is speaking is a member of PASNA. And so we're getting some good crossover for the AOFAS and get some other voices and real experts in adolescent deformity to talk to us. Don't forget to ask questions. We're going to answer them after the four lectures. We're going to start off with Dr. Colin May from Boston Children's, and he's going to be talking to us about adolescent bunion deformities. Great, thank you very much, Jacob, for the intro. And thanks, Chris and Elizabeth as well for the invite and sharing my screen here. It's a pleasure to be able to talk to you guys about some of my experiences related to adolescent bunions. As Jacob mentioned, I'm an orthopedic surgeon at Boston Children's Hospital. Like most pediatric orthopedists, I do a range of things, but for the most part specialize in the lower extremity, including foot and ankle most specifically. So just to get started, I consult for orthopediatrics and also a company called Wishbone Medical, but nothing really went to the talk today. So in terms of objectives, I want to discuss some of the clinical aspects and treatment approaches for adolescent bunions, and also highlight a couple of the unique associated conditions that are relevant to the adolescent population, which even those who treat adults may encounter along the way as well. Full disclosure, actually, on the bunion front, I think early in my practice, like many of you treated adolescent bunions, I found it to be quite frustrating, primarily just because of the recurrence issues that are known to be an issue in treating adolescent bunions as well as, I think, some of the limitations of the surgical technique aspects that I employed early on. I think with changes in some of the technique things, it's gotten to be a lot more fulfilling to treat this condition, and I like it a lot more. So happy to be able to talk about it at this point in my career. When you talk about adolescent hallux valgus, you know, the clinical presentation is quite similar to adults. So as you all know, medial MTP, prominence in pain, often kids will complain about difficulties with shoes, and I think unique to a really active population, I think many of the kids who have pain end up with some limitation of their activity. You know, cleats for kids that are playing soccer or lacrosse or football, you know, tend to be quite constrictive in the midfoot and forefoot, and so that becomes a real issue. Obviously, kids are also active in hockey and skiing, and those, you know, rigid kind of shoewear can be problematic as well. First let's just talk a little bit about definitions, because I think a lot of these terms get used interchangeably, and it can be confusing as to what people are talking about. Variably, in the literature, people refer to either pediatric or juvenile or adolescent bunions or hallux valgus, and often those are used interchangeably. For the purposes here, and I think maybe it's a little bit becoming more broadly accepted, juvenile would refer to kids which are skeletally immature, whereas adolescent might also encompass some skeletal immature children, but also teens, young adults, and the pediatric hallux valgus would encompass both of those groups, so both juvenile and adolescent groups. You know, this is relevant to an adult practitioner in that up to 50% of adult bunions had, you know, onset during childhood, and so quite commonly this is something that extends into adulthood from onset as children. A little bit on epidemiology, just real briefly, you know, in pedi-patients, it's a relatively low rate of bunions being present, just under 10%, but in, you know, in female kids, that rate is much higher, so 15% of girls have bunion deformities, and, you know, when you compare that to the incidence in adults, clearly much lower, and when, again, just to hit on the point, when you think about juvenile and adolescent bunions, there's a real female predominance, as high as 80% of the bunions are female, or in females, and also note, you know, up to half of kids have already developed a deformity by 10 years of age or earlier, you know, and that becomes relevant when we start thinking about how do we manage this deformity, particularly with some of the growth modulation techniques that, you know, we have employed in the younger kids. Another note on sort of the risk factors, because, you know, when we're talking about young people, those risk factors are different than adults, and so most significant risk factor is family history, for sure, and then the inherited traits like ligamentous laxity is being probably the most relevant one, as well as abnormal foot mechanics can contribute. When we look at the overall genetics, typically, it's felt that there's likely to be some form of autosomal dominant pattern with an incomplete penetrance, just because we're seeing this in multiple generations successively, but this is a multifactorial problem. There's not a particular gene, and particularly when it relates to various conditions which lead to ligamentous laxity, those genetics can change, but a family history is present in the vast majority of kids who are being seen for bunion issues. Just a particular note on adolescence and why we, you know, see bunion development in this age group, particularly in females, there is a peak in ligamentous laxity in females, you know, around puberty, and that's likely in part at least related to the relaxin gene. It's a prolaxity hormone seen in pregnancy as well, but also there's a peak during teen years and that can, it's thought anyway, lead to some of the ligamentous laxity type issues which can then accelerate progression of deformity in this group. This is a wordy slide, but some other etiologic factors which are unique potentially to kids and adolescents, you know, historically it was thought that this, you know, a pediatric or adolescent bunion was related to metatarsospirous, and I think that's still part of the etiologic mechanism, but other data is suggesting that maybe some of this is more due to tilting of the MTP joint, you know, with an increased EMA. There's also other suggested mechanisms from an obliquely oriented TMT joint to maybe abnormal cuneiform morphology, and also length of the first metatarsal, so longer first metatarsal has been associated. In contrast to adults, extrinsic factors like shoe wear tend to be aggravating factors we think, but not so much causative like they may be in adults. You know, I think a special note to make related to kids and adolescents just is the fact that bunions can be related to other conditions, right, so it can be associated with neuromuscular disease, fina bifida, the altered gait mechanics and the imbalance in the muscle forces around the foot and ankle often contribute, connective tissue disorders such as Marfan's and EDS, OI, and then, you know, particularly just, it's a rare condition, but one that's just notable, Alex valgus can be seen as an early sign of this fibrodysplasia ossificans progressiva, which is like heterotopic ossification on steroids. So it's one of those things where, you know, people seeing kids that have a bunion can be sort of a first diagnostic clue at something like this. When we talk about radiographic diagnosis of bunions in kids, it's similar to adults, you know, we typically see Alex valgus angle greater than 15, associated deformities include an increased IMAA, which, you know, gets to the point of metatarsus severus being, you know, part of the etiology of the development of this condition. An increased DMAA is also typically seen, but with a congruent joint, so that's some of the distinction between what we're seeing in young people versus adults is that the joints often congruent with an increased DMAA. And so, you know, I think historically, because of the high incidence of recurrent deformity, you know, people were very hesitant to treat adolescent and juvenile bunions operatively. And so non-operative treatment has been the mainstay and I think continues to be in most cases. You know, the growth is considered a contributor to recurrence, you know, as the bones are growing, it's changing the balance of forces around the foot and therefore potentially influencing the pull of the toe in a valgus position. And so, addressing this deformity after growth is complete is felt to decrease the risk. So, there is a push certainly to consider waiting until kids have finished growing before intervening. The kinds of things that we employ non-surgically in the young kid are similar to adults, so shoe modifications with a wide toe box, padding and taping, kids don't tend to tolerate that and so it's not often used, at least not effectively. Incense for pain and then Achilles stretching, clearly the, you know, there's some obviously controversy related to the relationship between bunions and flat feet, but clearly in a kid who's got Achilles tightness that may have a progressive flat foot deformity could, you know, influence the development or worsening of a bunion. These things that we employ aren't felt to slow progression or prevent deformity but may improve symptoms. Some thoughts on prevention, I think regular assessment, especially during periods of growth, and in kids that are young, so under 9 or 10 years of age, you know, consideration at least of some of the growth modulation techniques that I'll talk about in a second, but thinking about that as a way to slow progression or potentially prevent a bunion from forming, at least from forming worse than it may already be. Maintenance of ankle range of motion, as was alluded to earlier, working on Achilles stretching to try to prevent the potential increased stress on the toe in the lateral direction. You know, we talk about surgery, really the indications for that are extensive attempts at conservative management that have failed. Outside of the scope of the talk to go through the various procedures for how it's focused, you guys are probably more aware of those than I am actually, but general principles related to adolescence and as far as options, guided growth if a kid is young, so sort of pre-adolescent to early adolescence. Proximal versus distal osteotomies are combined, proximal and distal osteotomies and arthrodesis techniques are still employed even in young people on occasion. Soft tissue procedures and aching osteotomies are considered to be augments to these procedures but are not typically effective in an isolated situation. So I wanted to go through just a couple of selected cases that highlight some of the things that, you know, I brought up on the way here and so I'll go through those relatively quickly. So this is a young kid, so age nine, she's pre-adolescent but is having foot pain that's limiting her activities. She's got, you know, a relatively significant bunion, worse on the right side, but is already having pain at this point. You know, she's skeletally immature and so the concern would be that intervening here with an osteotomy and other procedures, you know, there is a rate of recurrence which is higher than an adult and maybe we should just wait, wait this out and try to, you know, see how she does and then ultimately she needs treatment once she's skeletally immature. There's been a push and I think in the young kid, a real reasonable consideration to do some guided growth techniques, so hemiepiphyseodesis of the lateral base of the first metatarsal to try to influence the growth of that into a more valgus position to get rid of some of that metatarsal severus that's present. So she had a drill and curatage hemiphyseodesis, can also consider screw hemiphyseodesis, that's another method that achieves a similar result. So she had, you know, good closure of her lateral physis but, you know, I think as is the case with this procedure, pretty limited improvement in parameters. So she, on the right side, which was her more severe side, did improve, you know, a few degrees in each of the parameters, on the left stayed pretty much the same. I think that's what a lot of us find in doing this procedure is that the improvement in parameters is somewhat underwhelming and, you know, that often is related to the fact that we're seeing these kids at a time when their growth is already getting close to being done and it's something that we can do before growth is complete but may not see the kind of improvement that we'd like to see. So one of those questions were the earlier you can do it, the better, but then you're operating on a very young kid and, you know, often there's an interest in wanting to wait. So that's kind of the push and pull of this procedure in young kids. Another kid, sorry for the kind of all the angles measured there, but a 14-year-old girl with bilateral bunions, this girl came to see me kind of at a time where what I was doing in terms of managing bunions was in the process of shifting. So on the first side, she got a double level osteotomy, so, sorry, proximal, that should have been opening wedge osteotomy and then a distal chevron to address the DMAA, did not do lateral soft tissue release but did a bunionectomy. She did well with that procedure and then nine months later underwent a seri procedure, so more minimally invasive technique on the other side, which is a distal osteotomy translation. Two years following, she's doing well with similar correction of the parameters on both feet and was much happier postoperatively with the seri procedure. I think she found the recovery to be a whole lot better and pain level to be much preferable and she feels like the correction was better on that side, which admittedly probably was. And so I think, you know, that, you know, I put that on there just to illustrate that as we have moved a little bit more forward, many of us anyway, into the minimally invasive distal metatarsal osteotomy front, I think we're finding a lot better satisfaction in terms of the patients with that, those techniques and with the recovery and with the corrections that we're able to achieve, with typically limited need for lateral release type procedures for most of the kids. A unique case in a kid with Down syndrome, trisomy 21, long standing bunion deformity, limiting activities. Since this is the sort of revision and complication talk, I wanted to show something that didn't go well. So she underwent a seri procedure, I was doing that at that point in my career, so had a bit of a fracture out of me there in terms of the osteotomy, but with significant correction and as is true of many Down's kids, she was very likely to be lax and so the seri procedure brought her toe really into varus initially, which is what we try to do because it stretches things out and goes back once the pin's removed. Three months post-surgery, hadn't healed the osteotomy. She had difficulty with weight-bearing restrictions given her developmental delays and didn't heal. So she was weight-bearing more, I think, than her osteotomy could handle. It's a decision I made at this point just to in situ place fixation. So she had a revision surgery with just two compression screws, healed that well and by two years she was healed with good correction of her deformity and was very happy with that. Another sort of unique to Pied's kid, just to illustrate some of the other conditions that are associated, this kid has spasticoclegic cerebral palsy with a severe flat foot and hallux valgus. He'd had prior lateral column lengthening and tendon transfer for his flat foot, which had not gone well, but he had a pretty severe bunion that was causing him a lot of pain. And in the CP population and the kids with, you know, little less demand, MTP arthrodesis is really a driver of many of the procedures that are done in that group. And so he had correction of his flat foot, the TN fusion and the MTP fusion as well for correction of the bunion and did well with that. You can see sort of the pre versus post alignment, both of his foot and his bunion and at two years out doing well there. This just to illustrate kind of a final case of where we have moved into. So longstanding hallux valgus with pain and now doing most of our procedures with just a distal metatarsal osteotomy through an MIS approach with screw fixation. And so that's kind of the evolution, at least in my practice, and many of us have taken over time is to do a little more minimally invasive technique with screw fixation. And that's true in the adolescents, just like I know it's happening in adults as well, which has, I think, been beneficial to our patients and has been where I've come back around to wanting to fix bunions. And I think doing it in younger kids, because I think we feel that the revision and recurrence rate is less of an issue in that group with the MIS approaches than historically the way that we were doing them. So I think due to complications and recurrence in young kids, you should reserve surgery for those that really have significant symptoms. I want to make sure that these are symptomatic kids before intervening. The caveat to that though is that for kids with open growth plates who are under 10, who may be less symptomatic than the older kids, but may still have symptoms, there is some consideration potentially intervening early, because that's the time when that can actually do some good. And so that's the one situation in which you might do a preventative or prophylactic operation for this, even without a ton of symptoms, just try to prevent the issues later. In the neuromuscular syndromic patients, TMT fusion is a reasonable option. And you know, I think it's been pretty well shown that soft tissue releases alone are generally not done in bunion deformities in young people and that it's really an adjunctive procedure. So thanks for the attention and having me today to speak to you guys about Alice and bunions. I appreciate it. Thanks, Colin. That was great. Okay. We are going to jump right into tarsal coalitions and rigid flatfoot. Maurice Bouchard is going to be talking to us about that. He's at Toronto Sick Kids. And thanks for being here, Maurice. Looking forward to it. Thank you. All right. Is it in full screen mode for you all? Okay, awesome. Hi, everyone. I'm Maurice Bouchard. I'm in Toronto. I, I'm actually dual fellowship trained in foot and ankle in pediatrics, but found myself more passionate and happy living in a children's hospital. So my, my practice spans all ages, but I definitely like to geek out on the foot stuff. I also do lower limb deformity correction as well. So a couple disclosures, neither will be related or discussed to the, in this talk today. So first we're going to talk about diagnosing the rigid flatfoot differential for this, and then we'll focus on one of the more common causes, coalitions. And then we'll talk about the management and in particular, those flat foot, flat feet with a tarsal coalitions. So we'll start right away with a case, this 13 year old male presented with a longstanding history of foot pain, worse on the right than the left. His flat feet got worse over time. He had pain in lots of areas, medial arches, distal to the lateral and medial malleoli, no family history, no other medical issues, and his pain was mostly activity related. But at this point was keeping him out of sports, which he loved. So on exam, we can appreciate that there's certainly a little more hind foot valgus on the right. We've got a little bit of a too many toe sign. And when he goes up on his tiptoes, he can kind of get himself to neutral. Maybe on the left, he can swing himself into a little bit of varus, and we can also appreciate he doesn't have a whole lot of a medial arch with some prominence there. So one of the things I'd just like to point about are the toe stance. Often kids don't really like to go up as high as they can. So we definitely like getting them way up on their tiptoes. And it's really important after in your manual exam to find out where that range of motion came from, if it was truly the subtalar joint or if they're faking through show pars joints. So when I see a kid like this that doesn't really have that classic flexible flat foot look, I'm thinking about a few things that might be the cause. So, tarsal coalition always comes up at the top of the list. It may be an idiopathic rigid flat foot. We don't see it all that often, though we talk about it a lot and it shows up in a lot of textbooks, this peroneal spastic flat foot, but I would say that I might see at most one kid a year that truly has isolated peroneal spasms, and sometimes that isn't even with a flat foot, but just an everted rigid foot. There can be arthritis, JIA, things like that, but again, that's maybe not the most common. Mist or partially treated, recurrent oblique or vertical tali, and neuromuscular feet like CP and many other variants, including CMT, can show up in this category. When we talk about tarsal coalitions, this is super common, probably up to even 20% of the population, though most of them go unnoticed or undiagnosed. The calcaneo-navicular and talocalconeal are our most common, as I'm sure you see in your adult populations, with the middle facet of the talocalconeal is affected more commonly. The CNs tend to present a little bit younger, 8 to 10 years of age, the talocalconeals a little bit later in early adolescence, and those talocalconeals are the ones who tend to show up with more pronounced deformities, flat foot being more common, though we can see cavus feet the further posterior that coalition is, and while less common, calcaneo-navicular coalitions can also have flat foot deformities associated with them. Symptomatic coalitions are probably about a quarter of the population, but we can actually get a lot of them to resolve with some non-operative treatment, or they just kind of burn out as their feet, tarsal bones are ossifying, they get a little more symptomatic, and then once their feet are spleedly mature, it can tend to settle down. So really, not a large population of kids with coalitions are actually getting surgery, and again, we really like to double check that they don't have coalitions on both sides, even if they present with just symptoms in one foot, and we're always looking for additional coalitions in the same foot, as that can happen in about 5% of patients. Imaging is pretty much standard, what you're probably doing in all your clinics, bilateral, apilateral foot in a weight-bearing stance, as well as ankles, looking for concurrent deformity at the distal tibial level, as well, or associated degenerative changes or instability. When I look at these, I'm obviously looking for the coalition, but I'm also assessing for any associated deformity as well. So back to the first patient, we can see on the left a little bit of a skew foot there, a more pronounced version of a flat foot with a skew on the right, and we can also see that in the loss of height of the foot, but overall, the ankles are in good alignment. When we look at the lateral, he's got a little bit of a negative Miri's angle with an apex all the way back in the talus on the right, and in fact, he's rolling a little bit on the outside of that right foot, of the left foot, but no major midfoot sag here. And if we look closely on that right foot, we can see a positive C-sign, which means that we're not seeing a patent talocalcaneal joint at the posterior facet on the right side, but we can see a nice healthy joint on the left. So Harris views are really great to get when you're suspecting a talocalcaneal coalition. The kids can sometimes struggle with getting these, but the teenagers usually can, so we can confirm, again, a finding of a talocalcaneal coalition on the right, and I will routinely CT scan all my kids with coalitions, again, to look for those accessory coalitions that might be in the foot that we haven't seen. I image both feet to look for ones on the other side, but the things I'm really trying to pay attention to here is I really want to know how healthy that subtalar joint is, and I want to know how much deformity is in that subtalar joint, and I don't really find I get a lot of extra information from an MRI, and especially in my universal healthcare system, I can get a CT scan in a few weeks, but I might be waiting months for an MRI, so that also from a financial and time perspective is my preferred imaging modality. So coalitions, we always start with non-operative treatment, as I alluded to before, activity modification and rest, anti-inflammatories, short course of immobilization, physical therapy, and sometimes if there's associated deformity, we can go with some orthotics. If they have constant or persistent symptoms after six months and disability from that, or if the pain is associated with degenerative changes, then we start thinking about an operation. So what are the operative options? In three major buckets, we can take out coalitions, we can do deformity correction, and we can also fuse the subtalar joint in the talocalconial coalition population. But how do we decide which of those to do? And sometimes it can be a little confusing, even though ortho bullets makes it sound really straightforward when we're a resident, we're studying for our exams. So the way I try to boil that down and come up with an answer is by asking myself three questions with each of these patients. So first, where is their pain? How well is their foot aligned? And is that subtalar joint healthy? And that latter one is really the kicker for which procedures you select. So in healthy subtalar joint with a tarsal coalition, I'm going to resect it. And if there's deformity, I'm going to correct that simultaneously as well. If I have a degenerative subtalar joint or pain at the subtalar joint, then I'm going to be thinking about a fusion. And again, if there's concurrent deformity, we're going to correct that. For the kids with severe hindfoot valgus, generally speaking, if it's if there's pronounced deformity, we're going to need to add a fusion to our deformity correction. We can sometimes get away with extra articular deformity correction, which is great, especially in the younger kids. But in these kids, I rarely take out the coalition, that talocalconial coalition, because it's acting like a tether on that medial side. But if there is tenderness there, I'll go ahead and add a resection as well. So now let's look at a few kids. This guy's 13, not a ton of deformity, has a talocalconial coalition. He has pain at the coalition, all the symptoms match. So we're going to go ahead and take it out. I like to do this with the trick actually that Dr. Zide gave me, which I loved. I used to burr these out line by line, but actually placing K wires above and below, and then just using some osteotomes in between to resect on block is so much more efficient. So it looks kind of like this, get it nice and exposed, protect the tendons, protect your neurovascular bundle, and then resect that. You can go get the final bits with a ronger. And at the end of the day, you want to use a laminar spreader to spread, make sure you can see the healthy sub-tailor joint, posterior facet sub-tailor joint, and that you have movement there. I like to interpose with a little fat from the posterior medial thigh and some bone wax over the cut edges of the bone. I prefer doing that over using any tissue from that area. For this next kid, calcaneoendovicular coalition pain right over there, dorsolaterally impacting their activities, no major clinical deformity, even though we see a little bit of a flat foot on the x-rays. So in this kid, we're going to go ahead and resect. And again, we've got a nice, otherwise healthy joint, no other coalitions. I like to print these out, particularly at an academic center when I have a lot of trainees. Visualizing them 3D can be quite challenging, and most people don't recognize how deep they go. And so I love having a 3D printout to just kind of help trainees know what we're doing. I use the same principle of putting K-wires above and below the area that I want to resect, get retractors down in between, and then whack the whole thing out. You should be able to put your thumb right down in the bottom of the hole, and it's again, about almost an inch deep. I like to put, again, fat rather than the extensor digitorum brevis. I feel bad sacrificing it, and often it's not actually enough tissue to fill that hole, and then coat everything, of course, with bone wax. So what happens when we have deformity and a coalition, and they're both symptomatic? For the calcaneoendovicular, I like to stage them because I feel a little guilty making a cut at the anterior process of the calcaneus twice in the same surgery. There's not any significant reports about ABN, but one of the other things that can happen is really instability of your Evans osteotomy and a little more subluxation of the CC joint. So I prefer to stage it, and I treat whichever one is most symptomatic first. This girl has pretty pronounced flat foot, especially on the right. She has a lot of pain, subfibular and in the arch, but actually no pain at the area of her coalition, and you can see she's got classic C signs on both sides, more pronounced negative Mary's angle on the right. When we look at the AP, we've got more forefoot abduction on the right, and the Harris views confirm an osseous coalition on that right side. Sorry, I was just checking the chat to make sure I was not late on time. So we get a CT scan on her, and this is where it gets really impressive. So we see that osseous coalition on the top left, and we see a cartilaginous on the top right, but then we look at her hind foot, and we see that she's got incredible subtalar valgus, and on the bottom left image, we've got subfibular impingement actually on both, but really more pronounced. So what do we do in these cases? If we were just going to go take out that coalition, we were going to have progression of the deformity, so we definitely need to make sure that we do both, and in this case, obviously I don't have the video here, but when we scroll through that posterior facet, we see that in fact that subtalar joint is quite diminished. The joint space is really thin. It's probably half the amount of the ankle joint. They should be even. So in this case, I'm going to go ahead and fuse it, and I may still need to take down the coalition to get the mobility, but I'm going to go ahead and fuse it, slide that calcaneus over medially as well, and add a midfoot procedure. So the literature doesn't have a lot to tell us what to do with these really deformed feet where we have significant hind foot valgus in terms of what we should do, but the classic landmark paper by Wild and Sherod at Royal Children's in Australia would tell us that when you've got hind foot valgus of over 16 degrees, you should not take out the coalition. When you have degenerative changes, you should not take out the coalition. When you have that subfibular impingement, do not take out the coalition. You've probably heard when the middle facet is over 50%, the posterior facet, you should not resect the coalition. However, the measurements of that are very nebulous, and in our current study group, there is very little consensus of how you measure the width or the size of a coalition. So nowadays, we would not really use that so much as a criteria, but really the health of the subtalar joint and the amount of valgus. So those would be the kids that you would not do, particularly a resection alone, but as I mentioned, maybe a resection to mobilize that joint during your fusion. Last case, we've got a 10-year-old girl who's had symptoms with ankle sprains and pain in the medial ankle for quite some time, and she has a mild cavus deformity, which is a little less obvious. And you can see at the back, it looks like almost a large os trigonum. And when we image, she actually has a coalition of the posterior facet. So as I mentioned earlier, these aren't as common, but they can be exceptionally symptomatic, and they can come with cavus deformity. So in these cases, we generally end up resecting the coalition, but they may actually need a concurrent cavus correction if the foot is not flexible after resection. So at the end of the day, what I'm hoping you take home from this is that when we're thinking about rigid flat feet, we want to think about coalitions. And when we see coalitions, we want to make sure that we think about concurrent deformities. We want to manage both based on their symptoms and based on their severity. And when we're talking about especially talocalconial coalitions, please always go take a look at that subtalar posterior facet and the valgus alignment of that subtalar joint. So in the end, treatment plans are individualized to the patients, but hopefully I've given you some key points to create a predictable algorithm. Thanks so much. Thank you so much, Maurice. That was fantastic. I really appreciate it. Now we're going to hear from Dr. Anthony Riccio, who is at Scottish Rite, and he's going to be talking to us about managing cavovaris deformity in pediatric and adolescent patients. Tony, you're still muted if you're trying to talk. I'm back. All right, perfect. Chris, Jacob, thanks so much for inviting me to be a part of this and speak alongside people I really respect like Colin and Marie. So my charge was to discuss cavovaris foot deformity in the young. And as I knew this was going to be given to a fairly advanced audience here at the AOFAS, I chose rather than give you a review of the whole topic to kind of get right down to the nitty gritty, which is kind of surgical treatment and kind of how to decide to approach these kids, especially when they have a relatively severe burden of disease. And so maybe my slide will advance and maybe it won't. There we go. So, you know, there are a lot of bad feet out there that those of us who have an interest in pediatric foot deformity have to deal with, but I honestly think that these really can be some of the worst. And oftentimes as the feet get worse and the burden of the peripheral neuropathy that drives the deformity in most of these children gets worse, it can be really hard not to get lost in the clutter and how to approach a kid who's kind of been walking like this for the last 13 or 14 years. I think, you know, in an effort of not trying to get lost in the clutter, we have to lean back on some guiding principles as well as understand and respect the goals of treatment, which, you know, when approaching a young person with a severe deformity like this is not like an adult patient to create a plantar grade foot. In children, it's always ideal to preserve motion and avoid arthrodesis. They've got many years of ambulating on these feet. Not all of them have healthy ankles and we can certainly accelerate some tibiotailor degeneration over time by fusing the subtalar joint or doing a triple. Historically, and a lot of my partners who are very senior would do big osteotomies, the old Iapus osteotomies or Lambernudi type things, and start resecting out large areas of bone to correct the deformity. And that doesn't always serve children well because you can basically create a relatively short non-functional foot and do that. And of course, you know, we want to avoid complications. I also think it's really important that when we approach these problems from the pediatric standpoint or the pediatric viewpoint, that we have to understand that this is really a soft tissue balance problem and therefore management of these deformities really hinges on the soft tissue components of the correction with bony surgery reserved to dial in correction after the imbalanced forces about the foot have been mitigated or rebalanced. And so, you know, those of us who talk about pediatric foot and ankles, you know, oftentimes talk about the principles and obeying the principles. And I think it's important to obey the principles, but I also think it's really important not to be bound to them because these deformities really do require individualized care. And so when I kind of, just like Maurice told you how she kind of thinks through the coalition, I kind of a set of things I think about as I approach these children. Obviously, like with any foot deformity, we want to understand the segmental deformities we're dealing with, you know, what's going on at the hind foot, what's happening at the midfoot, what's happening at the forefoot, and what's happening at those aspects of the foot in relationship to each other, not just in relationship to the ground. I also think, and I wanted to highlight this to the, you know, what I assume is a largely adult foot and ankle audience here, is that we have to look at the ankle too. I know there are several studies out there that talk about Aquinas not being a part of the typical cavovarous foot deformity, but in children who present very early with these deformities, and again, have a high burden of whatever peripheral neuropathy they're carrying, we often see an equino-cavovarous foot deformity, and you can't forget that deformity needs to be addressed as well. Obviously, we need to look at tibiotailor and subtailor health because this is going to help us decide if we're able to do a motion-preserving surgery or if it would be easier for us to do an arthrodesis, obviously, if the joints are degenerative, which they rarely are. Understanding and mitigating deforming forces is always important, and I think the audience here understands the forces just as well as we do in the pediatric world. The peroneus longus is pulling relatively stronger than the tibialis anterior, which is going to create pronation through the midfoot and cause that cavus component of the deformity. The gastroxilius complex, more powerful than the tibialis anterior, which can drive Aquinas, and of course, the posterior tibial tendon is relatively more powerful than the brevis, which will drive our hindfoot varus deformity. At that point, we have to understand any limitations imparted by soft tissue envelope. That's rarely a problem here, but prior surgeries, prior scars can affect what we can do and what we can move. At that point, we then need to think about what we can correct acutely by soft tissue surgery and soft tissue release, what should be corrected by acute bony surgery, and in the most severe cases, when maybe we should think about gradual deformity for very complex multi-planar foot issues. And lastly, we need to think about and anticipate any secondary deformities we might create during correction. Many of these children, obviously, as the audience knows, have claw-toe deformities, and when you bring a severe equinocave varus foot deformity into a better position, we often see splaying of the digits or even worsening of the clawing of the toes. And so like others, I thought it'd be interesting to talk about a case example. So this is a 10-year-old boy. He has just standard Charcot-Marie-Tooth 2A. His father had it. His father's father had it. This is an angioma-dominant condition, as you all know. And obviously, he's got a relatively severe burden of disease with not just cavo varus deformities of the feet, very characteristic clawing of the toes, but also clearly some equinus there at the tibiotalar joint. And so this is the kind of kid I see relatively frequently in my peripheral neuropathy clinic, and I have a whole clinic dedicated to these kids, which obviously draws a lot of kids in. We look at the X-rays, and we kind of go to our principles. And so we need to determine the segmental deformities. And obviously, you can see the altered cascade of the metatarsals indicative of pronation. We clearly have equinus at the tibiotalar joint, a lot of cavus right there, which here, there's a degree of both rotatory cavus from the pronation, but also angular cavus. And you can see the plantar flexion through the talonevicular joint. Obviously, we've got clawed toes, which we saw clinically, and then the drive-through sign, which is just our radiographic indication of the virus that we see on our physical examination. But we got to think about the other principles, right? So he's got a healthy ankle joint, he's got a healthy subtalar joint. We need to understand and mitigate the deforming forces, which are the forces I mentioned earlier, the classic muscle imbalance in the neuropathic capoveris foot. There's really no soft tissue envelope issues because this child hasn't had prior surgery. In this situation, what my approach would be and was based on my clinical examination, the amount of flexibility that was present, is that we could probably correct both the equinus and maybe even the virus by soft tissue releases alone. When I was learning about this, the virus almost always got a heel slide or some sort of calcaneal procedure. The more I treat these kids, the less and less of those I actually do. And then we think about what should be corrected by bony surgery, which in this situation will be the pronation and the cavus. And then we got to think about what might happen to those flexion deformities of the toes as we bring this child out of the severe equinocavus position. And so for me, this is gonna be a two-stage surgery. I need to loosen up the tissues on the plantar aspect of the foot and then allow stress relaxation to improve the amount of cavus. And I need to have an intact gastroxilius complex to push against very firmly in order to stretch out the long plantar ligaments, the tail and navicular joint, and allow some relaxation plantar, which will then facilitate whatever bony correction I have to dial in through the midfoot. So we like to do this with an open plantar fascia release and an old-fashioned Steinler stripping. It releases the intrinsics off the bottom of the foot, lets them slide distally, even get some relaxation, some release of long plantar ligaments. Others like prefer a plantar medial deep release. It's a very long surgery. I don't think it confers any benefits. This gives us a complete release of the plantar fascia, the intrinsic flexors of the foot, and the adductor if you choose to do it, though usually I don't need to without any risk of injury to the neurovascular structures and the nervous structures really. At this setting, I also like to take away the plantar flexion force of the longus on the first metatarsal head. That's a deforming force, and it's gonna resist correction of the cavus in our cast. And so under the same setting, I find it very easy to do my peroneus longus to brevis tenodesis. Take a tendon that's creating deformity, that's plantar flexing that first ray, that longus, and overtaft it under tension into the brevis so that it'll now maybe provide a little bit of a valgus producing force across the heel. But most importantly, I do it at this stage. I mean, it needs to be done regardless, but I do it at this stage because I think it's gonna resist my ability to get cavus correction in the cast. At that point, we put the child in a short leg cast, incredibly well padded around the metatarsal heads. These kids do, it's a hereditary motor sensory neuropathy. They have a sensory issue. So you can create ulcers if you're not careful. And I crank on them as hard as I can to correct that midfoot aquinas. And so we start with what you see on the left. We put them in this cast for two weeks and we end up after two weeks because further stress relaxation occurs, obtaining what we see on the right, which is a dramatic amount of correction with a relatively easy procedure. At this point, two weeks, we'll return them to the operating room. This is where you can address the aquinas component of the deformity with the TAL. This is where we're gonna do our posterior tibial tendon transfer to lateral cuneiform. My preference is to transfer this. I like completely removing the deforming force. And because these are progressive neuropathies, the tibialis anterior tendon is only going to get weaker with time. And so this will act as an internal brace and check rein to recurrence of deformity. I know a lot of adult folks aren't crazy about us doing this, but I found this to be a very effective surgery. If there's a lot of angular cavus like there was here, we can do a talonevicular capsular release and that'll help us to correct the angular cavus. And then at that point, now and only now, now that we have taken away the varus-producing force of the Achilles tendon on the calcaneus and the varus-producing force of the posterior tibial tendon which has been moved completely to the dorsum of the foot, can we assess the position of the hind foot? In this situation with this child, the hind foot was in valgus. We don't need to do a heel slide. We do, however, really need to pay attention to what's going on at the forefoot and look for any residual pronation. And so for me, this is done relatively simply. Again, this is something I learned from Dr. Zide. He's teaching all of us, Pete's folks, how to do a foot and ankle surgery. But we place a dorsiflexion force on the fifth metatarsal head and we basically just kind of push up on that to dorsiflex through the ankle. If the first metatarsal is not collinear with the fifth, then it's rotated down and we need to do something to drive it up. There's a lot of ways you can manage the pronation. There's several different osteotomies that can be done. People have described dorsiflexion osteotomies, not my preference, or described, I'm sorry, people have described closing wedge dorsally-based medial cuneiform osteotomies, not my preference because of where the tibialis anterior tendon is. But if you choose to do that, it's relatively straightforward. We just mobilize the tibialis anterior tendon. We cut a wedge or bone out. That goes away. We push up on the first ray, closes it down. That gives us some elevation of the first ray. My personal preference, which doesn't always make sense when you think about the deformity, is to do a plantar-based opening wedge of the medial cuneiform. The reason it doesn't always make sense is because we're actually adding tension into the system. We just went through all that effort to take the cavus out, and now we're gonna do something that elongates the medial column. But I just find it so easy to make a medial incision, cut that transversely at the medial cuneiform, put pin distractors on it, which allows me to exactly dial in the pronation correction we want, or the supination we want. And then we take a piece of allograft and throw that in. It's stable. It doesn't require any internal fixation. And so here's an example of a foot with the pin distractor in. We've done our capsulotomy, the telovicular joint, cut the medial cuneiform. Pin distractor goes in, and these should be videos. And you can see, as we expand the distractor, which is placed in the plantar aspect of the medial cuneiform, while holding a force on the fifth metatarsal head, you can see that fifth ray elevate up nicely, and now they're collinear with the dorsal flexion force. Again, looking at it in the sagittal plane, you can see that as we open up the medial cuneiform plantarward, we drive that first ray up, correcting the pronation fairly nicely. We then just fashion a piece of allograft and tamp it in there, and because of the pressure it's under, it sits in fine with no need for fixation. I know a lot of folks like this osteotomy, the dorsal flexion osteotomy of the first ray. It's very easy. It takes slack out of the system along the medial column, but it does require some form of internal fixation, either a small plate, or I've used a staple when I've done it in the past. And there's just an example of that with a staple in it. In the situation that we have a hind foot that is still in varus, then it's very simple to add in a heel slide, and that's dealer's choice for those who are listening to this. That can just be a regular slide. It can be a slide with the closing wedge in the fashion of Dwyer. Lately, I've been just doing MIS heel slides, which I think are very easy and simple and gives you as good a slide as you can get open. So this is my preference nowadays. So there's our patient, final correction. We've got the cavus and aquinas corrected, the hind foot's in valgus, the pronation's corrected, pretty dramatic change on the radiographs, and more importantly, a really nice clinical result for this child, who's now basically got heel-to-toe gait mechanics, still deformity. We never addressed his claw toes. He didn't want those addressed if there had been a problem, but a significantly improved foot position on both sides. I thought it'd be probably worthwhile just to quickly go over a case where the two-stage acute correction is not sufficient, and that's this girl. She's a 12-year-old with a very intense- I need to go quick, buddy. Oh, we don't have any time, Jake? I'm out. You're at 15. If you can do it in like two minutes, it's fine. Yeah, okay, I apologize. Obviously, nonambulant, I mean, essentially nonambulatory, just being dragged by her father with a very severe cavo-aquinas foot deformity. That's maximal dorsiflexion, no change in cavus or aquinas. We go through the same principles, and basically all of the deformities are the same as the child we just discussed. But in thinking about this, that is a degree of cavus. I'm not entirely comfortable correcting acutely with a combination of soft tissue and bony surgery. So for me, this I'm gonna correct in a frame. I'm gonna do acute soft tissue correction of the aquinas deformity. I'm gonna release the plantar fascia, do our tendon rebalancing, similar to what we did before. But at that point, I'm gonna stabilize my hind foot correction, cut the midfoot, which is done, my preference is a Giggly Saw percutaneous osteotomy, which is really easy to do once you've got your frame assembled. You set your Giggly Saw first. And then at that point, we can do gradual correction through the midfoot after distraction, bringing that foot into an improved position. And once we're done, actually having some decent ankle range of motion and minimal residual cavus with a child who's now can walk with crutch assistance at six weeks, walk in AFOs at a year, and even walk without AFOs at six years. So it's a very powerful tool, but it needs to be reserved for the most severe cases because it's a long haul for the patient and for you while they're going through it. So obviously not hard to get lost in the clutter. Out of clutter, we try and find simplicity. Don't panic. Remember, this is a soft tissue problem first, a bony problem second. Think about the principles you wanna use, stick to your principles, and you can do some pretty cool things for some pretty bad feet. So thank you. I apologize I ran long. Thanks, Tony. That was awesome. And let me get my PowerPoint pulled up. All right. I'm gonna round out this session and talk about late sequelae of clubfoot deformity. So we'll just jump right in. Nothing, no disclosures relative to this talk. So we're gonna talk about common deformities that we see in sort of old residual club feet. We're gonna talk about pediatric clubfoot management. We're talking about failure points and then strategies for surgical management. I'm gonna check myself on the clock. Chris, keep me honest. Okay. These come in a few different flavors. Probably the most common thing I see at this point is the under-corrected or recurrent deformity, which has some combination of the sort of standard things we learned about, the cavus adductus, varus, and aquinas. I just want everyone to pay attention to that elevated medial column. That tibialis anterior is driving the medial column up. And that is a theme throughout these deformities that we're gonna need to address. There's the over-corrected deformity, which is post-surgical. And it comes in some variety of valgus, planus, abduction, and then can also show up with a dorsal bunion after inadvertent transection of the peroneus longus. But once again, you can see that elevated medial column, which is sort of unusual in a standard plano valgus deformity, once again, as a result of that persistent pull of the tibialis anterior. And we see that right here. This is just a little bit more of a subtle finding on this young woman who's standing. This is a gal who was mid-20s and was a teacher and had had old surgery. And you see just a little bit of elevation of her medial column. And then when you have her on the bed and you have her dorsal reflex, you see how high she pulls her medial column up and really supinates through her forefoot and pulls into varus. Ankle impingement is another issue that we run into in the old clubfoot deformity. Oftentimes, you see some dorsal navicular subluxation. Once again, that's generally related to previous surgical management of the posterior medial release. And the other thing that we see with ankle impingement is a flat top talus deformity like we see here that creates this sort of hinge-like motion of the ankle joint rather than that standard rolling that we want to see. And then lastly, we see untreated deformities. Thankfully, these are pretty unusual. They are challenging and tricky and fun, but can be very dramatic and gut-wrenching and clinic-ending. So quick clubfoot crash course. This is not for my pediatric colleagues on the talk with us. Please do not make fun of me, any of you. I'm going to do my best. So we have to recognize the component deformities of the clubfoot. So like we all learned in residency, cavus, adductus, varus, and aquinas. But what probably most of us don't remember from residency is what's driving those deformities. So the cavus is driven by midfoot pronation relative to the hindfoot. The tailor neck is actually internally rotated, you know, anatomically. And there's a medial displacement of the navicular. There's an external rotation of the talus within the plafond. So externally rotated talus with medially rotated neck. And that results in medial subtalar joint uncoverage. And then there's contracture and fibrosis of the tricep surae driving the aquinas. So the important thing to understand is that this is not a normal foot. I think that one of the things that everyone, you know, when you're learning about these, and perhaps you were taught, is that this is a packaging problem. It's not a packaging problem. This is a totally abnormal foot. And this has been shown in anatomic dissection studies. There's a decreased quantity of posterior medial muscle fibers, fibrosis of the muscle tendon sheaths and fascia, and a shortened triceps and the distal leg, and fibrosis of the ligaments in the foot. So an abnormal foot in an abnormal position. And you just have to keep that in mind when you're treating these, because if you think you're gonna turn this into a normal foot through any amount of surgery, you have another thing coming. And as I say to the residents and fellows all the time, the goal here is to make the foot look like a foot. Don't try and make the x-rays look perfect. You just make the foot look like a foot. I got involved with this early in my fellowship, talking about the overcorrected clubfoot deformity. And there's a couple, there's one other paper about this that Jeff Johnson and his group wrote that goes through these. And interestingly, we see these overcorrected deformities less and less. The number of annual clubfoot surgeries has gone down over the years. And between 96 and 2006, there was an over seven-fold decrease in the amount of surgeries performed. So we just don't see the volume of overcorrected deformities as we used to. They still pop up every once in a while, but like I said earlier, most of these are gonna be residual or recurrent deformities. The Ponsetti method is sort of the gold standard. It should be initiated within the first month, a high rate of satisfaction with the appearance and function of the foot at long-term follow-up when this is done. And then just to remember that post-cast bracing is really important. There's all sorts of different protocols for post-cast bracing that need to be adhered to to avoid the recurrence. And then the last thing is I just wanna remind, for the crash course, I just wanna remind everyone that there are non-idiopathic club feet. These oftentimes require surgical treatment. These are the ones that are gonna be getting surgery. They often are resistant to casting. Most surgery these days is done with an open Achilles lengthening and a release of the tibia-tailor joint. There are still, every once in a while, cases that require the circumferential release and the true posterior medial release, but this is less and less common these days. So now getting into, as these kids get older, failure points in treatment. So we all remember doing the tibialis anterior tendon transfer for dynamic supination, waiting until you see the occipic nucleus of lateral cuneiform to perform the procedure. But some of these kids just don't show up and they come in with untreated dynamic supination, which then at some point becomes fixed supination. And now the kid's just standing there. This kid is around 20 years old and his medial column is elevated. His hind foot is in varus as a result of the dynamicity never being treated. And so you can see his elevated medial column and his heel varus. This is actually a nice one to treat if this shows up in your office. This can be treated with pretty straightforward procedure where you just transfer their tibialis anterior to the lateral cuneiform and do a lateralizing calcaneal osteotomy. And generally you can get a really nice result with these residual slash recurrent deformities. Okay, failure points in casting. So like I said, most commonly we're doing Ponseti at this point. If you don't correct, and each component of the casting has to be done in a particular order. So if you don't correct the cavus, you can't correct the varus. If you don't correct the varus, you can't correct the aquinas. And so you'll end up with stuff like this, or if you push really hard in the cast, you can create a rocker bottom. And then once again, failure to comply with bracing is the leading cause of recurrent deformity. So now a few cases. So here's a case of a foot that is recurrent, never had any sort of surgical treatment, and probably was never corrected to begin with. And I like showing this case because this is a really severe amount of deformity. And what I just want to bring up is that as adult surgeons, we see this sort of a thing. And I think most of our adult colleagues would say, oh, you just do a triple and get that thing realigned and it'll do fine. But it is important to remember that especially in sort of the teenage world, maybe up into the twenties, you can still consider casting out a lot of this deformity. And this is where you involve one of your pediatric colleagues. I thankfully have Dr. Riccio down the street and with whom I do a clinic. And so I don't do these casting, casting out of these deformities. He does the casting out of the deformity. And you can see because this kid never had a surgery, he's not stiff. And we're able to cast out essentially all of his deformity save for some of his Aquinas. And so instead of doing a triple or some massive surgery with a bunch of osteotomies, we are able to do this with kind of minimal surgery. We have to check the ankle, make sure that he doesn't have a flat top deformity that he has around a Taylor dome that'll work well with an Achilles lengthening. And so this kid gets an open Achilles lengthening and a tibialis anterior to tendon transfer, and that's it, and gets a really nice durable correction of his deformity. So I think that's really important for us as adult surgeons to recognize if you have this sort of 15, 16, 17 year old patient show up in your clinic is to enlist the help of your pediatric colleagues. Surgical failures. So if the subtalar joint is over-released and the interosseous ligament of the joint is released, that's what causes this unstable joint and excessive valgus. Most of the time, these are coming in pretty stiff. And so most of the time, these are gonna get treated with a triple. Every once in a while, you'll have someone a little more flexible where you can consider osteotomies, but most of the time, that's gonna be a triple for these patients. The dorsal bunion, like I said, is a post-surgical problem related most likely to inadvertent perineal injury. And also same thing with the dorsal subluxation of the navicular, which can cause anterior ankle impingement. So this is a case of a woman with Freeman-Sheldon syndrome, which is sort of an arthrogrypodic-like condition. And in this one, she was treated surgically, but never really corrected. And she comes in and she's 18 years old. She has rigid deformity, lateral column overload, anterior ankle impingement, and a dorsal bunion deformity. So here she was when she was four, and now here she is at 18 years old, and you see the severity of the deformity. We got a printout of this one just so we could stare at it for a while and decide what we wanted to do. And then once again, as Dr. Riccio alluded to, we sort of break things down. At the ankle, we have a flat-topped talus and dorsal navicular subluxation or dislocation. We have a really diminutive talus we're gonna have to deal with, and the heel is invarious. And then we've got supination through the forefoot and elevatus with a dorsal bunion. So I did this in stages. The first stage was a tibialis anterior tendon transfer and a triple. The reason for the tibialis anterior tendon transfer at the first stage is that there is no way you're going to get that navicular down there without alleviating this force here. So we move that over and we bring this down and we do our triple and correct our hind foot deformity. We still have some residual dorsal bunion here. We've corrected some of it by moving the tibialis anterior and bringing that navicular down. But what ends up happening is that because that medial column is elevated for so long you get this relative shortening of the flexor hallucis brevis. It's not the longest that's short and tight. It is the brevis. You don't see flexion of the IP joint. You see flexion of the MP joint oftentimes with extension of the IP joint. And so it's the brevis that's tight. And in this particular case the way that we treated it was that we'd already moved the tibialis anterior tendon in order to remove the deforming force. And then we need to take tension off the contracted FHB. So that do just by shortening the metatarsal a little bit kind of with an extra articular oblique while-ish kind of an osteotomy distally that brings that translates the head down and shortens a little bit the first metatarsal. So here she is before and here she is after. Last deformity to go through. Hopefully I'm doing okay on time, Chris. Flat top talus. Once again, hinge deformity happening here. Just drawing this out and seeing that it's really a small arc of motion that they have. And you cannot change how much motion they have. So instead what you can do is you can change the plane of their arc of motion by doing an anterior closing wedge osteotomy of the distal tibia and bring them from here to here so they can get their foot flat and have a little bit of dorsiflexion. And that's him post-operatively. So high points. It's not your usual deformity, right? It's not planovalgus with, you know, with forefoot supination as you would think of in like a standard planovalgus deformity or capovarious. You have to really tailor these treatments. Tibialis anterior is a major deformity driver that we have to address. Don't forget that some of these deformities can be casted. Tailored dome shape dictates your procedure. So if you have a round dome, you can do something with the Achilles potentially, but if not, you're going to need to do an osteotomy. And it was never a normal foot. Don't try and make it into a normal foot. And just some examples of that craziness. So crazy deformities with nice clinical corrections, but with x-rays that look ridiculous. This is a young woman who we've got currently in this frame. And here's this gentleman who had untreated deformities, came in when he was 28 or 29, something like that, and ended up with pan tailors, but it's done very well. Thank you so much. All right. Let me unshare my screen. Incredible work that you guys are doing. And same to Dr. Riccio. Thanks, buddy. Okay. Let's see what's happening in the Q&A session down here. It looks like our doctors have answered most of our questions, which is great because I have a million questions to ask. If people have questions, please go ahead and put them into the Q&A box, and I'll be happy to bring those up and we can answer them live. And I know Colin had to step out, but I think he's still available to us. So Colin, if you're available, let me know. If not, I'll sort of skip over Bunyan for now. No, I'm here. Oh, perfect. Great. Okay. So here's my contention. I think that, and we show this in a study, so 95 plus percent of these adolescent deformities have an elevated distal metatarsal articular angle with a congruent joint. And so to answer someone else's question I saw in the chat, we never recommend doing a lateral release or a medial capsular invocation because those things would cause incongruency of the joint. So I'm very resistant to that. And as a corollary to that, it brings up the conversation of sort of skeletal immaturity and doing hemipiphyseodesis. Those things don't make sense to me, right? The growth plate is proximal and it's causing longitudinal growth. The articular surface is angled into valgus. And so any proximal growth is not going to change the angle of the articular surface. So number one, I don't think that skeletal maturity matters even a little bit. And then number two, it doesn't make sense to me that hemipiphyseodesis should do anything positive. I mean, maybe correct the intermetatarsal angle, but at the cost of actually sending that joint surface pointing farther into valgus because we have that distal metatarsal articular angle angled in that direction. And so I really feel strongly that that is not a good idea. And I think there's a question in there somewhere for you, Colin, rather than me just standing on the pulpit. But I was wondering if you could just sort of talk to us about those things. Well, I think first off, I completely agree with you that the DMA is present in the vast majority. And you're right, doing a lateral hemipiphyseodesis of the proximal metatarsal has the potential to make that worse. I guess the question, well, in my estimation, I think hemipiphyseodesis does not correct much deformity. And so I think if you can reduce the prominence of the medial part of the metatarsal head a little, you're probably not going to make the DMA issue worse. And so you may produce symptoms. I think it's not a very powerful tool in my hands. I just never get to these early enough really to do the procedure to correct much. There may be a role for doing it from a prevention standpoint if you think that it's going to get worse over time. But I do agree that you have the potential anyway for making the DMA problem worse by making the tilting the sole further. So it may be that that's just something you should be looking at before doing that procedure is just how much of a DMA increase do they have. Yeah, I totally agree with that. Thanks. Okay. And now I'm going to go to... David, can I add a comment to that? Please. Yes, absolutely. So I've done a couple cases now that are somewhat recent because I hadn't really found kids that I thought I had a great indication for it. But there are some that are really quite young that have a significant metatarsus primus varus as part of their deformity. So one of the kids I have is actually a kid with ectrodactyly. That's really so severe and so pronounced with other lesser toe deformities. The other is just a kid with juvenile bunions, but not a crazy DMA, but just crazy eye angle at age eight. And so I've tried that for them because I can't even imagine if they were 14 now with that deformity, it would be so hard to get a complete correction with any combination of osteotomies, rotational scarf, translational osteotomies, double osteotomies, adenacan. You'd be thinking about fusions. And so given how young these kids are, I've been tempted to do it for them because I feel like even if I can improve the eye angle by five degrees, hopefully then I have a much better reconstructive option when they're teenager. Perfect. And then Dr. Cody asked in our little private chat over here, why no first TMT fusions for adolescent bunions? So Colin, do you want to take that one? Yeah, sure. I think from my perspective, particularly in the skeletally immature kid, there's not much of a role for TMT fusion. I just haven't seen that it's necessary. There's not a lot, at least as far as I've seen, of instability there that would require a fusion. You can get the correction other ways without fusing a young person's TMT joint. So I think there's just a general feeling that we have as pedi-orthopods to try to shy away from fusion as much as we can. And I think that that extends to that procedure as well. I would do it if there was an indication that I felt warranted it, but I rarely see that. Yeah, I guess you can just kind of jump in a little bit to elaborate why I asked the question. I feel like with the minimally invasive osteotomies that you're talking about, where you're shifting the distal metatarsal, you're kind of changing the shape of the midfoot and in those bigger deformities, sometimes you can see subluxation at that first TMT joint. I mean, I worry about what happens with that long-term. And I feel like if you fuse the first TMT joint, you're actually getting a more anatomic correction, which is my preference for adolescents. I just didn't know if there was some other reason why you think it's bad for kids. Yeah, I mean, I think if they have an open growth plate, for sure, that's one question as to whether or not you can fuse it without affecting the growth of the person. But then also, there's not a ton of motion at the first TMT joint that's still shy away from it in the young people just because of athletic and activity demands. I'd rather not have seen the instability issue. Yeah, I agree. Liz, in general, sort of in PD world, we're trying to avoid fusing things that don't need to be fused. And the other problem with lapidus procedures is that they still aren't addressing that distal metatarsal articular angle. If anything, once again, they're going to make it worse or at least no better. And so I have done a lapidus. I've had kids with a lot of ligamentous laxity where I've needed to do a lapidus to help with their bunion correction. But I've done that in addition to a biplanar chevron distally in order to realign their metatarsal head. So you just want to make sure that you're correcting all the components of the deformity, I think. Okay, Jacob, there's a question. The only thing I would just add is for me, that indication has been where I've got a really bad concurrent flat foot with a bunion, and I find the lapidus really powerful in those adolescents. But similarly, I often find I have to add a distal osteotomy to correct the DMA. Jacob, so there's a question in the... I was going to jump in, just ask a quick question to the panel. First of all, thank you for taking care of these kids and these incredibly complicated deformities. Amazing what you guys can do. My question is, as somebody who sees some of this stuff coming, graduating out of your clinics, what would you want some of the adult foot and ankle people to think about? They see these things that you've done, and now the patient's coming to us. How do you manage that transition, and what do you want us to know coming out of it? Just sort of generally, not... You mean just with all pediatric stuff, or... I mean, I don't know. How do you communicate, and how do you think about the transition from the pediatric world to the adult world? Yeah, it's interesting. Tony and I set up this clinic at Scottish Rite just for that exact thing, to sort of work on transitional care, because a lot of these kids get lost in the mix, right? A lot of the time, a lot of pediatric orthopedic surgeons will say, oh, there's nothing to do here, or, oh, your bunion's not hurting you now, or your cavovarious deformity's not hurting you now, let's not deal with it. Then those kids just sort of get lost, and I think that a lot of them either just learn to deal with it, or don't show up until much, much later in life when things have really started to cause a problem, and so I think that there is a loss of care sort of in those teenage years, where it's like the pedipod sort of at that point is like, eh, they're getting a little old, it's not really a growing kid anymore, and the adult orthopedic surgeon's like, eh, you're still a kid, I don't really want to touch you yet, and so I think that... I don't know if I have anything that I want people to know specifically about the kids, but I will say that there is a lot of work being done. Don't forget that FAI isn't the only journal that exists, and JPO and other pediatric journals have a lot of good information on how to manage deformities coming out of childhood, and so that is there, and then also I would say especially as a foot and ankle surgeon, if you're not friends with a local pediatric orthopedic surgeon who has at least some interest in foot deformity, you need to make those friends. I can't tell you how many times I have texted, called, emailed, whatever Tony and all of his partners to figure out what to do with some of the kids that show up into my clinic or who come in with syndromes and deformities that I go, what is this and what am I supposed to do with it? I know what ectrodactyly is, like Maurice brought up, that everyone else sort of probably has forgotten on this call. Ectrodactyly is like the lobster boy kind of thing, and so anyway, you know, it's just sort of, I think making sure that you're thinking about things and realizing that it's not just cut and fuse, there's more to it than that, and so now I'm going to, I am going to jump on this question on the Q&A, so, and I'm actually going to give this one to Tony, so the question was, are there any studies on, you know, older patients who have had circumferential clubfoot releases, what kind of problems did they end up having, what to expect? I don't think, Naveen, I don't think that there's any, like, not to my knowledge, there's no adults, you know, true adults having clubfoot releases, but there are certainly older kids who are having those releases, and so I'll pass that off to Tony to sort of give us his thoughts. Yeah, I think if I read, I think you and I read that question a little differently, Jacob, I think he was asking, are there any studies of infants or children who had circumferential releases and what happens to them as adults? I think, I'm guessing that's what Naveen was getting at, and there's, well, there's plenty of studies that, you know, have looked at long-term follow-up, you know, five, six years, I'm not aware of any where there, a patient who had, he just, he just clarified, yeah, so I, so I was right, all right, no, no, that's what I thought, that's what I thought he was saying there. So here's the truth of the matter, Naveen, is the circumferential release, the circumferential posterior medial release at this point in the idiopathic clubfoot deformity is an archaic surgery and is really not part of our armamentarium anymore. We, you know, initially when the rest of the world followed Iowa's suit and adopted the Ponseti method, we realized quickly how powerful it was of a tool to correct infantile clubfoot deformity. And then what came out several years later was not only was it great at correcting deformity while preserving motion and not creating further stiffness to an already stiff foot by doing a circumferential surgery, but it was also very effective for relapse clubfoot deformities and recurrence. And it allows us to really limit the extent of surgery we need to do. And so, you know, yes, there are plenty of studies that have shown that, you know, especially motion analysis studies at skeletal maturity that show, you know, decreased tibiotailor motion, decreased push-off strength, altered pedobarographic weight-bearing patterns, relative high frequency, especially after that surgery of flat-topped talus, which results in anterior ankle impingement requiring subsequent surgeries. There's numerous studies that have kind of looked at the downstream effect. You get a plantar grade foot, but it's a foot that doesn't move very well. And it's often a foot that's attached to a talus with a flattened dome that can cause ankle problems. Fortunately, and I'll let Maurice weigh in on this because, you know, she kind of does, takes care of as many clubfoot as I do. But fortunately, I'll tell you, in, what, 15 years of pretty much doing nothing except pediatric foot and ankle deformity, I have yet to have to do a circumferential release in a neopathic clubfoot, and I really never intend to. So I think it's a damaging surgery to some extent, because you're taking a foot with, you know, that's stiff and you're adding stiffness to it by doing a surgery and you're sacrificing motion for the way the foot looks. And I'd rather have a foot that still moved and maybe had some residual deformity than one that's just stuck and stiff. Maureen, thoughts on that? Maurice, I'm sorry, sorry. I don't have a lot to add. I would say maybe there's been one or two kids that I've needed to do posterior release on, I think, that are idiopathic. And I also think that the approach to which we are taking these more extensive soft tissue releases these days are very different from what you would read from the papers that came out in the 70s and 80s. You know, we're much more deliberate about the tissues we're releasing and we're starting superficial and we're moving deep as we need. We're not cutting the talocalcaneal ligament, which was a big problem that led to the translational valgus of the subtalar joint. So I think the results are also better when we have to do that. But if you look at the literature, the number of folks globally doing extensive releases now is significantly less in reserve for very difficult resistant cases. And I think that you could also argue that a lot of the kids we think are idiopathic that end up needing this usually end up kind of showing up with something else bizarre down the road, like a perineal nerve palsy or something else. So they're usually not the straightforward kids. So yeah. Yeah, I agree. I agree. Thank you. Yeah, I'll just add to that real quick to this, Colin. You know, I think it is true that we aren't doing many releases anymore, but I think maybe to Jacob's point from his talk, we are seeing a lot of the results of these surgeries being done 15, 20, 30 years ago, people coming back. So as Naveen was mentioning, I think that's where the real problem lies is dealing with the poorly done, you know, historically, posterior, you know, circumferential releases and figuring out how to manage that. And I think that's where I struggle a lot in my adolescent and young adult population with those patients coming back. And I think Jacob's talk was excellent on how to do some of that, but that's a real difficult one. I think not enough out there on how to manage those kids, adolescents that have previously had surgery. Thanks, y'all. Yeah, I'm going to say one thing, and that's, I think, Colin, we can all agree it's because it's a really hard thing to study because it's such a heterogeneous group. Exactly. And the residual clubfoot could be a dorsal bunion. It could be an overcorrected clubfoot, an undercorrected clubfoot. It could be the static supination. So I personally, you know, well, I think all three of us love to do research, but that's one thing I have found daunting to tackle because I can't put any of them into a box or a category. Maurice, I love that you showed that 3D model of the CN coalition. I think, you know, explaining the depth, just how deep those things are and how much bone you need to resect. And we're always emphasizing, you know, it's a rectangular excision. It's not a triangular excision because then you leave the base of the coalition and it leaves them stiff. And I think that's a really important point. I actually have a question about the talocalcano coalition. Just because of your background with peds and adult foot and ankle, you know, I think there's a point at which resection of the talocalcano coalition, even with a healthy appearing subtalar joint on CT scan probably doesn't make sense. I think that at some point you get old enough, you're used to having a stiff subtalar joint and resection really is not the best option. Do you have any thoughts on that? Is there, do you have an age cutoff or any sort of suggestions for us as the adult surgeons? Yeah, I mean, I agree with you. I think that's very true. I wouldn't say that that cutoff actually is necessarily in adolescents because I think the ones that are younger that don't have a lot of deformity have developed a lot of compensatory motion through show parse joints or through their ankle joint. And so I would be hesitant to like, I would just, if that subtalar joint ends up maybe gaining five or 10 degrees, it's not gonna be a lot, but at least I'm not then like stiffening it up to a hundred percent and then accelerating the rate of changes in their adjacent joints. And then I find the adolescents that are coming to me with really stiff or bad ones typically have deformity. So it's so rare that I'm seeing kind of an older adolescent at that point that's coming with just pure isolated coalition symptoms. I think they've kind of, the ones that have a milder deformity or no deformity kind of burnt out their symptoms by 17, 18. So I don't know, in my practice, I can't say I've really done an isolated resection in an older adolescent because it just, the indication hasn't been there. So I think to your point, the ones that are coming back as adults with new onset symptoms of just a coalition are probably more symptomatic from the stiff subtalar joint than the coalition itself. And you're probably just managing that stiff joint. I don't know if that addresses what you're thinking. Oh, it's perfect. Thank you. All right, I think we're gonna call it y'all. That's our hour and a half. So I'm gonna toss it over to Chris. Thanks to everyone on the panel. That was outstanding. I just really appreciate you all giving us your time and your expertise. Those, I really learned a lot. I appreciate it. Yeah, no, and thank you also. I just say, before we jump off this, Dr. Rickshire, there was a final question here about cavovirus. If you don't mind maybe typing a little answer or giving a suggestion for something that they could, they could look up, I'd greatly appreciate it. No problem, I'm happy to type an answer. But- I may need more information based on that question though. Anyways, that's a tough act to follow, but we're gonna do it with another amazing talk here, I'm sure. So the second round here is gonna be on the complicated athlete. And I'm really excited for this one when we were trying to plan out what to talk, what to ask people to talk about. This was one of our top topics that kept coming up because I think there are some people who are doing it great and this is a topic that I, you know, in my practice don't have a lot of experience with and probably don't wanna get super involved with. But I would love to hear what the panelists have to say. I'm looking forward to it because I think we can all learn about managing athletes better. So to start, we have Dr. O'Malley talking about considerations for handling the professional and collegiate athlete. And I will flip it over to you. Thank you, Dr. O'Malley. And you're still muted. All right, can you hear me? You got it. Okay, well, that is an inspiring group of talks. It reminds me why when I was a medical student, I was gonna be a pediatric orthopedic surgeon. It also reminds me why I chose the right path because those are hard cases, but you're really changing people's lives. I mean, a lot of what I do are probably changing people's bank accounts and other things, but those talks are really inspiring. So I learned a lot because I still see, you know, enough adults with, you know, pediatric deformities floating around. Thank God I do have David Sheer and a couple of colleagues at HSS that helps us. So I have my pediatric orthopedic surgeon to help me. So that really makes it help. So I'm gonna talk about handling professional collegiate athletes. I don't have any disclosures to do with this. I'm the team orthopedist for the Brooklyn Nets. I'm a consultant to the Giants and the Devils. People ask how this happened. It was not a plan. I played division three football. I didn't see any elite athletes during my four years there. I ended up doing a fellowship at HSS and part of my fellowship was with Bill Hamilton, who was the first sort of the Dean of foot and ankle sports medicine. And he taught me a lot and it went from there. But then I just started in practice at HSS, not really thinking I was gonna be a sports foot and ankle person. I was just gonna be a foot and ankle person. HSS is the largest musculoskeletal provider in the world. Dr. O'Malley, do you mind just clicking into presenter mode? I thought I was in, okay. Ben? Thank you. Okay, so we're the largest musculoskeletal provider in the world. We have all these teams and I would see teams from like, you know, the Cyclones and all these different teams, but no, any of the professional athletes that I saw for the first 10 years in practice, all went back to their regular doctor, normal doctors to have surgery. In 2005, Answorth Allen became the head doctor for the New York Knicks. He's a sports guy and he said, I've got this job and it's all foot and ankle. You'll be my assistant. I think the first team orthopiast in the NBA who's trained in foot and ankle. And then the next year, we had a couple of problems with the nets. So I privileges with the nets. And then since that time, I've been very involved in the NBA. Once you get involved in the NBA, you have the NBA Physicians Association and also the Trainers Association. And this is where you meet people. And this is where my patients come from. So if you look at where the patients come from me, it's the team docs, the performance staff, or occasional players. But we have the teams that you meet and you meet them because after you cover an NBA game, you go visit the other team and you make sure that everyone's okay. And the other team, you meet the performance staff. So after 20 years of this, you know everybody in the NBA. And then you know the agents. And the NBA is unique compared because the NBA agents are really powerful. There's six agents that probably have half the league compared to the NFL. So there's probably 450 players in the NBA with all guaranteed contracts. NFL now, we have some guaranteed contracts, especially at the quarterback and receiver position, but there's 2,200 players in the NBA. The most powerful agents probably Drew Rosenhaus, who has I think 65 or 70 players. So the NBA is really controlled and where their players get care is really controlled by these agents. So you start to see them, they start to send you all these guys. So I have a few rules. Number one, don't be a fan. This is for taking care of these guys. In my office, there are no autographs. There's no pics, no Jersey side. All these pictures I have here are at least five years after the player had an injury. And it was just as kind of spontaneous. Let's take a picture, but none of it during the course of their treatment. They're there to give you a medical surgical opinion. I mean, you give them an opinion that the player and agent and team make the decision. This is a player who I saw about a month ago. I saw him at nine o'clock in the morning. And then by, they came out on Twitter. They had a list rank injury. And then by six o'clock, you'd already seen Bob. And I think Bob operated it the next day. And probably earlier on in my career, I've gotten a little bit grumpy because I'd already seen this player before and I'm on the staff of the team. But I mean, you don't push, don't worry if they go somewhere else. Eventually they'll come back to you. I mean, people went somewhere else for many, many years. I saw them, I gave an opinion and I never saw them again. I tell them the same thing I had from the beginning. If you're gonna have surgery with me, this is what I do and this is why I would do it. And then I leave the room and I say, all right, now you have your agent, your team make this decision. Because when you're in the room, you're thinking about the best treatment options. You're thinking about what's the complications and how can I get back to play? But the player's not thinking about this at all. First of all, I think, am I gonna let this doctor operate on me? Will I get back to recover? How long will I be out? My contract, my next contract. And there's so many factors involved. You just have to block it all out and just look at them and say, this is what I think is best for you as a player. Number two, rule number two, don't talk to the coaches. I won't get on the call with the coach. I will talk to the GM. The GM are definitely more independent of the whole thing. The coaches are really tough to talk to. So this is really magnified by at Penn State where Scott Lynch was got in a fight, tussled with the coach of a player return and he ended up getting a big verdict for that because they were really limiting his ability to give good care. So coaches and the team doctors clash and that's a big issue. So stay away from the coaches. GMs are much more independent. Number three, if you do the surgery, don't post on social media. There's posts all the time with my name on it. I don't post anything. I think if you post, you're sort of becoming a fan. You're going back to rule number one. If your practice, your hospital wants to post, that's fine. But I don't think you want to post anything. So those are the sort of three things when the players come in. They come in, we don't get autographs. We give them an opinion. We let them make their decision and then we don't post anything. Now, the truth is taking care of these people is really a low paying full-time second job. I have my practice of regular patients. The majority of my patients in my office are just, you know, people with foot and ankle problems. As a team physician, I mean, for NBA, your game coverage, I usually cover 35 out of 41 home games. You care of the visiting team, you have draft preparation. It is a big commitment for that. For this, if you're a surgeon for pro athletes, it's always on the weekends and nights. This is like a whole thing that impacts your family, your social life and your weekends and nights. So when you get to the game, like we sit on the bench, this is the first year we're off the bench and we're very happy about it. We'd get to the game, we'd leave, have a whole day of patients. You get there, there'd be a timeout and everyone's supposed to be standing up. We stand up, we go right to our phones and we're trying to finish our day of messages and callbacks of patients. And actually it became a little bit of an issue with the GM because you guys can't be on your phones. I said, well, we can't, then we can't be on the bench if we can't be on our phones because you finished a long day. There are things that go on in your life that you need to handle and they can't wait. So now we've moved a whole row back and we're very happy. There's a myth that taking care of multimillion dollar athletes is lucrative. We've tried to figure out how much an NBA team physician makes. We have a survey went out. It seemed about between 75 and $100,000 a year. The average NBA salary is $11 million. So it's not much. If you look at this for $100,000, you're covering 35 games. It's somewhere near less than $200 an hour and that's being very generous about it. So none of us would really take a job on the weekends and nights for less than $200 an hour. I mean, you'd just be rather doing anything else. So if you look at the water boys in the NBA who go to the same number of games as you, some of them get paid $100,000 a year and the mascot gets paid a lot. So I told my son, don't be pre-mascot. Rocky the mountain lion gets paid $600,000. He goes only to the home games. So if you have to look at this, this is not a lucrative thing to take care of these people. And so in three, because one, the pay rate from the teams isn't very high compared to what everything else gets paid. And two, the workman's compensation rates are per state. So it's a lot of stuff I fixed as Achilles, but the real story is the state of California paid me $982 to fix that Achilles tendon. And I spent hundreds of hours post-op taking care of this guy because I was worried he would have an infection. I was worried something was going wrong. So hope high profile. I mean, I was stressed for weeks over it. We figured out, I think my office manager figured out I've got about $14 an hour to take care of Kevin Durant the first six weeks post-op. He had a contract for 160 million, including 40 million for the first year he wasn't gonna pay. So there's a big disparity in terms of like the care that you give, the stress that you have in the remuneration. The workman's comp rates are really what everyone gets. Dr. Elitrash in LA stopped accepting workman's comp. And he says he has a contract with teams outlining unique prices. It's true that these workman's compensation rates were not meant for professional athletes. These cases are time intensive and it takes so much time. Since 2020, I've charged them all commercial rates except for the teams I take care of. It's worked out, but I mean, I should charge the same amount as the water boy. But unless you take care of a lot of guys, you don't really have negotiating power to do that. So most of these players that come in are gonna be workman's comp rates and in college degree school rates. So taking care of elite athletes is really a low paid second job none of us need. It's a high level of stress, but the real issue now is coming liability. This is the big ugly. There are so many cases of medical malpractice involving professional athletes, right? And the numbers are huge. So the Sports Medicine Society has come out with a statement protecting athletes and team physicians who care for them amid the rising complexity and liability risk. Said our ability to serve all of our patients from playground to professional levels at risk. And Scott Rodeo said the visibility associated with care for these athletes may not be worth the liability anymore. And it's true. I mean, Shadier Sanders has a $5 million NAL contract. He's a senior in college, but these numbers are getting bigger every year. There's a high school quarterback who's just said to have signed a $9.5 million NAL contract years in Miami. I mean, these high school basketball kids are getting A.J. Dispensary, he's got $4 million Nike. There's a nine-year-old who just signed an NAL deal. I mean, they're getting smaller and smaller. So while this used to be my problem and a few other problems, it's everyone's problems. It's become Posner's problem. If you see a 13 or 14-year-old, the Tarsel Coalition who's an elite athlete at that level, and they have an NAL deal, and something doesn't go right, and they can't compete at the highest level, this is gonna be an issue going forward. And no one has this kind of malpractice with these numbers. So if you're a team coverage and you're covering doing a solid for your local high school or your alma mater or your local high school where you live, you need to ask who's covering you, the school, the school district. If you're in any team, you're at risk now. And the numbers used, I mean, the numbers are crazy with these NAL deals. So team doctors can be sued for malpractice when they fail to the standard of care for the patients. And it's usually four areas, failure to diagnose, inappropriate treatment, surgical mistakes, and informed consent, right? So you can be sued even when none of this happens. So here's an undrafted third string quarterback. We'd all fix this. You know, where they fixed the deltoid, he's got a small posterior piece. He got an MRI. He's got a little chondral injury here on the MRI. Probably most of us wouldn't get an MRI. Now we get an MRI and all these eversion injuries. He got treated appropriately. A year later, six months later, he comes in to see me. He's got a big cartilage defect and a lot of edema in his talus. We go in there, we try a biocartilage graft. I mean, there's like biocartilage in de novo. It was a huge lesion right in the central talus. He got a $28 million verdict. He was making $500,000 a year. So he got paid for the next 49 years of football. Nothing really was done wrong. Now, maybe informed consent, maybe, and the word is there was nothing documented about that MRI, and that's what happened there. So was it failure to diagnose? No, inappropriate treatment, surgical mistake. Maybe the informed consent wasn't perfect. This is in TMZ, that major botched my knee surgery. He played, he had a ACL, went back and played 13 games and re-injured his ACL. And in the suit, it said failed to create a proper tunnel position in his knee, damaged cartilage. So was it failed? No, he got good treatment, appropriate treatment, tunnel position. I think the tunnel position is a little bit controversial, exactly what the tunnel position is. If you have a small chondral defect, what the treatment is at the appropriate surgery, what to do then is controversial. I don't think any mistakes were made. I think it's just informed consent on this one. Here's a guy, another with him, went in for a knee scope for a loose body, he got a micro fracture, anesthesia did the pain block, and he had complication from the pain block. And so because of that, he's suing everyone. It wasn't, he got the right diagnosis, the appropriate treatment. Maybe the informed consent on the pain block was there. So if you look at this, it goes the most recent- Dr. Malloy, we have a couple more minutes, but thank you. So we'll get to this, because this is the one you got to, where you have a guy who's a backup player, gets awarded a $43 million, gets his PCL and a small cartilage injury. NFL comes to back him up. Wasn't any of these things that happened. And it's a perfect storm, he gets this big verdict now. So all this happens, and it really is, the point is the chain of care. If you're operating these guys, even if you're not a pro athlete, you need to know what's going on after they leave your office. So they lost their team doctors over this. We have guys who've had Achilles rupture. I told them that you can go in a pool. That's not a pool, that's a waiting pool. They had to repair. Could I get sued for that? Oh, absolutely. But it wasn't because of a surgical mistake or failure to diagnose. So if you look at these guys who have this, people are getting sued at the end of people's career. I'm getting sued on a static nerve. This is a popliteal block. And a kid went afterwards. So what we do now, my take home for this is if you have an injury on a player who has some potential, we have a whole statement now at HSS. It's about two pages long for these lead athletes. We have to discuss that despite optimal surgical treatment, he may not return to the same level. It may not return to professional sports. That we've discussed it with his agent, with the team doctor and the trainer. And it goes through each of these consults. So it goes, it's all about documentation. And so we have now at HSS, if you have a professional athlete which we have so many teams we cover, we have these three page list of these players are signing this now. And it's all due to protect yourself. So the lessons I learned in doing this, this is really, it's a privilege to take care of these guys, taking care of these athletes, but you need to document everything, especially phone calls. There is no free, like, hey, can you look at this? If I see it, someone sends me an MRI, I get on my phone, I document it and I charge them. That is a telemedicine visit. Informed consent is the most important thing you can do. You have to tell them this can go wrong. It's an inexact science. Faultless critical, especially if the player goes outside of your care. Another little tip, if they travel, just think about a DVT, because we've had some of those and avoid peripheral nerve blocks. So that is really your lesson. So you have to think that the issue of the professional team physician has now gone to the level of the college physician, the high school physician, and even the grade school physician with these NAL deals. So you need to protect yourself and you need to document everything, because that's where all these lawsuits are coming from. It's really lack of documentation. And it's people trying to be nice. People trying to do other guys a favor, trying to do an agent a favor or a player a favor, and you get in trouble for that. And the final lesson, so we don't know whether these payouts are gonna be really going that far. We don't know they're gonna be, these $43 million are gonna happen. We think they're gonna be reduced. And so thank you, be careful. Thank you, that was awesome. Next up is Dr. Ortiz from Chile talking about the aging athlete. And hopefully that will be, this next one will be slightly less stressful for me to listen through. But that was wonderful, Dr. Malek, thank you. So Christian. Okay, let me try to get to my screen. Thank you for this invitation. I'm very honored about this. And let me put this in presentation mode as soon as I get it. I see your email right now. Okay. Try unsharing and then share just the screen of your PowerPoint. Okay, give me just a second. I don't think any of you are interested in my mail. Okay, let me unshare, share again. Sorry about this. About now, can you see anything? That will be good once you put that in presenter mode. Okay. We'll do that in a second. Well, thank you for this kind invitation and I was that was a very entertaining talk I remember that Bob Anderson explained some of this to me a few years ago. I'm happy that in Chile none of our athletes Get such an amount of money so I cannot be sued for that amount of money. I'm still trying to reach the button To make this in a presentation mode. Just excuse myself for this just to your left It's that little thing that looks to go to your right down at the bottom, it's a little square with a Keep going at the bottom of the PowerPoint other way To the right you're saying? Yep a little left Okay Okay. Now I got it. It was hidden. Sorry, so I have no disclosures related to this talk I was trained in 1998 the old ASMI the American Sports Medicine Institute Some of you may be familiar with that institution that finally disappeared My mentor was John Gould and after I came back to Chile, I was very much involved with the sports. I Worked for more than 12 years for one of the major soccer teams here in Chile which is a picture of that is on the left hand side and Right now I work for another soccer team and we take care as a group for the all the Olympic athletes in Chile, so Everyone knows that the older competitors have an increase in numbers This is just one is that these statistics that come from the National Senior Games Associating Association the initial event that happened 37 years ago had 2,500 athletes now it has more than 10,000 athletes and What do you mean by an athlete and that's the beginning of a discussion? person who has a regular competition against others and requires requires some form of systematic training and What is the definition of a senior athlete? It actually depends on these sports and the Association For as I said for the National Senior Games is older than 50 years old For the Amelie American College of Surgeons is older than 65 But it's older than 50 50 years old if they have any comorbidities and of course in different sports They has different definitions This is This is another way of looking at professional older athletes you have Lionel Messi 30 years 37 years old and Cristiano Ronaldo 39 years old still playing professional and 40 years old LeBron James Some people that you may know and of course you have this very well-known Spanish Rafa Nadal Who happens to have a Miller-Weiss disease most of you know about this and these are professional? athletes at the very edge of retiring But if you take a look at some other Less conventional sports you see that people play different sports at much older ages and in some other countries You see this Japan professional soccer player who is still active at 50 years old which is obviously depends how professional and how And what is the level of of the country at where you play, but some other sport sports people play? At the very old age here. I have a picture of the right on the right side of a Chilean ping-pong player that was That participated in the last Olympic Games at the age of 50 years old so all these people are actually professional players in different sports, of course, but And they need to be taken care. This is a Chilean soccer players 36 years old kind of offers. He's a for his profession and he's six weeks after a bilateral Arthroscopic brass and wool plus augmentation without a with the brace and you can see he's not playing But at six weeks we were able to bring him back to full training It will take it about six more weeks for him to go back to full sports also, we need and another thing is that we need to take care of retired professional players and This is one post That was in in the newspaper here in Chile when I took care of one of our most famous Chilean tennis players and he torn his Achilles tendon, but when he was just presenting an exhibition not professionally playing so that's another group of Professionals and you need to deal with them at this point. You don't need to deal with the manager the The GM, but you just need to deal with him his friends and a lot of people around this is about the same thing This is another example of an Argentinian famous player That of course when he retired his two uncles Were in severe bad condition one of my friends here in Boca Juniors Performed two arthroscopies to remove osteophytes and Sadly, he ended up with this severe unstable ankle that needed to be Taking care when he retired So in his 40s near to his 50s He ended up with an ankle replacement on one side and a fusion on the other side The fusion was the first one and then he realized that the ankle replacement was going to be a better idea So we're moving from a professional active old athlete into retired old athletes But we also have people who are amateur But they actually do practice quite a lot sometimes and they participate Almost at the same level as a professional athletes and these people can get very old as you see in these pictures and We wish we would do everything perfect like you see with this tennis player and Everyone wants to be treated like a pro and that's for me one of the big deals as dr O'Malley was mentioning before most of the people we treat are actually non the professional are the other people who think They they deserve to treat to be treated as professional so, of course we have all the Traditional conservative treatments, but these people most of these people are also asking for the less Conservative treatment and they are looking into magic solution for everything and that's something that we all need to deal with And of course sometimes we we need to explain clearly What works and what doesn't work for these people who as I said before are are expecting everyone? to treat them as professional athletes, even if they are not in their Competing competing as professional. This is an example as I mentioned before for a chronic Lateral ankle instability in a 50 year old runner We treat them with an arthroscopic repair of the lateral ligament augmented with with the brace This is another example a pro senior tennis player 37 years old Achilles tendinopathy with either reattachment and open reattachment with Augmentation so that typically allows them to go back to play at around three months Another This is a surfer so we can we can go from any any kind of sports and in this particular Patient I began with an with the tendoscopy and I honestly I didn't see much so I ended up opening up everything and I found out a distal insertion of the peroneus brevis that I removed and then I Reconstructed or repaired the retinaculum and he is doing fine right now Another example 37 year old pro polo player And who ended up with a severe arthritis after a talus fracture and we ended up with a ankle replacement And This is going to be more extreme patient that Plays golf and competes in Peru He moved to Chile to get surgery for this very ugly ugly ankle You have to believe me on this he's Highfoot was very flexible. And of course, I was thinking about correcting the valgus deformity plus an ankle replacement and I ended up doing an arthroresis and Medializing calcaneal asturmi plus the ankle replacement that ended up very well and he went back to sports He's this is not his picture. I took it from the web, but this These videos are the videos he sent to me after about a month from the surgery when he was beginning the rehabilitation This is another extreme case, of course, this is a 95 year old nice man who came up to my office Complaining that he has been in a wheelchair for the last Three or three or four months and he allowed me to share his picture and I decided to perform an arthroscopic fusion and He was able to stand up. You see he's in the wheelchair He's in the about three or four weeks after the surgery and he told me doctor now. I'm able to walk so sometimes sometimes Expectations need to be fulfilled and you need to do whatever it needs, but of course you need to Present everything the pros and cons of every treatment So as a summary, I can say that the aging population is increasing all around the world aging professionals But at the same time aging amateurs But I think that most common than that are people who wants to be treated like pros And they are very demanding. So you need to control Using all the tricks. Dr. O'Malley just told us. Thank you very much for your attention guys Dr. Ortiz, that was a excellent and I look forward to asking some questions about those at the end, but if you don't share your screen Let me share done and then Next up. We have dr. Mark Dracos also from HSS and he'll be talking about deformity And when should we be addressing it for our athletes? So, thank you very much, Mark And I think you're still muted Can you hear me now? You got it. Hey, so thanks for the opportunity to speak Because that so my charge was deformity when does it need to be addressed? Thank you for inviting me to speak after hearing Dr. O'Malley's talk. I might want to change my answer to this seeing what the liability involves, but I will try to get through it These are my disclosures So I'm going to over use just some backgrounds and different foot and ankle pathologies some case presentations and then some areas for a future study So we're talking about the pathologies and athletes This is a lot of what you're going to see is stress fracture, particularly fipna, tarsal, navicular, sesamoid, distal and gluteal tibia Ankle instability, perineal tendon tears, posterior tib Pathology, tailrose, heels, and turf. So I think those are kind of like the main like athletic things that you'll usually see And then you have all sorts of different foot deformities So, you know the two pictures on the right are kind of the extremes of you know Cavus and a pes plant of an august foot on the bottom But fortunately the really high level athletes usually aren't at the extremes, although there are plenty of five feet Out there and then you can have midfoot abduction and adduction and tibial deformities as well So, you know traditional views of osteotomies and athletes was historically these procedures were acceptable for kind of standard populations But were considered potentially career ending with the athletic population And always required caution and consideration before proceeding And even though the osteotomies may correct alignment They may make athletes stiff or change the biomechanics to not allow them to perform at the same level And there's only a handful of success stories like the two pictures on the right And so as such many people kind of consider osteotomies as the last-ditch effort to repair Or to protect or repair to prevent further degenerative changes or occurrence So this is something we'll commonly say this is a professional football player And so with the caovirus alignment, you're at an increased risk of fifth metatarsal fractures, sesamoid fractures, ankle instability, and perineal tendon tears You know on the other side, you know when you have a flat foot Increased risk opposed to your tibia dysfunction, achilles, plantar fasciitis, arch pain, subfibular impingement, and bunions So When you look at the literature for this, unfortunately, there's not a lot of stuff to guide us and that's what makes this challenging This is actually one of the only studies I saw that was looked at return to sports specifically after osteotomies And so this was 42 patients who had basically a medializing calcaneal osteotomy and an FDL transfer for a flat foot No true flat foot type procedure And they found that most of the patients actually got back to sport, but there are only three high-impact athletes So one professional football, one professional volleyball player, and one professional basketball player So one professional football and one professional volleyball player were able to return to sport Now these are a couple other studies looking at first-rate dorsiflexion osteotomies And people with subtle cable varus feet The second study was in navy seal candidates who were high demand. They found that you know The guys who had higher arches had significantly more fourth and fifth metatarsal stress fractures And then when you did this osteotomy the rate of that actually went down So and recurrence went down as well. So that was something that they felt could be used in a high demand population You know perineal tendon tears are the chronic ones anyway are often associated with the varus hindfoot These were a couple studies looking at how the osteotomy protected your perineal tendons after surgery This was one study back in 2012 didn't show any difference in return to sport between patients who received an osteotomy versus those who did not Although it was a short-term follow-up And then the final study was kind of a the title of that paper was you know When do you need an osteotomy and this was their recommendation at the end? Was that if the heel does not show the physiologic position of one to five degrees of valgus but prevents a varus position Risk of ankle sprain and perineal tendon lesion is significantly increased So again kind of like soft anecdotal evidence, and again looking And now With MIS, you know, you can do these percutaneous osteotomy and maybe the patients will be a little bit less stiff Maybe there's a little bit less inflammation and quicker recovery So it's a whole new avenue of things to potentially look into but again, there's not a ton of data specifically speaking at return to play And athletes so getting to the meat of it, you know when I see like a chronic stress injury You're trying to try to look for causes right to a root cause analysis And obviously we look at metabolic and vascular, you know This is someone who has low vitamin b or a female triad poor blood supply I think the environmental factors play a role. Um, you know, uh, a lot of these injuries I didn't start really taking care of these athletes until I took care of the Higher level athletes where they put crazy loads on their feet like the basketball players. They have 80, you know in the nba They have 82 games plus preseason plus playoffs. It's just a lot of load But for the purposes of this talk, we're going to talk specifically about deformity and when we should do something so, um, this was a case that uh, So first of all, we're going to talk about fifth metatarsal fracture so Uh in the nfl there's about 50 identified over a three-year span Uh, I said a few years ago in the nba the fifth metatarsal stress fracture made up about 18 percent of lower extremity injuries and um, this is a the foot, uh, this is actually one of uh, dr Mallory's patients he shared me and both he and um Generic talked about the specific nba foot, which is a lot of these guys have flat feet But their forefoot is adducted. So their metatarsals are adducted And they have prominence underneath their metatarsal base And the refracture group lives most had the most pronounced metatarsus adducted So there's an increased risk in larger players mostly centers and forwards In the nfl a large narrow straight metatarsal and adducted forefoot increase your risk Um, so this is a case of uh, dr. Mazda share with me 26 year old nba center Big guy 7 1 280 pounds who presented with the history of fifth metatarsal pain and refracture Presented with a refracture mid-game injury. He already been through three surgeries And um, this is again kind of that or part of it had some features of that classic nba foot, which is He had a metatarsus adductus see the screw is well positioned. It's actually bent So now this is one where I think it's just the loads that this guy was putting on his foot Were too great for the amount of for the bone to basically, uh withstand given his morphology. He had a little bit of cavus um, and so the thought was if you did a osteotomy, could you correct us so Procedure that was done was a first-rate dorsiflexion osteotomy Revision bone wrapped in with the screw. Um, he went on to heal and it's actually still playing a decade later. So Um, it was a successful operation in terms of offloading the area and getting it to heal um Uh, this is a 23 year old female gymnast with several year history of right chronic ankle pain instability. She had outside surgery on outside hospital Recurrent instability slight varus alignment suplex anterior drawer Uh stress x-ray showed 16 degrees of varus a bite and square of nine distal tibia varus of eight so I think in my mind when you're Considering osteotomies. It's kind of like you're you know, you're trying to build an argument And so this is a gal that sat in varus. She also had a history of failed operation before and she had generalized ligamentous laxity And um, you know, we got some alignment bones as you can see she actually sits in a little bit of varus um So this is one where we did a um, you can see how loose she is on her stress x-ray Um, this is one where we did. Um Super malleolar osteotomy to get her out of varus in addition to doing a hamstring, uh autograft lateral ligament reconstruction um and you look at her uh alignment significantly improved so We addressed the instability we augmented with the graft and then in addition to that we addressed the deformity at the same time She got back to gymnastics um this is a posterior tibial tendon, uh tear case today, this was a 25 year old ultra marathoner with a six month history of right ankle pain For those of you that don't know ultra marathoners run 100 miles, uh races Uh, she felt a pop at mile 38 of the race and then finished the race So apparently you don't need your posterior tip to run and um, she presented to me and what happened was that she had had uh, some tendonitis and then um, Been seen outside and given a cortisone shot to run a race And so she saw me about six weeks after her injury And I thought her alignment was actually pretty normal and she was 25 and pretty young Um, and basically what she had done is she had popped her posterior tib So because her alignment was pretty normal and I thought it was related to the injection I basically just did a um, Reconstruct and so I used a gracilis autograft and I reconstructed her hamstring because there was a gap I really didn't do anything about the alignment. Um, I figured i'd just give her an orthotic and kind of see how she did Um, she made it through two marathons and then popped it again So I then ultimately went back and did a real A flap of operation where I did an osteotomy fdl transfer She got back to running marathons, but did not get back to running ultra marathons. Um, so, um That was one where I probably should have addressed the deformity in the first place, even though it was subtle um This is a show a couple cartilage lesions So this was a 13 year old who presented with a one-year history of bilateral ankle pain He had a bilateral pes plantar valgus and Achilles contracture He had this really large osteochondral lesion on his lateral talar dome Um, he was pretty symptomatic from it. Um was having trouble even walking And the thing was huge. It actually ended up being about like a third of his uh talus It's more like almost like an osteochondritis desiccans Um, and so what we did for him Was uh when he got in there the cartilage cap actually didn't look that bad It was almost acted more like a non-union. So he kind of treated it like a non-union where we Debrided the the lesion, got rid of any fibrous tissue, bone grafted it, put in some bioabsorbable nails to actually fix it. And then to kind of protect it, this is a before and after projector, we fixed it. I did do an osteotomy of his heel, put him back in a more neutral alignment, get him out of valgus and protect my cartilage repair. This is him at eight months, he went on to heal and he actually ended up playing high school football and actually became a Marine and was able to basically perform all his duties at the highest level. And we did end up doing this bilaterally. And this is him, I actually saw him seven years post-op, he was actually doing really well. This is another cartilage lesion, this is a 22-year-old Division I collegiate soccer player with a complex surgical history with persistent pain over anterior joint lang. She basically had had an ankle instability and then had collateral deltoid and ATFL repair with internal braces and chondroplasty. She's pretty stiff, so I had multiple debridements after the fact. And she came to me with her primary complaint of stiffness. And you see that she had resected a fair amount, but she was sitting in a little bit of valgus at the joint. Unfortunately, you know, this is someone who basically had some early, what amounted to early ankle arthritis on the lateral side. And so in this case, because again, it was a fairly large cartilage lesion, and formerly I thought we needed to address both of those things. So we ended up doing an osteotomy, supramalleolar osteotomy to address her alignment, as well as a calc osteotomy to protect the cartilage repair, get her out of valgus at the joint. So you know, the question is, you know, what to be a deformity in a chronic injury setting when you perform a structural correction. So really there's only anecdotal evidence, so I'll give you my level six evidence, or my level six opinion on the thing. So I consider this certainly in revision cases, you know, if that tarsal stress fractures and instability, if you've failed an index procedure, you know, with kind of appropriate technique, at least start thinking about it. If there's a large cartilage injury with joint tilt, almost always, I think you need an osteotomy to protect whatever cartilage repair, if you just fill in the divots, especially if there's like a bipolar lesion, it's just going to fall right back into that divot. So it's something to consider. Because of my experience with peroneals and posterior tib in the chronic setting, I tend to be a little bit more aggressive. I think you can get away with dorsiflexion first-rate osteotomies without too much stiffness. And certainly if they're extenuating factors, such as generalized ligamentous laxity for instability, I think you should consider it. You know, if the expected level after activity of the, after the procedure is low, I think it's very reasonable. You can do this in high-level athletes and may be able to get away with it, but certainly more research is needed. And you'd be very careful about making these athletes stiff. And, you know, again, Dr. O'Malley's presentation about liability, if you're doing stuff where there's not a lot of evidence, even if you're right, you know, you just have to be, you know, very careful. So I'm not really doing this in a lot of the index procedures. So certainly for just metatarsals or just, you know, isolated small OCLs, I'm not doing it. But like I said, in some of those select cases, I think it's very reasonable. And again, I think you can get away with the first-grade dorsiflexion osteotomy. Just be aware a lot of the cartilage procedures are a little bit less predictable and can't guarantee. A liberal use of orthotics and vitamin D load management, I think is healthy too. And one other pitch I want to do, this was a study we did at HSS, just looking at the strains in the bone with different orthotics. And so we put strain gauges in the metatarsal and had people go through a gait simulator and then used all these different orthotics just to look at motion and how much you can protect them. So I think, and what we found was that, you know, using a carbon graphite plate was actually the most effective at reducing the strain in the bone. So, you know, even if you're not going to do anything from an operative standpoint with regards to their deformity, certainly orthotics, certainly have the discussion with people's certainly realize it plays a role in all of this, I think is important when you're building a case for this. And like everybody gets something usually from an orthotic standpoint when I've seen. Thank you. Thanks, Mark. That was great. For our last panelist here, we have Dr. Anderson. And he'll be talking about sky-high expectations for the patient and the team. Looking forward to hearing what you have to share with us. Thanks. Thank you, Chris. Hopefully you can hear me and see the slides okay. Perfect. So I've been managing or caring for the professional athlete for over 30 years and the climate's changed. And after hearing Dr. O'Malley's talk, I'd even have second thoughts at this point in time. But if you are going to take care of these high level athletes, I hope to give you some information here on how to at least monitor the expectations that you provide them and those around them. My disclosures do not pertain to this particular talk. When we're talking about treating the elite career, the complicated athlete, it's really it's not for everybody. This takes a lot of time. I think it's important that you refer players away when you're uncertain or you lack expertise, not only with the surgery, but the post-operative management of what the surgery is. And you really just got to remember to always do what's best for the patient. Don't let your ego get in the way. And again, you got to remember that the rehab is important as a surgeon. If you're the surgeon, you're going to have to have some kind of involvement in the rehab decision making. You know, how quick can you go because you're trying to protect the repair, but you also have to avoid things like atrophy, arthrofibrosis, nonunion. So a team approach, and I'm going to mention this several times in this talk, your team approach is mandatory. You have to enlist all those around you to basically not only determine expectations, but monitor them and then appropriately communicate them back to all parties involved. So let's just start from the beginning. You got a surgery that needs, you know, to be done. You've got a major preoperative decision making, and that takes a lot of time. You have to set expectations from the very start. You got to put a plan together and that plan has to be put together together. Everybody has to hear what you're thinking and everybody has to be a part of that plan from surgery all the way to return to play. And you got to educate the parties involved, what the risks are, what their general prognosis is. You're trying to balance healing time and increasing activity. And oftentimes what I find is I count backwards. I ask them, when do you need to be back? When do you expect to be back? And then count backwards on how aggressive your return to play has to be and then what expectations you can provide them in that regard. So again, it's obvious, I mean, everything heals better with more time. Unfortunately, when you're taking care of these elite and career athletes, time's not in your side. You get pressure from multiple parties to get them back as quick as possible or what may be deemed as safe as possible, whenever that may be. And you get questions like, will she or he return? And when? And will they have the same talent? And what are the risks involved in that regard? I think the one last thing just to talk about in general is what I said before, is you got to keep in mind that this athlete is your patient. It is a patient, it's your patient. You got to maintain perspective. Just like Marty was saying, you can't be a fan of that person. That person's your patient. And you have to do what's right long term, not just what the short term is. A lot of the teams, a lot of those around the player want to look at the short term. You have to look at the long term and beware of those outside influences. So what it starts with is basically sitting down and spend a lot of time with the athlete. You have to understand the player's psychology, their perspective. You basically have to function as a psychiatrist. You have to listen, you have to educate. And I always offer additional opinions if they seem uncertain or uncomfortable with what I'm telling them. You know, basically, yes, you're the physician, but you have to understand what's going on behind the injury. What are the business issues or the social factors that may influence the expectations that the patient and those around them have? Things like college scholarships or eligibility or redshirt years. When you get to professional level, the guarantee contract, which Marty said is obviously more common in NBA than it is in other sports. And basically, then you get into that worker's comp mentality where they have any desire to return. Oh, things like contract year, impending free agency may also influence your discussion of expectations, return to play, or perhaps at the end of your career that they decide, listen, I have no plans to come back. And obviously your expectations will be much different in that regard. You also have to understand the individual that most are motivated to do well, but some may not want to get better. You've got to be aware of injuries, surgeries, recovery in certain career athletes like third stringers, the wannabes, or those are aging out of the sport and just looking for one last paycheck. So all these things are important things to consider. And there's other considerations as well when you're setting expectations. Recovery and return to activity depends on the injured part. A fracture is much different than a ligament, and that's very much different than a tendon. So all these things are going to take a different amount of time where you can clear them to increase their functional advancement and then get back to sport. Other considerations are basically the specific date for the actual return as documentation. What we're talking about here is season schedules. When does their season start again? How many months do you have? You may be able to go much slower if the season is not going to be around for six months. And then, of course, what's their talent level? Is this an individual is meant to play at that professional or collegiate level at all? And so all these things need to be considered. The other thing is that similar injuries and similar surgeries are not all managed the same when you look across sports. So they're not all your expectations for an Achilles tendon rupture, an NBA guy may be completely different than your expectation discussion in a NFL guy. Basically, basketball is a vertical sport. They rely on leaping ability, explosiveness, whereas football, more horizontal, more speed and power. So, again, these are things you have to consider as well. And I think lastly, you really have to treat everybody differently based on where they are in their level of competition. You can't treat a professional athlete like you can a college or high school player. I mean, there's a lot of medical considerations. And unfortunately, as Marty said, our NAL is changing everything, even at the high school level. So with that introduction, so to say, let's just talk about setting expectations. And basically, we're talking about here discussions about return to play. And what does return to play mean? Is it return to activity, return to practice or sport? Is it return to full participation? It's a very confusing term, and it's oftentimes a guess. It's a nebulous term. It really should be defined as a safe return of the athlete to competition, whether that's practice or games or no restrictions. But it also should include consideration of the risk of re-injury or compensatory injury, particularly to the contralateral limb. You know, when you go and you look at, okay, how do I want to get this guy to recover? What expectations to discuss with him? Good luck, because return to play data is very sparse. It's frequently alluded to as a broad term. But when you really look at it, most of the numbers out there for us are very average. They're average return to play numbers for a specific injury. But you look at it further, and what percent actually came back? You really don't know. What's their performance or functional income? That data just is not that available. There's only a few reliable studies to really help guide us in discussing expectations with our athletes at this level. This is one of them, talking about high ankle sprains and what you'd expect out of a West Point grade 2 versus a West Point grade 2A, and so on and so forth. So again, there's not many good studies. Most of the studies out there are just not accurate. The problem is that they're publicly obtained, internet-based studies that lack completeness. There's no access to raw data in these publicly obtained data source reviews. And so that's the issue we have right now, is you've got to be aware of the conclusions of a lot of these studies out there. These are just three studies that pertain to the NFL return to play, and none of them are based on the NFL database. These are people that are looking up data off the internet and then saying, okay, based on this, you can get back and play at this particular time. And again, you've got to be very, very careful of this, and unfortunately, publicly obtained database studies like this can have lasting erroneous implications on the athlete himself. When you look at this paper about Achilles tenor ruptures, saying that a third of the guys never came back, and if they did come back, they didn't function well. And that's completely untrue when you look at the true raw data at the NFL database level itself. So and then the literature sparsely returned to how to return to play. I mean, as far as protocols, there is no protocol to follow. There's nothing validated. Most of it's anecdotal. It's level five evidence on these papers there on the right. There's consensus panels that come together to talk about return to play. There are opinions. Again, they're all level five, so you really don't have much out there when you're starting to look at protocols that you can discuss with your player as regard to expectations return to play. You know, again, these are systematic reviews. There's no evidence-based criteria. And you look at this with the sparseness of data and literature, you're sort of out there on your own. And because of that, that's why you really need to really, you know, weigh on the shoulders of those around you. It's a team approach for this ongoing monitoring and modifying the expectations of your athlete as you go from surgery to return to play. What I always say is that return to play determination is not the doctor's responsibility. It's not our role. My role is to orthopedically clear that player to advance his functional recovery program. It's not a cop-out. My responsibility is to determine the healing progress and status. Has the fracture or osteotomy healed? Are the ligaments stable? Is it safe to progress? I think that's our role as the physician. And then you rely on everybody else to, you know, basically help with that functional recovery. I totally agree with Marty. You know, do not talk to the media. And beware, the media holds to expectations and return to play estimates. I always let the head coach, head trainer do the talking. I do suggest to them it's best to overestimate. It protects you, the player, the team, if you overestimate the anticipated time to return. My new answer basically over the last few years is I say, listen, I think it's best we're going to reassess at X number of weeks or months how you're doing. I think it's okay to be vague when you come to this return to play estimates and some of these expectation advice that we're giving. And again, just like rehab, it's a team effort. You have to work closely with the trainers, the therapists, and you've got to communicate and document everything in this day and age. But it's not only informing the player, you've got to inform parents, coaches, agents of your concerns and potential risks and stand your ground. You've got to think long term. They're all thinking short term. You've got to think long term. What's best for the health of this individual? Don't give in. You're going to get a lot of pressure from multiple parties. You can't give in. You've got to educate everybody around this player that these injuries and surgeries take time to heal. There's a lot of long term considerations. And again, if there is a complication, if there's an issue that happens in the recovery period, that's going to fall directly back on you, the provider. What else is going to run away? But it's going to be on your shoulders. You're going to be responsible for that complication. So again, just stick to your guns. I think also what I've learned, do not make the care of the athlete an ego thing when it comes to rehab. Trying to get somebody back quick to make you look good as a physician will eventually bite you. You say, I got that Achilles rupture back at four months. Yeah, well, if he overstretches, over lengthens and never plays again, that's going to be on you as well. So be careful of that. On the flip side, you also got to be careful of the athlete trying to make return a plain ego thing for him. So you got to educate that athlete what's best for him or her long term. What are the risks of coming back before you're fully healed? And can we adequately protect you from recurrent or further injuries? So again, these are things you need to consider. You know, we go through this whole process, we have to monitor the expectations. I think we told them right off the bat, you got to keep monitoring, you have to adjust as you go forward. And you have to look for a certain return to play criteria. But unfortunately, that criteria is difficult to find. There are no absolute contraindications to return to play. There's always a significant pressure to use approaches a little bit outside the box, comes to biologics and things like that, or hyperbaric, or all these shockwave, who knows, all these different things that are out there. And your decisions are made case by case. And in the past, those decisions have been very subjective. Forks have got more objective criteria. Now it starts in the office, you know, and you go like, well, you know, what can you really do in the office? Not much. Simple things. Yeah, you can look at the 25 hop test or 25 single and heel rise. But really, does that really clear a guy to get back into advancing his functional recovery back in the field? No, absolutely not. What you've got to do is, again, you've got to use your team around you, your expectation discussion, your return to play determination as a group effort. You have to use all these little things here to help you. You have to look at all your various type of offloading opportunities, your Cybex, your Biodex, look at strength deficits, and then all the other things you can do to help them through this recovery process. You know, in monitoring expectations and helping you through this return to play determination, you'll see a number of functional assessment plans. They have to all be in order. Most teams have their own. You as a physician, the surgeon, should review every one of these and make sure they aren't doing something more aggressive than what you feel is best for a good long-term outcome. These functional recovery plans are very, very detailed. They take a long time to go through, but again, if you're going to operate on these people, this is part of your responsibility. You have to look at these plans as well and make sure that they set with the expectations that you discuss with that player from the start. So again, these are very specified. They're very individualized. Once you're through the initial functional recovery program, you go to an advancement, your neuromuscular re-educations followed by plyometrics, which you can see is very, very, very detailed and something you need to have a hand in. Your surgery does not end at the time of surgery. You got to stay involved with the patient's recovery program. Fortunately, we now have objective criteria that help us with this return to play determination. This technology is very helpful. We have computerized treadmills. We now have the DARI motion health data. These are functional assessments where you can evaluate a person as a baseline, and then when he gets injured, you can look at his same motion data to see if he's fully recovered and ready to go back on the field. So again, this is an interesting technology. And of course, now the big thing is GPS, a real-time assessment of player effort and participation. But really, it's more than that. It's a real-time assessment of rehab efforts and recovery. And this is fantastic for on-field work. You really get to get an idea of when that guy's ready to actually go to practice and eventually to play based on this GPS information. And then nowadays, you can do everything virtually. So I do take a lot of care of a lot of patients that are not, you know, in the local vicinity. And I rely heavily on text messages, emails, and of course, video review like this. So much of the progression can be observed virtually. You can still stay involved in some of the progression that the player and those around him want to do. But even with all this technology, once an athlete passes the testing and can demonstrate pre-injury levels of output, the risk of the decision to return to play has to be shared. Everybody has to be involved, and particularly the player. And that's going to require good communication. And then, of course, you have to document everything without ever missing a beat in that regard. So again, we're talking about setting expectations. Make sure they don't get sky high. And really, this comes down to a lot of discussion about return to play and then monitoring that. There are no protocols. And I'm sorry, we don't have any. So you have to use all resources around you available. Don't get trapped. Do what's best for your patient and consider their long-term health, not just the short-term. And again, good communication, documentation with all the parties involved, parents, agents, so on and so forth, from start to finish. We've got a lot to work to do on this. I mean, unfortunately, again, as I said, there are no protocols. Decision-making for setting expectations, we've got to have validated protocols. And I think that's something that all of us need to work very hard towards to make it easier for anybody who's going to take care of the high-level athlete. Thank you very much. Well, thank you. That was amazing, Dr. Anderson, as all of your talks are. If you don't mind unsharing, and then we'll get all the panelists back up. First of all, thank you, everyone. That was great. You talked a lot about NIL contracts. And I think most people on the call probably know what that is. But do you mind just defining that for people who might not be as in the sports world? Marty or I? Yeah. Name, image, and likeness. So again, it's now where athletes, nonprofessionals, those that are not under contract making a lot of money can now actually make some money when a school or organization utilizes their name or whatever for jerseys and photos and advertisements, so on and so forth. Marty, you can expound on that. It started with the lawsuit at O'Bannon with the EA Sports about their using his likeness. So he sued, and it finally turned into now that the college athletes could use it. And it started with the outside boosters would have this pot of money that they would use to attract players. Now the schools are, so the University of Michigan just announced last week that they have $23 million set aside for their athletes for this year. And the NCAA put up for all the players, most lawsuits started to up to this year. It's $2.2 billion is in back pay. If you're a Division I athlete between 2000, I think, 16 and 2021, you're eligible for some NAL money that you weren't allowed to get because the NCAA was blocking. Now each state as well has decided whether they'll allow high school athletes to do NIL money. And most of the states are allowing it now. So it's trickling down. I mean, it's the wild west because, I mean, there's a NBA guy got, yeah, go ahead. I was gonna say, if I can add one thing is that, you know, Marty alluded to this loss, the lawsuits are going to loss of future earnings. So what's changed now is that a high school kid gets an NIL, he gets injured, you do the surgery, he does not come back to the same thing. He can now sue you for loss of future earnings because he's already been in a former relationship with an NIL. So it's- Before it was just maybe he was gonna be good. He should have, could have, would have been this great athlete. Now it said, well, he was making 4 million as a senior in high school. If you project that out, I mean, we had a meeting with Adam Silver a couple of years ago and they predicted that if you were a lottery pick, this was two or three years ago before the salary cap, if you're a lottery pick and you got, and you extended your contract after your first year because you did well with your team and your team was able to pay you, you would make $400 million in the course of your career. The numbers are just absolutely insane and it's a trickle-down effect for everybody. I mean, and the numbers are big for these high school kids and these kids are rolling in, you know, you're talking about this return, but I'm talking about a kid who didn't even, has not even played. And the day after I operated on him for his fifth metatarsal, we met with him because he got, well, is he gonna play this year? I said, why? He has a $500,000 deal if he returns to play in college this year. The surgery was 11 hours old when we're talking about this stuff. And it's going on without really any, without us knowing. So my point is when I'm talking to the player about their foot or whatever they're doing, they have so many other things going on and this NAL stuff is putting us all at risk because now there's a number on what they would earn. Well, well, I mean, good for the athletes and good for, I mean, some of the college players are just getting taken advantage of there by the schools, I think. So I'm happy for that, but it does put a whole new pressure on the doctors, on you guys taking care of them. I'll just, for the, any audience, if you have any questions for the panel, please put them in the Q&A questions. I do have a question for Dr. Ortiz. I know you are traveling the world right now, but. I'm connected. Yeah, you showed, you snuck a couple of total ankles into a sports talk, which I don't think has happened before, but I was excited to see that. And I wanted to ask, like, how do you counsel your patients? If you're gonna do a total ankle, what are you allowing them to get back to? And how do you talk to them about that process? Because as you said, everybody is an athlete. Everybody's playing pickleball. Everybody is, wants to be, show up their neighbor on the court. How do you handle that when you do something, like a fusion or a total ankle? As was mentioned before, I try to keep expectation very honest and very real. So I tell them that they are not allowed to practice any impact sports. And I allow them to play tennis. And of course they can cycle, they can swim, they can practice yoga and stuff like that. And all the way up to tennis and of course golf. But they're not allowed to practice any impact sports or running. And of course some people even play basketball and do crazy stuff. And I see them because Chile is a small country. So people tell me, I saw your patient playing basketball the other day. So of course they never tell me, but I know some people do crazy stuff, but I don't allow them. And I'm very honest about this. I fully agree with all the speakers who previously mentioned that you need to be very careful. I'm lucky enough that my athletes don't make enough money to sue me for $400 million. But they still sue me for less amount of money. It's worldwide. My patients are not any better behaved than yours. And I doubt anybody else's on the panel is either probably worse for their athletes than for our regular patients here. No, that's great. I guess what I'd love to hear and maybe a little discussion from you guys, but there's a lot of downsides that we were talking about. It's easy to focus on the downsides, but I think that especially Marty and Bob, you've really enjoyed this as part of your practice. And it seems like it's really been a valuable part of your career, something you've really enjoyed. What would you say to somebody who's just getting out or first five years of their practice who's interested in learning more about this? Like, how do you get involved in that type of work? I mean, not initially at the level you're doing it, but starting down that road if they wanted to. Mine was easy because you need friends, right? So you start in, as a foot and ankle person, most teams are covered by sports guys. And I think it's become easier now. And Mark would say, because Mark did a sports fellowship and a foot and ankle fellowship. Mark was one of the first ones who was deciding he was gonna do this right away. But most of the people are, you become a consultant to a team. If you're a foot and ankle person, you're usually the foot and ankle consultant. So I'm sure every professional team has their foot and ankle consultant that they use. And it's just a question of how much they will allow you to be involved. The people who I worked with were very generous in terms of allowing me to help take care of their athletes. So that was the entryway there. And then once that comes on, it's really relationships with, in the NBA, certainly it's relationships with the agents and it's with the performance staff of those agents. And I think the best thing I could tell you is patience. I didn't start doing this really until I was 45 that I saw my first professional athlete. And probably till I was in my early fifties that they actually came with any regularity, probably 55. So it rarely happens early on. When you're starting in practice, they'll let you do, you know, Hallux Rigidus or Achilles tendon. Not a professional athlete though. They would come to me and they'd go, I'm going somewhere else. And so it just takes a long time. And if you're just honest with them, and you're honest with the agents and the players, they'll eventually come. It's a matter of just, you know, you can't say, if you want to take care of a team, you want to participate in a team, even at a consultant level, you can't say no. You got to be available. And that's, you know, that's just part of it. And if you're going to say, well, I'm going to go away for a couple of weeks. I'm sorry, I can't do that. Or I got to do this, this, and this. You know, you're not going to get asked again. And so if you really do want to take care of an elite athlete, even at the high school level now, you got to be available. And that's the other thing is that I think this day and age, I think you can still have a lot of fun not taking care of a professional team. I think you can take care of a high school or a D3 team and have a lot of fun and a lot less stress, a lot less malpractice concern. And I think in this day and age, if you're coming out and you say, oh, I want to be a sports foot and ankle guy, that's great, you know? But I really would tell you, you can probably have more fun and get just as much success out of it at taking care of some of the non-professional teams. And I think lastly, too, is that, you know, if you're going to do this, you really want to hook up with your sports guys. You want to be in a group that has sports guys that are covering teams, like Marty said, even high school, college level, and then just tell them, listen, I'm available. If you have any foot and ankle problems, or you want me to come and stand on the sidelines with you in case there is a foot and ankle problem, that's how it all begins. Yeah, I mean, you feel like at me, I started with, when I was with the Nets, I had two, I think I got to know most of the foot and ankle sports guys. When I had two fifth metatarsals I fixed, they both refractured like a month apart from each other. I was like, oh my God, these things are refracturing. What do I do? And look, and just, so I just, I still talk to Bob and Tom Clanton and Dave Porter. We're still on a text group. We still ask each other stuff all the time. You can't be, you can't know everything. You can't see everything, and you have to ask for help. And I think I became friends with these other guys because I would ask for help. I was like, all right, I'm doing something wrong. It seems like this worked, but I was only doing these infrequently, and now I'm doing them more frequently. I'm having more complications. What am I doing wrong? And I am completely blessed and grateful that I've had this time with these players and these teams, and it's really defined my life. It's been great. I'm still doing it. My only point is in the past two or three years, the numbers have just become so crazy, and it's not just the elite athletes. I'm uninsurable. There's no commercial insurer to insure me. I can only be insured by the hospital. That my insurance, I had private insurance. They dropped me after they saw something in the paper about I outperformed them. They just said, you're done at the end of December. So with that being said, something's got to give in this whole landscape of these numbers becoming so crazy that the players even at the high school and college level are making so much money, and you are not being, like as the team doctor, you're not going to make money taking care of them, and the balance is becoming so skewed. It used to be when someone had a $5 million contract when I started this, that was insane. The average NBA money now is 11 million, and that's not a startup. So it's just really, it's changed so much for us over the past two or three years. Well, we got a question from the audience here, Dr. Stupay in New Hampshire. So she is asking, for those of us not taking care of pro athletes, but the high school collegiate team that you were mentioning, how do you help counsel them and mediate the return to play after more simple injuries like a common ankle sprain? And she had, are you leaving it up more to the athletic trainers, the PTs? She provides them with some handouts of things to look for, but like what's sort of a practical approach that you might give to a new surgeon counseling that, you know, 16 year old who's not going to go pro, isn't on an NIL contract, but just wants to go back and play, you know, sophomore year, junior year of their high school soccer team. Maybe over to, I'll throw that one to Mark because he hasn't talked yet. Thanks. So kind of to jump on what you were saying, it's definitely a team approach. You know, my basic criteria is that I tell people like, I want the player to be able to protect themselves. So if they're limping, if they're favoring their leg, you know, in my opinion, they probably shouldn't be out there. And then, you know, with the therapists and the trainers, we usually put them through a bridge program. So to kind of Bob's point before, they have to do provocative maneuvers before they get back on the field to show that they can handle the loads that they're going to take. And practice can be very different than games. So what I usually do is like, let's say for your garden variety ankle sprain, I mean, I'll certainly send them to therapy and then I'll put it in kind of like the parentheses, you know, the bridge program, which is you advance them every week and when they can do provocative maneuvers and they're not showing any limitations on mobility or limitations on mobility, then they can potentially return to play. In terms of, you know, do they have to be 100%? My answer to that is probably not. So it's not like that we have 100% strength, but certainly if they're favoring a limb, you don't want them to injure something else or, you know, protecting it and then, you know, causing other damage. So I've definitely utilized that approach. You know, I think it's certainly different with high school than, you know, the college and the pros, but I mean, kind of the point that the other guys have been making as well. I mean, there's been a professionalization of youth sports with, you know, around year, like travel teams. You see a lot more chronic injuries now in younger people who are playing year round, which you didn't really see until they were getting older. So it's just something to be aware of. And I think to counsel parents and look at how much an athlete is doing, particularly when it relates to stress injuries. That's harder, way harder than the professional college because the pro athletes, they have data. This is what his load is. This is what his load last year. So we have a guy about to return. They say he's doing the loads of a 25 to 30 minute game. I mean, you don't have that data in high school. You don't have any pre-injury level. Those are the hardest ones to call. And so you really have to rely on the therapist. I mean, you're really, where are we now in terms of the rehab? And high school is way harder than pro in college. So it's, you rely on the therapist and getting them back to return to sport specific training. Bob, how do you do the high school kid? Yeah, I mean, the high school kid are like the intramural. You know, basically what you're talking about here is like an intramural, you know, recreational type athlete at the high school level. And this is where actually you can, I do rely on some of those office maneuvers. You know, I tell the, really shouldn't go back until they can hop 25 times without pain or can do 25 single and heel rises. And then, you know, I do rely, you know, pretty much every high school now across the country, well, in the big cities at least, has an athletic trainer on staff. And so pick up the phone, you tell them what you want. You got to work on perineal tendon strengthening. You throw them some Theraban and you help them through some of that educational process. A lot of, you know, take home materials on home exercise programs. And then talking about brace management and brace prevention when they do come back. And it's just a little, it's sort of the very low level type of things that you can do. And again, if they're not progressing well, send them to your local physical therapist. But Marty's right. You don't have the, you don't have access to all the technology I was talking about for some of the higher colleges and professional teams. The Tom Clanton article's good. I give that to the therapists all the time. They need something too. So Tom Clanton, like the four return, you know, the four things they should do to return after an ankle injury or sports. It's really helpful because it gives, puts us everyone on the same page. And it gives, and the therapists like that article because it gives them some kind of, you did your 25 hops, you did this, you did this. And it gives some pushback to the parents and the coaches too. They haven't completed this level. So I often give the high school athlete the Clanton article and show them that. Yeah, well, I'll find that and we can see if we can share that with the audience members through the AOFAS if they wanna find that article too. You know, so I'm from Boston, or I live in Boston now from Connecticut originally, but, you know, I think the, I often think of like the ultimate return to play foot and ankle thing was the bloody sock and Curt Schilling and the, you know, like we have to get them back for the critical game, right? But if that's on one extreme of, you know, get them back playing as quickly as possible and just get them through the last couple bits of a season here, how are you managing the different levels of player? So there's the high school, you know, the 16 year old with maybe a, like a subtle, a subtle list Frank or a high ankle sprain that, you know, you might maybe should be stabilized, but they could struggle through the last couple of games. Somebody college, like their last senior year, they're not gonna play professionally. And then the professional players who have that contract and they really need to play. Like, how do you take something that maybe could wait, but, you know, in somebody who doesn't have the athletic impulse or requirements, you might do surgery on sooner. Like, what's the balance of that? And maybe Dr. Anderson, you could start. I think it's all about long, what is their long-term risk? I mean, that's what I look at is, I mean, what kind of risk are they putting themselves at if you let them play through an injury or through a subtle this or subtle that. I look at what's a long-term risk, what's long-term harm of doing that, number one. Number two, am I gonna be able to fix it as well down the road as I could now? You know, and is this something that, you know, if it doesn't work out, we can always fix it later and still have the same result. So those are the things I look at. I agree. I often tell them, if you're gonna go back with this injury, one of the things I always say, you can go back, but that could be very good. You know, if you have like a really high ankle sprain and you got two weeks left and your deltoid's out and your syndesmosis is out and we're thinking about doing some tight ropes and maybe repairing your deltoid, there's very low chance that if you go back that you're gonna be anywhere near as good as you were before. So I'll tell them, if you can go back and play at a high level, I think, for some of these things, you can wait, especially at the end of their high school or college career. I think two or three weeks probably doesn't make a difference as long as there's no cartilage injuries. They're clearly at an increased risk for developing a cartilage injury if their ankle is grossly unstable. So we can wait on some of the things. There's very little data, but we can wait on some of the things. I mean, the easier ones, again, are the guys with guaranteed contracts. So you're just like, what's your goal? I got a contract for next year, I'm out. Mark, what do you think? You gotta take care of more college guys than I do. Yeah, what I would say is that I think there's definitely different stuff that you've done for the pros than for high school. Like injections, let's say, like doing like an anesthetic injection. I can tell you in certain sports it's super common in basketball, you've never done it. But like in hockey, it's very routine. A lot of times with the hockey guys, you have to fight to keep them off the ice versus other people who potentially have injuries linger a little bit longer. So I think there's a difference in sport. I think it depends on the athlete too and kind of get the sense of like what they wanna do and what they wanna get out of it. But especially as you get up in the levels, there's more riding on it and there's more eyes on you and you know anything you do is probably gonna either be second guessed or be seen by like three or four other people down the road. You just have to do what's best for the person and kind of be honest about what you're gonna do and what the expectation should be in terms of what the real risk is for returning to play. And document everything. Yeah. Yeah, if you look at all those lawsuits, most of those would have gone away with just better documentation. It's probably true across the board for a lot of what we do. And Bob and I have talked about this extensively. It is the off the cuff consult. Can you look at this? And really, even if you're not gonna charge it, if you are doing that, the only good thing that came out of COVID probably for me was that all these interactions are telemedicine visits and all these should have been documented, which I wasn't before. I was given opinions all the time and I'm not sure where they went. They went into the air. But now if I give an opinion, I go on my phone and I make a little memo and I send it to one person and she writes it up and they send it to whoever called me. One of the most refreshing things I heard from this is that even Dr. Anderson, Dr. Malloy, you have your text message thread of buddies who you run things by. And I think that all of us need our friends in our corner backing us up. And I think that's great to hear. One thing I'd like to add, I mean, I don't know if the impression is it's super stressful. I think it's a lot of fun. And that's one of the reasons that I got into it. And it's like a third of all football and basketball injuries are foot and ankle. Like, so I won't be surprised if more foot and ankle guys kind of take the lead in those positions down the road. And I think one of the other trends though is that like anything, you get better at what you do a lot of. So certainly at the higher levels, like the foot and ankle injuries are gonna be handled by foot and ankle specialists. It used to be a lot of the sports guys were doing, and some still do the Achilles and the metatarsals. But I think over time they're looking more to people that that's kind of their bread and butter and what they do and are trained in it to do it. So, I mean, I'm not jaded yet. Oh, no, I'm not jaded at all. I think it's great. And I also, it's really nice that every NBA team who calls me, they pretty much have a foot and ankle consultant. So that's good. That's what they should have. It's just like they have a hand consultant, they have a foot and ankle consultant, which wasn't true 10 years ago. They didn't even ask their own guy. I would just say, yeah, your guy can do it. Well-trained, he can do it. It is fun, but it's also very time-consuming and it's gotten more stressful over the years. Yes. Well, I need to stay in the game. Help us out. Hey, look, this is gonna end soon, right? We need young guys. We need young guys trained. We need young guys asking questions. Feel free to ask questions. No one has all the answers. We clearly see new stuff all the time. And just then we think we're the smartest guy in the room. We're like, eh, that didn't work. We need to figure out a better way to do things. Absolutely. Well, I think we're coming towards the end of this session. I just wanna thank all the panelists. This was really informative for me. I really enjoyed it. So thank you for donating your time. And then in terms of next steps, we're coming to the end of tonight, but we will be starting again tomorrow, same time. So that's 4 p.m. Central, 5 p.m. Eastern. And I look forward to some more great talks. And thank you all. Thank you. Have a good evening. Thank you. Thanks for asking. Bye-bye. Good night.

Advanced Foot and Ankle

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adolescent deformities

pediatric patients

adolescent bunions

tarsal coalitions

cavovarus deformities

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