union. And so I think about a house, right? Do you need more workers to build your house? Do you need more materials for the house? Or do you need the house to be there and available so that everyone can do a good job? You know, a better scaffold available. And so thinking about each of these options when you have that available may play a role. And so autologous bone again has all those three characteristics, but autologous bone has graft site pain. And I used to love getting bone graft, but I got an inpatient who had a, you know, an infection in their heel. You know, the tibia hurts when you drill into it. And if we can avoid this graft site pain and graft site infection, I think it's important. I still think there are patients you should get autologous bone on, but if we can find a way to avoid that extra bit of surgery. PDGF expands the cells that arrive and attracts more cells and vascularity to the area. I don't think it personally is telling cells to make more bone, but I think the cells that are coming in that are already going to make bone, there's going to be more of those cells available. And then the role of the carrier, I don't think is clear. BMP2 definitely makes bone. In subclinical models, you can put it in a pouch model in a mouse, anywhere on the mouse's body underneath the skin, and it's going to make bone. But it's drainage and swelling is a concern. And then it's definitely being used off label and it's expensive and may not be covered. P15, it's going to get the cells that are going to make bone to bind to the area, but there's no long-term data, no high-level studies. PRP, can we correlate some of the PDGF data? Maybe. But it's going to, again, be patient-dependent, right? Is the patient's PRP good in the older patient who has medical comorbidities? I don't know. It definitely needs more high-level studies before we add it in, uh, on a consistent basis and say it's as good as any of the other options. And so my protocol, the average patient and minimal comorbidities, I'm going to use platelet-derived growth factor augment. I think it's got the best literature to support it. Older patients, I'm probably going to add autologous bone with PDGF, uh, because I want to have as many cells as possible that can expand to help me. The medically complex, revision cases, diabetics, um, you know, I need to make sure I make bone. One surgery had done, I'm worried about coming back. I'm probably using BMP2 with autologous bone. Just a tip, if you're thinking about BMP2 with autologous bone for my spine guys, because, uh, Scott Bowden's my, uh, chair, you know, you wrap the BMP2 around your autologous bone and then put that into the joint. Uh, it's, uh, they call it the, the BMP2 sushi roll here at Emory. Uh, but that's a tip if you're going to use it to not just lay it flat across the surfaces, but put the bone graft in between it because it causes that bone graft to expand out through the collagen matrix that it's held on. So things we didn't discuss, right? What are these carriers that we are using and what are some other options to affect carriers that are going to affect your healing, right? Beta-tricalcium phosphate, ceramics, collagen. What's the effect of the microenvironment? Um, that's where we're headed next, uh, from a research perspective. What are the effects of the devices that we're using? Compression? Is there too much compression? Is there too little compression? Um, I think it's important to think about that. What's the role of the synovium? Uh, what's the role of osteoclasts? You know, we talked about primary bone healing, but we didn't comment at all about how we modulate osteoclasts, uh, and that type of thing. And so just a couple of brief cases, uh, this is just a 45 year old female end stage arthritis. Didn't want to wait. If you know, I make them wait till they're 50 for a total ankle. She wanted her fusion done. Simple fusion with augment one year out. She's doing great. Uh, I think we got good healing in the front, but again, that's not as robust as I'd like it to look. I, you know, I'd love to have, you know, more robust type healing there, but she got a good successful outcome and I didn't have to take bone graft type to 75 year old lady, really significant flat foot deformity, bad hind foot arthritis. I used augment, but I went and got her own bone as well. Um, you know, right in her distal tibia, added it to each of the sites. I feel like we got a nice fusion, good correction. Um, and she's really happy with it. She's probably going to need an ankle replacement in the future. Uh, but I feel like we did a good job for, uh, it's a 75 year old guy travels for work, came in and let this, and it's just amazing that he can walk on his ankle and foot. Uh, and so, you know, what do we do here? You know, I'm doing a trans fibular approach. Uh, I'm putting a TTC nail in and then I'm combining it and putting it a BMP two at each of the sites. Cause I want one operation. This guy was a big guy, you know, BMI in the forties. I don't want to be coming back or introduce the risk of a non-union on him. Uh, this is him, uh, recovering him at a year with all his consolidation of both sites. Uh, lastly, this is one of my cases, uh, early in practice. I, you know, took her, did cross screws, went and got bone graft. She got a non-union, um, autologous bone doesn't always work. Uh, took her back. Uh, I wanted to make sure I had the best chance possible to change the screw trajectory, got a new screw across the joint, added a staple in, reprep the joint, uh, and added BMP two with, um, uh, some, uh, demineralized bone matrix. Uh, and I feel like we got a good result. Uh, so we had a lot of references in that talk and please email me for my slides. Be happy to share them. Um, I want to acknowledge my collaborator, uh, and, uh, my research assistant, uh, and just say thanks. And please here, here's my email. Any questions about, uh, uh, this kind of stuff? Happy to answer. Thank you. Jason, totally unbelievable work. Uh, thank goodness that all of this is being recorded because I'm going to have to watch that like six more times to fully grasp, like part of what you were saying. Uh, but totally awesome. Um, one quick question from the audience. Uh, so do you use any BMAC for your difficult fusions? And if so, when I have not used BMAC for my difficult fusions, uh, I tend to go either with autograft bone. If I'm going to go, my thought with BMAC is I'd rather get autograft and have the cells. And I know you can get some of that, but I feel like you can do just proximal or distal tibia, uh, and then combine it with something. Uh, I, I didn't see a ton about BMAC. I asked my research assistant to help me when we were sort of looking at the literature. Cause I know a lot of people talk about adding that in. Um, but I don't, I haven't, but I know others have and have good experience. Um, and I, man, I'm really, uh, really happy with how this session, uh, like every talk really dovetails into the next. Uh, and so, uh, I was, I was, I was, I was watching Jason's talk, Brian. It made me think, you know, as you're docking that those, those tibias, when you're doing bone transport, and this is a selfish question, cause I've got a docking, uh, that I got to do in like, in like two weeks, uh, with one of my partners. So do you, do you primarily graft those? And if so, with what? Yeah, it's a good question. So it's very, very patient specific and as much based on what their soft tissues are like as anything else. Uh, yes, I've done docking site procedures, usually with a mixture of autographed and allograft bone, not usually using biologics, but I've tried some of that recently because I haven't had good luck with my docking site procedures. Uh, so yeah, I mean, I'd be interested to see, um, you know, I think, uh, I, in the, in the ones where I've used biologics, I've been using BMP, um, uh, to try to get those to heal because I think definitely, uh, the vascularity is affected. Um, that's also why I'm more interested in the, again, like not necessarily masculine, but the doing like an initial spacer to create that induced membrane there. I think it also maybe helped that a little bit too. Yeah. Um, I think that's, um, insightful for sure. Um, uh, and then, uh, I was going to ask, okay, so Todd, uh, I was going to ask you, so, uh, when do you, when do you, um, primarily like, how do you use graph primarily in your, you know, in your bad cow fractures that you're going to primarily fuse or your bad P lines that you're going to primarily fuse? Like, do you use graft in those situations? Do you not, is it autograft, allograft? Like what's your sort of, what's your, what's your algorithm for that? Yeah, I think, um, everything that Jason talked about, I think I've used all of those except for P15. I didn't know what that was. Um, but I'm glad I'm not the only one. Um, I I've sort of gone to more in general for fusions. I like to combine some bio with some auto kind of like what Jason said at the end for older patients. So I've done a lot of proximal tibia autograft over the years. If I'm going to be doing something in the calc, I do a lot of calc bone graft, but, um, if I'm going to be doing a subtalar fusion or something like that, I don't want to take bone from the calc there. So do proximal tibia. Although I just had a patient with a kind of stress fracture, then stress fracture, non-union to proximal tibia. So that's been my first like big problem with proximal tibia bone graft. Um, so in general, I've, I've used that. And again, a hundred percent agree with what Jason said to me, it's patient dependent. It's if they're older, you know, I try not to operate on smokers, but in trauma, you sometimes have to, if there's any reason that they need more than I'm going to use some type of auto and, and, uh, and bio. So it's probably the easiest way I can answer it. Uh, and then Amanda. So when you get into that situation where you have a dead tailor body and you're, and you're gonna convert them to a TTC, you know, one of the questions that comes up is sort of, can you just use that dead talus as your graft to keep your length? Or do you need, do you need to cut that out and put an ephemeral head or something else to maintain your length? You know, what are, what do you, what do you think advantages disadvantages? Uh, so I think there's no great answer to that, obviously. I think that, uh, there's a little bit of like, uh, the qualitative, is it dead? And then the quantitative, how much of it is dead. Um, and so I think if like one of the MRIs I showed had predominantly like medial, um, AVN without as much lateral AVN, and I think you can still probably get like a decent fusion, um, across those. Um, if it looks like the entire surface is dead, then I think that's, um, much harder to predict that they're going to have a union. I think there's still like low demand patients, like kind of the same patients that trauma guys say you don't need to prep any joints for, for a TTC, for an ankle fracture, right? Like, I think there's some patients that can get away with just, uh, a nail without revascularization of the talus or a true bony fusion. Um, but they're kind of at the same risk of hardware failure and things like that. If you don't end up, uh, neat, you know, if you don't end up getting any fusion and they're otherwise healthy and going to live longer than whatever your expectation is. Um, so, but I think for me, it's like, it's like very, uh, quantitative. How much do I think is actually, uh, totally dead and how much do I think I can get to fuse across some enough bony surfaces to leave it. Uh, and I have definitely, uh, put a couple of TTCs in for that reason. And I don't know that they've fused. I've never rescanned them, but they're kind of like, okay for now. And they're about, I don't know, a year out or so, maybe a year and a half. Um, so I guess I'll let you know how the experiment ends. All right. Let's go to Todd's question first, and then we'll do Chris after that. Thanks. See, I was going to ask Jason, one of the big, I think, um, products out there that you didn't talk about is, I don't know how you categorize them, but like the Zincamal stem cell products, um, like just to throw out and Vivagen and Trinity and those types of things. And, uh, I learned something recently at a journal club we had where I've used those products a lot over the years and thought they really worked well, but then it was sort of told me those are all like cortical bone fibers and something with HLA-B27, very few of them are going to actually work. And so maybe it's just the scaffold and this company was pushing more of these vertebral body. Like they, they, um, they harvested from vertebral bodies and the, the, the biology there was much better. And so anyway, I'm just curious if you have any insight on those products. No, I think it's a, it's a great question, right? You know, you talked about for a while, it was the three things we talked about. And then everybody wanted the periosteum in when we first, when I first started in practice a decade ago, I'm trying to remember the name of the product, but it was like the hot product, right? They're like, Oh, we got periosteum too. That's coming in. And then everybody was like, no, no, we got these special cells, but it's interesting. I was on a, um, uh, a committee for a master's thesis a couple of weeks ago. And one of the committee members and I were talking about ahead of time, and she's an expert in, you know, human mesenchymal stem cells. And she told me recently that, that, that within a patient themselves, like she harvests them and does this bone and she had human mesenchymal stem cells that were very active and completely non-active within the same person who they took the stem cells from. And so my concern with using something like that is we just don't know what we're getting consistently. Um, I know that's what I know the company you're talking about there, the vertebral body's better, and we have all these young patients we got them from. And so I just don't know that that's what you need. And then, you know, I think taking the patient's own cells as well, right? Because if you bring these mesenchymal stem cells in that have been modified or a little bit, how are they going to react to the local environment? You know, they're not the patient's own cells, um, I think is a question mark as well, but I agree there's a lot of those out there, but the challenges is all these products are coming through spine first. And then people are like, well, I'm going to use it off label foot and ankle and get the foot and ankle surgeons to use it because, and I would just love for another company to take a shot at doing a big study like PDGF is so we have some more good literature to support it. Uh, Chris. Hey, um, you know, one thing that sometimes gets talked about in non-unions or these bone defects is using bone simulators and things like this. And I've been, I've had very sort of mixed feelings about them, but I'd love to hear, um, what, you know, your thoughts are on that from the panelists here. Uh, is this something that you kind of say, well, we're going to throw the kitchen sink and try everything. It's not going to hurt, but is it going to help? And I think there's, I question some of the industry data out there and I do use them sometimes, but other times I, I don't know how much is really making the difference over just doing a really good revision surgery at that point. Uh, I think I could go ahead, Brian. No, as I say, yeah. I mean, coming from the drama world as well, I mean, we, we, there's a, they don't work. I mean, I think that just to put it out there, I think that, you know, it, it sometimes makes you or the patient feel better. Um, but I think that the data is quite limited and not any non-industry funded, uh, study looking at them. Um, and so, yeah, I mean, I, I will use them sometimes in patients who are like, I want to avoid surgery. Uh, and we just, we're trying to do something. Um, but in terms of when I, I do not use them at all in a revision setting. I throw them at patients. I get it. We don't have any data on fusion and I don't know how they would affect the fusion environment based on all the stuff I talked about, you know, are they upregulating cells to become osteoblasts? But I think there's some benefit from a psychological standpoint that the patient feels like they're participating in the process a little bit. And if it's 20 minutes a day to put a, you know, a little device on their site and it gets them sort of thinking and participating and active and it helps them psychologically. And maybe it's a placebo for me as well. Oh, but I tend to do it just to treat, to, to treat myself and treat the patients when I'm looking at that case that I don't want to go back, especially in that high risk patient. Um, Amanda, uh, you know, I have, um, through my adolescent practice, uh, I get a lot of patients who are, uh, lymphoma, leukemia type patients, or, or who are, you know, these disastrous rheumatologic problems that are on chronic steroids and end up with, with Taylor AVN. Uh, and oftentimes they, yeah, it's not just like they have like Talus AVN, but they also have like painful bony infarcts in the distal tibia or in the calcaneus. Um, and, and, and interestingly, most of them end up showing up before they have a flattening or deformation of their, of their Talus. And I've done, and I've done cord decompressions and, and sort of, you know, for the tibial infarcts, I'll, I'll just, even though those aren't supposed to be painful, I'll, I'll open them up and to breed out that dead bone. Um, and I just throw in some kind of allograft cause I don't really know what I'm doing. And it's, and it's, and it's worked, um, the majority of the time. And I'm, and every single time I'm surprised every single time, I mean, I must've done it at least on at least a dozen times between people who have had bilateral, uh, bilateral issues. Um, and I'm just curious what your experience with cord decompression has been, you know, what kind of patient you're seeing that for? Um, I just, when we did it in residency for hips, I just feel like it never worked. Uh, but it, but it seems to work for the Talus. You know, it's interesting. I'm doing one on Tuesday and it's like, you know, a chronic opioid user, smoker, like every risk factor, like alcoholic. That's why she has it. And I really just don't want to do something big on her and she doesn't have clavs. So I'm convincing myself that a cord decompression is going to work. And I like pretty much know that it's not, but deep down, I just really hope that this one time it works. Um, and my overall adult experience is like, I don't know, in five years, I've done like three of them and none of them have gotten better. Like they haven't gotten worse, but they haven't been like, Oh, I'm so happy. My AOFAS score is 90. Like, um, so I think maybe like many things, you know, kids are like starfish and they just grew a new ankle after you did a cord decompression and they're fine. Um, and, but I don't, I don't know that I can like replicate this already trash literature that's published about cord decompressions. Um, like, Oh, we looked at three studies of four patients who like, and they said they would do it again. Like that's not real data. Um, so, um, I don't know. Uh, I think that I, my experience in adults is not good, but much like a bone stimulator, it might buy me some time to doing something bigger. Um, and it can't, I think the morbidity is low. Um, but I think if it's truly dead in an adult and you're trying to go back and do some type of like revascularization type of thing where you're trying to stimulate dead bone, I think it's just, it's like, it doesn't make any sense in my head. Like the idea doesn't make sense. Um, the vascularized bone graft makes sense to me, but I don't know how to do that. So, um, somebody does let me know. But, um, but I think in kids, there's probably maybe just like enough collateral flow or healing that they can somehow, you know, you can stimulate it back. That's my guess, but I don't know. Go ahead, Jason. No, I had a question for Todd and Amanda sort of made me think of it. You know, we talk about doing sort of the patient with ankle and subtalar arthritis, uh, you know, they may have a calc fracture. Um, do you think Amanda, uh, and Todd too, as well, cause you both talked about fusions that we bring blood supply back to the talus when we do a subtalar fusion so they can have a total ankle later. Like we argue that in my clinic all the time with my partner who wants to do like 3d printed taluses. And I'm like, no, no, let's just do a subtalar fusion first. And maybe we can do a total ankle later. Uh, I'm curious, do you think it will affect blood supply? Uh, I, I, you know, there's a study, I think out of Korea that quotes that, that they did that first for totals for that sort of tibiotalar. So just curious. Yeah, honestly, I have no idea. Like you, I think, yes, it makes sense. Maybe, maybe that's happening. Um, but who knows about the blood supply to the talus and are you, are you just vascularizing it by your approach to the subtalar joint? And I mean, there's all those studies. So I think, I think to your point, I think I was actually sort of thinking of a similar question for the panel. And I think one of the big debates in our society now for these situations is especially like Taylor ABN and those types of things is, and in the setting of a total ankle, are you trying to get fusions and then do a total ankle above it? Or are you trying to take out the, basically do a total talus when you do a total talus, when you go to a tater with a total talus and ankle replacement above it, when you do a total talus, but then have bony surface to fuse to the, to the calcaneus or, you know, have a 3d printed surface to fuse with calcaneus. That's, that's one of the big things right now. I think, um, it's not, obviously there's not a ton of those out there, but just, I think we all don't know the answer to that. So I have no idea the answer to your question, but I think, um, those are the things I think about in those cases. I would like to give kudos to the foot and ankle society for coming up with the word tater. Um, it's just like the most genius acronym we have for any surgery so far. But, um, uh, I also do not know the answer to your question. It doesn't make any sense to me that that would actually happen. Like if you have this area of dead bone and then you have like living bone, maybe on the bottom and it fuses the calcaneus, do I suddenly envision like little nutrient vessels growing into dead bone? Like this doesn't make sense in my head. Like I can't see the cartoon picture happening. Um, but if I can't see a cartoon picture happening, you can't be real. Um, but, uh, like it seems like it works better, but I don't know if that's just because you have like a bigger post that your talus is sitting on that, you know, like it's just a bigger, a more stout thing, but maybe you see less failures then, but I don't, I don't know. I think it's, I think it's such an interesting thing to think about the, you know, the difference between doing a total, taking out the dead talus and putting a total talus in and then seeing what happens with the joints around it versus doing fusions and then doing the total ankle above it, just because once you do the fusion, that's, you're not, total talus is no longer an option. I mean, I'm, you know, assuming that fuses. And so, but then, you know, I, one of my senior partners is now retired, said, oh yeah, all the people are doing total taluses, they're saying you need, if you do it, you have to put it in growth surface into the calcaneus, so it fuses. But if you do that, and then they have a smooth surface on top, that isn't gonna articulate with the polyethylene, then, and that fuses, then you can't convert that to a tater later, so you always have to go to a tater. So I mean, it's like this vicious cycle, I think. Let's talk for a second about amputation. You know, obviously this is a foot and ankle section, and we're talking a lot about salvage and all these crazy things that we do, or try to do. But, you know, I'm sure, hopefully it's not just me, I assume lots of you have patients that you cut their leg off, and they go, God, why didn't we do this a year ago, or two years ago, or whatever, and they're just like so happy. Like, you know, and I'm all, you know, no matter how bad their pilon is, or whatever, I'm always telling them, hey, let's just try and fix it, or fuse it, or whatever, we can always cut this thing off later. And maybe not now, but as I have gone through my practice, and I see these patients, you know, when I was 25, if I had had a bad pilon, and seeing how a lot of these patients do, if I had known, I might have just told you, like, I have a bad pilon, like, let's just cut it off, and keep on going, keep me playing sports, and going for runs, and whatever. You know, what do you guys, how do you counsel your patients? Like, when is it time to throw in the towel? You know, who's the right patient, the wrong patient, to think about doing a BK? So, I think the hardest part about talking to 25-year-old you, is that the day before your pilon, you were like running, and had a totally normal ankle. And so, that's the thing, it's the psychological, I don't think it's the outcome, it's the psychological aspect. I mean, this is such a hard, like, again, doing trauma stuff, I had a, you know, 20-something-year-old firefighter who got hit by a car, and the guy had a open, he had a knee dislocation, vascular injury, open, 3B, talus, and calc. And like, it is just, I mean, like, and we did everything. Like, we, you know, we framed him, we got his knee reduced, framed him, he got his vascular repair. Later on, it was good enough that we fixed his talus. And like, the whole time, I'm like, please just want an amputation. And the guy had like 10 surgeries, flap failed, and then he ultimately did have an amputation, but talking to him and his family about it, like, day one after his injury, they looked at you like you were just throwing in the towel. Like, you were just like a hack. Like, you wanted to just cut his leg off, and it's like, no, but like, I know where this is going. And so, the psychological aspect of it is massive. And like, yeah, I mean, I have no idea. There's some patients where I'm like, this leg is unsalvageable from day one, and I've X-fixed it, and I just want you to participate in the conversation. I think the hardest part is people who are like, maybe there's a chance, and like, there's a chance you'll have a leg, but as one of the guys in my trauma fellowship was like, we can keep your leg, but you may not want it when we're done. Yeah, you know, and this might be from my wife, who's a psychiatrist and psychoanalyst, but I spend a little bit of time with some of those limb salvage patients, and I talk to them. Sometimes I can't help them, and I say, look, you need, it's okay to be upset. Like, this sucks. Like, this is really unfortunate. And I use some more colorful language with the right people that I won't share online, but you know, I'll hold their hands. I say, sometimes you have to grieve the loss of function, right? You were a young, healthy person running a 5K, you know, a week ago, and now your life has gone sideways. And, you know, I think we can help them physically, but then acknowledging the psychological components is really critical. Yeah, I would just also throw in there that the way we present the amputation to them is critical. And I think that when I talk to people about this, I was like, I do not think of this as giving up. I think of this as a reconstructive surgery that will alleviate pain and improve your function. And like, this still is a huge component of like, I do not want to lose my leg. But like, that is the thing is like, you've got to say like, this is a surgery that will make you better and you will be better after this operation. I think, yeah, I think that's a great approach. And I think the other part of it is they just don't, because we see what we see, they can't imagine, you know, what it's like to not have a leg, but they also don't know how bad it's going to be with that residual, you know, with that limb, with that non-functioning leg. And it's impossible for us to tell them. You tell them all we want, but they just, they're never going to understand it because they don't see what we see all the time. I also think it's a timing too, right? It's not the first Pilon ORF that, you know, the trauma guy saw, it's the coming to me for the third opinion. I see it because my partners down at Grady do all these great trauma cases and they do a great job. These patients get terrible arthritis and bone loss. And I'm like, we're going to do two, maybe three, could be four surgeries later, and you may hate this, or we can do an amputation. And that's the, I think it's much easier then, than the time when their Pilon is open, their X fixed, and you've got to talk to them about it. Once they've had that initial operation and that three months and it's not doing well, then I think the conversation is different. But I think it's also talking to them about like, listen, this may take a year and a half and then we cut it off or we do it now. And a year and a half, you may love it, but you also may hate it. And it's really difficult. I think you also have to consider when you're saying who do not offer an amputation to, is that I am very reluctant to offer amputations to patients who will not be able to walk with a prosthetic, right? You're morbidly obese, you're super deconditioned, you're like super elderly female, like people who you think are going to, like it's almost easier to talk to a 25 year old about it because they'll get a sweet prosthetic, particularly if they have insurance, and they can do all their stuff, right? Like they can run, they can get their life back, they can work, but I am very reluctant. I mean, I talk about amputation, but I do not, I really try and do limb salvage and my morbidly obese, low energy, whatever disaster that has gone on to four surgeries and the whole thing, right? Like those patients. And I would say that's my like, do not list, do everything I can because it's not like necessarily a death sentence, but you've ruined their life. They're never walking again. They're just in a wheelchair. All right, y'all. This has been an awesome session. I can't thank you guys enough for joining us. Just spectacular. Thank you so much. All right, Chris. Thank you. As we're coming into the final turn here, this is going to be our last symposium. And one that I'm just really grateful for all of our speakers here. We're going to start off with Holly Johnson, but who's, you know, one of us, but we have Sami Dolashahi, who is a close friend of mine. And he and I have saved a lot of legs together at Beth Israel. And then also Dr. Mark Weyers, a vascular surgeon from Beth Israel as well. And I'm sure they have many things to say about limb salvage. And I'm just very much excited to learn from them. And then also Whitney Herg, I might have said that wrong if I did, I apologize, to talk about the psychology of pain. And so I think I'm really excited to hear what you guys have to say. I'm going to turn it right over to Holly to get started here. All right, thanks Chris so much and Liz for the invitation. I'm going to share my screen. Okay, great. Give me one sec here. Can you all see it, Chris? Looks good. Okay, perfect. So I'm going to talk about opioid-free or really opioid-less surgery. And hang on, these are my disclosures, none of which have any relevance to this talk. So my upbringing back when I graduated med school in 2001 and residency and fellowship in 2008, was that pain was the fifth vital sign. Nobody gets addicted, that was really rare, or at least we thought it was. You would basically prescribe to avoid phone calls and routinely we prescribed 60 to 100 pills per procedure. And at that point, when I was just starting my practice, prescription rates had quadrupled between 1999 and 2010. We started to see a little bit of a decrease from 2015, but prescription opioid overdoses were out of control. And this is really mainly a US or North American problem. And we've seen this really slowly get better, probably reaching the worst in 2021 and hopefully on the downslope now. But if you look at these two maps and even if you can't read exactly what they say, the blue and the green on the upper left represent high rates of opioid dispensing per 100 persons. And then in 2023, you see a lot less of that. And again, this is just a sign that we're going in the right direction, although we're definitely, we're not there yet. So less opioids are definitely being prescribed. And I think some of this is due to the new state mandates that have decreased. Number one, the number of pills we're allowed to prescribe, but also the length of time we're able to prescribe them. There's mandatory opioid training in many states. Some specialties have started to publish prescribing guidelines and opioid-free surgery. There's much, much more patient awareness now than there was. And I think a lot of that is due to the OxyContin suit, which really showed me that physicians, we really let ourselves get taken advantage of and we're definitely part of the problem. So foot and ankle has decreased opioid prescriptions significantly, but again, we have a long way to go. So, you know, I've been taking a look at this since 2016, when actually I had a patient die of a opioid overdose and it had a huge impact on me. And so I wanted to sort of see where we were and where we should be. So I sent a survey out to all the AOFAS North American members, basically asking them their anesthesia protocol and how they prescribe medication based on four categories of surgery that you see there listed. And what I found that no matter what the procedure, surgeons were prescribing opioids, and even almost 50%, if not more, were prescribing refills, even for minor soft tissue procedures. And we learned that the average number of pills per procedure was 42 to 64. There was a huge variation amongst the members and there was no consensus. And we actually had no idea what patients really needed. Then I went and I compared what happened in the AOFAS to the Dutch Foot and Ankle Society and sent them the same survey. And what I found was absolutely astounding and completely changed my practice. For minor procedures, they were prescribing no opioids. And for major procedures where we were prescribing on a median of 60, they were prescribing 15 at most and no refills. And this really opened my eyes up to kind of what we should be doing. So then I changed my protocols a bit. I started with a big patient education push. I started to give out handouts and have a discussion pre-op with patients and give out disposal information and gather data on 244 patients over a couple of years. And I recorded opioid consumption and leftover pills. And what I found was that patients only took half the pills prescribed regardless of the surgery. So if we prescribed 30 pills for a triple arthrodesis, they were only taking 15. If I prescribed five for a Morton's neuroma, they were only taking two. And so this meant two things. Number one is they didn't need all these pills, but number two, there were so many that were leftover roaming around in the community, or at least maybe in our water system worse. So then around this time, I published the results of both the AOFAS and the Dutch Foot and Ankle Study and FAO. And I came up with these recommendations for what we should be doing. And I look at these numbers now and it makes me sick to my stomach because I don't even come close to prescribing this level of pills for oxycodone or hydrocodone for any of these procedures now. At least I had started using ibuprofen and acetaminophen, but even over the last five years, I've changed dramatically. And sadly, FAO republished this in 2023. And I just think that really this paper should be thrown in the garbage and we need to start over again. And we really just need to think beyond opioids for post-op pain management. We know that even short-term opioid use is so dangerous. Almost 9% of opioid naive patients will persistently use. And the highest risk are these recreational drug users. And I think that recreational drug users are on the rise now that marijuana is legalized in many states and we're just seeing this being much more common. There are actually more people at risk now. And we also know that the prescribing number matters. So I'm just gonna show you this slide quickly. We often talk about these morphine milligram equivalents and MMEs, and just to give you some perspective, a five milligram oxycodone is 7.5 MMEs, dilaudid is 10. And so when we look at numbers like the prescribing number here, even if you're prescribing 16 oxycodone, 2% of your patients will become persistent users of opioids. And that number just goes up dramatically as you increase the number of pills you prescribe. So you directly can have an impact on a patient's, a patient's risk for becoming opioid dependent. So when I think about patient postoperative pain and how to treat it, I think of multimodal therapy with all of these things combined. Surgeon education is important from the get-go. We know that it works. We all should be employing formal education for residents and fellows, understanding the prescribing practices of ourselves relative to our peers and how reducing the number directly impacts patients, learn how to communicate with patients about post-op pain medication, learn how to prescribe alternative medications. And then again, going back and re-looking at our established protocols. HSS, this is an old study from HSS where surgeons were mandated to take a one hour online class. Opioid guidelines were established for each service and they collected data four months later and there's a significant change in prescribing practices across all services. So we know that this does work. I also think it's important to educate the PACU staff and just eliminate that concept of, quote, stay ahead of the pain. That's completely made up. There's no staying ahead of the pain. It makes no sense to take a medication that is a half-life of three hours or less before your block even wears off. So I tell my PACU staff, please don't give my patients opioids in the PACU. They don't need it. We have IV tortille, IV Tylenol. They just don't need it. And it also sets the patients up to not expect to be taking opioids post-op. I think regional blocks are important for me personally. Most of my patients get them. We know that they decrease post-op pain scores and opioid requirements overall. There's not a clear benefit with continuous infusions where patients go home with these continuous infusions post-op. There are some complications. Patients will have residual paresthesias. And so in my practice, I avoid regional blocks in high-risk patients, such as patients who've had a prior nerve injury or have radiculopathy, or where from a legal or liability standpoint, it's dangerous, such as a pro athlete or a high-level collegiate athlete. But we do know that regional blocks work. NSAIDs are crucial. They decrease opioid needs 20 to 30%. When you take ibuprofen with acetaminophen, they work synergistically. So they work better together. So I don't stagger them. I have my patients take them together at the same, take those two medications together routinely sort of around the clock for the first one to three days, depending on the procedure. And I think that the idea that short-term NSAID use is gonna cause non-union has really been debunked. There's no human studies that demonstrate this risk in short-term use. And our European colleagues have been doing this for years and they don't have increased risks or rates of non-union. The anticonvulsants like gabapentin and pregalbin, there's no clear data in the foot and ankle literature, although there have been some studies demonstrating the efficacy. I think that it's definitely clearly shown that for post-op pain, for any nerve pain, for patients with depression, these medications work, but it would be nice to see if they could completely replace either NSAIDs or opioids on their own, that's yet to be shown. So this is probably the most important part for me is patient education. And I think the pre-op discussion is critical. This is where I set expectations of pain. I discuss the alternatives to opioids. I talk about the side effects of opioids. I talk about how long they should expect to have surgery and also how to safely store and dispose their opioids. Every patient of mine gets a handout, what to expect after surgery for pain. You should expect some pain after surgery. This is normal. No one's gonna be pain-free. And as one of my greatest mentors used to tell patients, no one ever died of pain. But I think it's important just to set the expectations. Tell them how long it's gonna hurt. Tell them what the average level of pain is. I've been in practice 17 years. I can tell patients with a lot of clarity how long I think they'll need to take each medication and for how many days. And make it competitive. Tell them what other patients tolerate. And then a lot of patients will adhere to that. Our patients don't want to take opioids these days. I actually prescribe NSAIDs and acetaminophen. So when they get the prescription, they know that it's part of the post-op protocol and they actually take them. And I think that's better than just telling them to take them. They often just defer to the oxycodone in those cases. And then of course, we talk about ice elevation and other alternative methods to decrease pain, which hopefully we'll learn about in some of the later lectures as well. And then I also talk about the opioid side effects. Nausea, vomiting, constipation. Greater than four days of being on an opioid increases risk of addiction substantially. That's all it takes is four days. And I tell patients that straight out. I also screen each patient for a history of substance abuse or use in their family so they know their own risk. These tools are available online and they can give you a framework. But I ask every patient these questions so I know where we start. And then I give them a handout for safe storage and disposal. I explain to them how to get rid of extra pills. We don't want them flushing them down the toilet or leaving them in their medicine cabinet for their kids or neighbors to get to. And this really avoids pill diversion. So personally, I started decreasing opioids back in 2016 and I have recorded as part of my first post-op note how many pills people have taken for really every patient over the last eight or so years. I haven't seen any increase in phone calls or any change in patient satisfaction scores and it's dramatically changed my practice. I have a clear one to two minute open discussion with every pre-op patient. I prescribe NSAIDs and Tylenol unless they're obvious contraindications for everybody. Most of my patients get blocks and I prescribe minimal opioids. And I would say in my practice, 95% of patients take no opioids. And that includes not just my MIS bunions, but my triples and my flatfoot reconstructions as well. And I think a lot of that is simply due to patient education. So we clearly need to establish updated guidelines. Do not look at that republished version of the paper I wrote back six years ago. It's way outdated. Educate your patients and yourselves. Look at your own data and examine your own prescribing practices. Are you, your PA, fellow resident over prescribing? Have the open discussions with the patients, set expectations, understand multimodal therapy. And if you're not already, try giving lessons, see what happens. I swear you won't get more phone calls. Patients won't, you know, dox you on online. They really do appreciate it. And this, by the way, is a great paper, a great summary essentially of this talk by Casey and Amy Hsu that I think everybody should take a look at. Thank you. Thanks, Holly. Very inspiring. And I couldn't agree more with the sentiment. Next up, we have Dr. Sami Dolshahi. Thanks so much, Chris. Thanks for having me. Can you hear me well? All good. Good. Sorry, it keeps going to the end of the talk. There we go. So thanks everyone for having me. Basically, I'm an orthoplastic surgeon, so plastics trained, and my practice is essentially dedicated to kind of everything at the interface between plastics and orthopedics, and I had the pleasure of working with Chris for several years, and we did a lot of interesting cases, and hopefully I can share a few of them with you. Just to give you a better understanding, for those of you who don't have an orthoplastic surgeon working at your hospital, it's basically everything that overlaps in terms of MSK with plastic surgery. So there's some hand surgery, microvascular surgery, and just general recon, kind of that's where orthoplastic surgery takes place, and as you'll see, it excludes all of breast, head and neck, and cosmetic surgery. So we're basically really dedicated to limb reconstruction. And it works, and I think the reason it works is like we're one team. So I'm, you know, I'm your partner as opposed to just a colleague from a different department that on the side will help you with some lower extremity issue, and our fates are really linked. There's this co-dependence that I think you'll get a sense of during this talk, and also immediate access. So, you know, I get a phone call, you know, Chris has some something going on, some difficult case, and then we just get on the phone and start talking about it, or the other way around. If I have a challenging soft tissue reconstruction, I can reach out in real time. So this is really, I think it works because it's not just a side gig or interest, this is kind of what we are dedicated to. And it makes things a bit easier. So this is kind of a side note, but it's kind of relevant. So if you have a complication, some soft tissue issue, and you need a free flap, it's not a big deal anymore. So we do so many of these, it's not a 10-hour ordeal. Like I have a lot of orthopedic colleagues that work in various places across the state or out of state, and they don't have a plastic surgeon doing this. They have to tell their patients, well, I'm sorry, you know, you got to get this 10-hour reconstruction. Really a skin-to-skin, a simple, straightforward, soft tissue-free flap is like two hours, should be. So in preparing this talk, I was thinking, you know, what could be helpful for you guys in the foot and ankle for the complex recons? And I think four things I want to talk about. One is incision planning. Two is soft tissue coverage. Three, vascularized bone. And I overheard some discussions about bony defects and so forth. And then lastly, nerve. I'm keeping it vague because there's a lot of different things in nerve, including compressions and injuries. So incision planning, I think this is probably the most challenging part. Let's say you have to go into this ankle and do some procedure, and the patient has had a skin graft on the ankle. These cases can be tough, how to access it. And this is where I think involvement of orthoplastics really early on can help before you make the incision, way before, so that I have a chance or your orthoplastic colleague can have a chance to potentially optimize the soft tissues. This is a case where I have the patients in my office, I make a quick video and then send it to the foot and ankle partner of mine and say, look, I think maybe make an incision here or there, or I think this is the problem and so forth. And this was actually a case where that's exactly what we did. A patient needed a total ankle. And I made the video and I'm making some comments. I think we should go here, not go there and so forth. And actually my advice didn't work out very well because the patient ended up with a problem. But this is the advantage of this approach is immediately within 24 hours, flap goes on, everything's debrided, the hardware doesn't get infected. And this is the result. This is another example of a patient that needs an ankle procedure. This is a free latissimus flap, some skin grafts. I mean, planning incisions on a patient like this can be really challenging. And I think this is where getting us involved early makes sense. Now, once there is a problem or one soft tissue coverage is needed, this is what the next portion of the talk is about. And really soft tissue coverage comes into play when there's a complication, something like this, a wound that gets infected over a plate and then you're going to deal with it, or it can be optimizing the soft tissue. For instance, if you need to do a total ankle and one of those previous patients, their skin grafts all over the place, scar, then what I can do is do the flap before, and then we can re-elevate it. And then you could do your ankle procedure months later and you have ample tissue to close. I can't talk about this sort of surgery without talking about Achilles wounds. This is the bane of my existence. I've seen every type and I've taken every bit of hardware out, every different way of fixing these. So sometimes to be honest, it's just a matter of doing a good debridement and a good closure. But in other cases like this, we need to cover usually with free tissue. And this is an example where my favorite flap for this is the MSAP, which is based, it's a medial sural artery perforator. And you can see the flap outline on the calf there, and you just take it out with the patient prone and then hook it up into the posterior tibial artery. And it's a pretty straightforward reconstruction and gives typically what you need. The only problem with this is if the patient's obese, it doesn't work as well. This is the long-term result. This is another example, just to show you kind of how the planning works. I routinely do a duplex ultrasound, mark out the little perforators that come off the posterior tibial artery. I don't even have to go into the PT. You can take a little perforator and use that for your inflow. This is the flap elevated on the calf. Then you take it down, hook it up, and a little skin graft on the donor side, and you're done. Other examples, just to give you a sense of kind of what we do. This is some hardware that gets infected. And this, I got to this patient pretty early. It was a hematoma, a wound complication, and then I got to flap it before everything got infected, which is ideal. And in this case, I just did a very simple muscle flap. So muscle flaps are a little bit traditional, and I don't love them in the foot and ankle because they can be quite bulky, but they're quick and easy. And the donor side is typically like this was a gracilis flap, very simple and low morbidity. Yeah, now I've gotten a little fancier. So, you know, we have all these traditional flaps that we used to do. And now we're doing, like you guys, the MIS in the foot and ankle, we're doing more MIS microsurgery. And the way this works is basically, you don't need some major vessel, you don't need some major piece of muscle, you don't even need big recipient vessels, just a little branch of some random vessel works just fine. This was a young medical student actually, who had the calcaneus fracture fixed from a lateral approach got infected. And you can see the calcaneus there. And basically, in the human body, there are 376 tiny blood vessels that go into the skin. So you can literally take any of these blood vessels with the overlying skin and take it as a free flap. So basically, you've got 376 free flaps that you can take from anywhere. And this is one example where you can take it from the groin. So the incision is the donor site is well concealed in the groin in this young patient, take a tiny little flap, small vessels, you put it in there, it's like a little potato chip, plug it in. And there it is very nice, elegant, you haven't harvested any big blood vessels or muscles or anything like that. But the minimal donor morbidity smokers. So these are obviously patients that you more likely are going to have problems with. And sometimes you don't have a choice, you have to operate on them. And when there's an issue, I go pretty aggressive with the flap, I don't love the radial form flap because of the donor morbidity as a hand surgeon, I don't think it's a great, great flap. But in smokers, it has phenomenal blood supply. So you can really get away with a lot. These are all next couple of cases are all smokers, some plate exposure, and a smoker, just take a radio form and plug it in there. This is what it looks like. That's the donor site. This is another example of medial malleolus coverage with a radial form flap. Again, you can get away with a lot. These are very, very well perfused because there's like 10 perforators in that little skin island. But even with the radial form flap, you see how the flap here on the calcaneus survived, but the incision I made to access the posterior tibial vessels broke down. So these are really tricky patients. And I just take a flap that's very reliable. Switching gears to vascularized bone, I hope this is of interest because I did see those, I did listen in on that discussion earlier. So I think we underutilized this. This is an example. Here is a fracture that was fixed, nonunion, infected nonunion with open wound, which you can see there. That's me doing, I didn't get a better, I'm sorry, I don't have a better picture of this, but that's what the wound looks like. I was doing the ultrasound. Here I harvested from the thigh, patient is pretty large, so you can see the thickness of the flap. But this is just to give you an example of how creative you can be with these. So this is the lateral thigh flap together with the lateral femoral cutaneous nerve. And I also, in this case, harvested the lymphatic channels. And you can see right here, this is actually a small lymphatic channel that's draining the flap. And I took this, the duplex ultrasound, transferred this to the tibia. And then I hooked up the saphenous nerve to the lateral femoral cutaneous nerve. So the flap regained sensation. And then I hooked up all the lymphatic channels with small lymphovenous bypasses. And then obviously the blood vessels, that's operation number one. Then we came back and the patient had a non-union. So I harvested the medial femoral condyle flap, which is a bone flap from the medial knee. And this shows you the flap of the blood vessels. And then we plugged it in. This shows the anastomosis that's patent at a year end to side into the anterior tibial artery. And the patient went on to union with the vascularized bone graft. This is another example example where we had a subtalar fusion with a frame and a big open wound in a Charcot patient. And the first step was again, a thigh-based flap to cover the skin defect. And then we came back. This was actually, Dr. Miller, in my case, took the frame off because of ongoing non-union. I pulled the flap out of the way. He did his TTC fusion. I took the fibula out because you don't need the fibula anymore. So harvested the fibula with a little skin and then transferred it as a free flap, a second free flap, so to say to the ankle. And this shows a double barrel fibula that I placed to augment the TTC fusion. And this shows you the CT scan of how we oriented the fibula. This is the CT showing you how these were incorporated. In any case, went on to union. Last topic is nerve. And this is near and dear to me because I think we see a lot of these. And I think as soon as you start doing these cases as a plastic surgeon, they come from everywhere. And so one category of patient is obviously peripheral nerve compression. And the reason I'm showing a common perineal nerve compression is because every so often when you fix an ankle fracture, the patient gets very swollen and they can develop these nerve compressions, as we all know. And this can be really amazing. The patient shows up with a foot drop, young patient, you decompress them. It's a 10 minute operation and foot drops gone within a month. So if you can get to them early, it's pretty amazing what effect it can have. Superficial perineal nerve compression we see very commonly. And this can be in your trauma patients or just exertional calf pain patients that show up in your office. And this is an example of how we address this. And this shows the exit point of the SPN through fascia and you just release it. This is a different patient, actually no, same patient that I decompressed and she actually had two separate SPN branches. This is another patient and you can see all sorts of unusual neuromas and things. And these can be really rewarding cases. Another example of a case with two separate branches of SPN, and we actually happened to just do one yesterday. So we do see this pretty often. And other circumstances, and I'm going to end with the next couple examples, is nerve injuries. Unfortunately, even in the best of hands, we do see the nerve injuries. And I'm just going to show a couple of examples of how we manage these from the orthoplastic standpoint. This is a patient who had a strayer and ended up with a neuroma of the sural nerve. And you can see here the neuroma and continuity, which I excised. And for neuromas, there's a lot of different options now, including repair with nerve graft. You can just perform a neuralysis and you can do things like targeted muscle renovation, RPNI, there are newer techniques. And this is an RPNI where you take a cuff of muscle and transfer it to the end of the nerve. This is another example of a neuroma. This is a terminal neuroma. So the nerve was transected, unfortunately. And here you dissect it up. You take the medial and lateral sural nerves and deal with them, bury them or do an RPNI or TMR. This is a superficial perineal nerve. Patient underwent dry needling and they damaged the nerve. There's a neuroma here. So I denervated, cut it, and then I did a targeted muscle renovation where you find a motor branch nearby with a nerve stimulator. And then you hook up the superficial perineal nerve to that motor branch and the nerve will re-nervate that segment of muscle and the pain goes away. Another example of a neuroma, actually I caused this when I was doing a popotility compression. I injured the lateral sural nerve and I had to fix it. And the neuroma actually recurred after I fixed it and I had to go back and again. So these can be really challenging cases. And nerve grafts have been described as another option. And this just shows you a few last examples of a sural nerve, which I repaired with a nerve graft, another one. And so to conclude, I think what's unique about the orthoplastic approach is we typically approach the problem with the end in mind. I'm not looking to fill a hole or plug a hole as we typically do. We're trying to think of the issue down the road. So this, for instance, shows you an end-to-side anastomosis because I always try and preserve flow to bone so that your fracture can heal or so forth, or your fusion can heal as opposed to going end-to-end, for instance. Little nuances like this, I think, can go a long way. Or in a case like this where there's exposed hardware, I don't just flap it. I also will reconstruct FHL with tendon graft and fix the nerve that was injured in the process. So it's a kind of, I think, a more holistic, comprehensive approach. And in conclusion, when do you call your orthoplastic surgeon? I would say right away. Ideally, if you can, even before the problem arises so you can potentially approach it in a more preventative way. Thanks. Sammy, thank you so much. Awesome talk, as always. And I'm glad to see that those aren't all my complications. So thank you for doing what you do. Next up, something different. We're going to talk about the psychology of pain, and I'm looking forward to hearing from Dr. Herg. All right. Looks good. You guys- We got it. You can see it? Okay. So I'm incredibly grateful to have been invited to participate in today's talk, especially my colleague and friend, Dr. Izide. Thank you for inviting me to review the role of psychology in treatment of chronic pain. Nothing to disclose. Here's a quick overview of what we're going to be going through today, start with the case example, and then move into the diagnosis of chronic pain, as well as the multidisciplinary treatment. So here's our patient, Tom. Tom is a 15-year-old Black, Hispanic, cisgender male. He has a past medical history of a right ankle sprain that he sustained two months ago. And this occurred when he was playing varsity baseball, where his dad happens to be the coach. He has been consistently stable on exam. Radiographs and MRI have been without any sort of remarkable findings. He has no other past medical history, but you do know in his chart that there is a family medical history of chronic pain. And he's now in your office, and he is complaining of daily pain that's an eight to nine out of 10. And when you ask him to localize that pain, he's sort of vague, and his answer changes a little bit over time. He initially is indicating that the pain is in his ankle, and then it's moving down through his foot, up through his tibia. You have previously counseled him to come out of his boot that he started wearing independently. You've instructed him to focus on range of motion and strengthening, and he has been unwilling to do so. And he is wearing that boot around the clock. And as part of your exam, parents happen to mention some other things as well. So they know that Tom's grades have started to go down, that he hasn't been spending as much time with friends. They note that he seemed a little bit irritable, and Tom does acknowledge that, yeah, he's had some problems sleeping. You notice in his chart that his weight has gone down a little bit, and he denies that this is on purpose. He says that he just hasn't been as hungry, and he has not returned to baseball. So what are we missing here? Some things that hopefully stand out to you are that Tom's pain is well out of proportion to his injury. He's not recovering as expected. It's already been two months since his ankle sprain. His distribution of symptoms is unusual and sort of amorphous and changes over time. And his imaging has been consistently normal and non-significant, and certainly does not explain the severity of his pain. So when you see this constellation of symptoms, I would argue that the pain has transitioned from being a symptom of Tom's initial injury to becoming his primary problem. And so we are now dealing with chronic pain. And in cases of chronic pain like these, the exciting injury or event resolves. So in our case, Tom's initial ankle sprain has fully resolved, and we don't have any evidence on radiographs for other scans that there's a mechanical problem, and instead the pain is our problem. And I do think it's incredibly important that we as providers feel comfortable explaining the neurobiology behind pain. And this is critical so that patients feel validated in understanding that yes, there is indeed a medical explanation for their pain, and you, their provider, don't think that they are making it up or that it is all in their head. This buy-in will dictate the patient's willingness to commit to a multidisciplinary treatment plan, and it will also inform their motivation to remain adherent to your recommendations over time. So I would recommend using a diagram like this, where you explain that pain is typically triggered in response to tissue damage, like what happened to Tom when he sprained his ankle, and that that damage sends a signal through the pain nerve, through the spinal cord, and then the signal is transferred up to the brain, and the brain recognizes that signal as being painful. And then you can explain that in cases of amplified pain, there's also an abnormal short circuit happening in the spinal cord. So that normal pain signal is not only traveling up through the spinal cord to the brain, however, it also goes to the neurovascular nerves that control blood flow throughout the blood vessels, and these nerves cause the blood vessels to constrict. This constriction reduces blood flow and oxygen to the muscles and to the bones and leads to an increase in waste products, like lactic acid, and then this lack of oxygen and acid buildup causes new pain signals. And then these new pain signals are going both up the spinal cord to the brain and across that abnormal short circuit, causing a further decrease in blood flow and leading to more pain, and this pain very quickly becomes amplified. Now, admittedly, this diagram, the explanation, is a little bit complex. So especially with kids and with teenagers, I also like to use an analogy, and I tend to use the analogy of a fire drill. And I explain that the body's fire alarm is going off, meaning that the nerves are indeed sending signals that are going up the spinal cord to the brain, which the brain is interpreting as pain, but there's no real damage. And so it's like the body is stuck in a fire drill and the body does not know how to turn off that alarm. Additionally, when we're conceptualizing chronic pain and explaining chronic pain to our patients, of course, we have to take a biopsychosocial approach, as we know from research that many non-biological factors may impact a patient's experience of pain. And I think that this information matters both from an education and explanatory standpoint, but also because it provides us with opportunities for intervention. So when talking with patients, I explained that pain is also informed by psychological factors, like a patient's experience of mood or anxiety symptoms, their feelings of self-efficacy, as well as their cognitive and emotional flexibility and their coping skills. We talk about how pain is also informed by a patient's health habits. So things like their physical activity level, sleep habits, engagement in smoking, any use of non-prescribed substances, as well as, and perhaps most importantly, their individual beliefs about what it means to have pain and how pain should be treated. The experience and expression of pain may also be influenced by social factors at the family, community, and cultural levels. So for example, parents' beliefs about pain, their own experience of pain, their own experience of having pain treated has the potential to strongly impact a youth's understanding of their pain and how to cope with it. Similarly, peer and community interactions may provide unintentional secondary reinforcement for pain, things like increased attention, increased care, increased resources. And then finally, even someone's culture can influence their experience of pain. Some cultures tend to discourage the expression of emotional symptoms, but place significant weight on physical symptoms. And so it might be more socially acceptable to seek care for pain rather than for some sort of an emotional symptom. So when we are thinking about treating chronic pain then, the focus shifts to maximizing a patient's functioning rather than waiting for pain reduction with the critical understanding that functioning will improve before pain subsides. And so when we orient treatment towards maximizing functioning, we are then shifting our attention to optimizing the patient's health behaviors, things like physical activity, nutrition, hydration, sleep, as well as providing psychoeducation on specific psychological coping strategies to help manage that pain. And when we dive into the psychological intervention component of chronic pain, there's a significant body of literature that supports taking a cognitive behavioral approach to pain management. CBT for chronic pain is multifaceted and includes skills in all of these different buckets. When we think about cognitive skills training, this includes providing psychoeducation on thoughts, feelings, behaviors, and the bidirectional relationships between each of those factors, educating patients on the existence of thinking traps, so things like perseveration, catastrophization, and explaining how these cognitive biases may influence a patient's perception of or experience of their pain. We also work on addressing and reframing catastrophic thinking, as well as hypervigilance to pain signals. And sometimes we even do things like imaginal exposures to help promote pain coping. Thinking about relaxation interventions, this is where we focus on skills like diaphragmatic breathing, progressive muscle relaxation, guided imagery, sometimes incorporating biofeedback as well. Lifestyle and physical activity interventions, this is really where we partner with our physical therapy teammates, working on reducing barriers to appropriate physical activity for kids. And so this will include helping kids and adolescents to understand the concept of deconditioning, why we need to work with physical therapy, why we need to be using a home exercise program, why we might need to be doing activity pacing or a graded return to sports or activities. Also focusing on scheduling pleasant events, things that are positive and enjoyable. Again, with the understanding that functioning will improve before pain goes down. In terms of sleep interventions, we focus a lot on sleep hygiene, helping kids to use appropriate sleep behaviors in the evenings, reducing daytime napping, making referrals to any specialists if that seems appropriate. And then we also spend a lot of time working with families and with schools. So when we think about our work with families, we are really working from an operant conditioning perspective, where we want to provide psychoeducation to parents and to other caregivers about pain and behavior management strategies. And so this includes eliminating check-ins of a child's pain level, giving attention, teaching about the role of attention and giving attention to appropriate coping behaviors, withdrawing attention, meaning ignoring verbal and nonverbal complaints related to the chronic pain, and making sure that if the child does ever experience pain that requires them to have a reduction in functioning, that we're treating that like a genuine illness. We don't get to come home from school because we have pain and then watch movies and play video games and text with our friends and eat candy. We also work with schools in similar ways, collaborating with teachers, with nurses, with other school staff to make sure that they are appropriately responding to kids' pain complaints. So if we go back to Tom, what additional information do we need to provide him with sort of comprehensive treatment? I would argue that we need a lot more information. I would want to know about his physical activity. What are we doing on a regular basis? Is he participating in any physical therapy? I would want to know more about his sleep complaints. Is it problems falling asleep, staying asleep, et cetera, things related to his nutrition, hydration, any use of substances. And again, most importantly, what is his understanding of his pain? Does he understand that his pain has transitioned into chronic pain and how does he think that should be treated? Similarly, I want to know about his family. I want to know his family beliefs about pain, how they understand pain to be treated. I would want a lot more information about that family history of chronic pain. And how are folks responding to his pain? How are his family members, teachers, friends, teammates responding? Is he getting any sort of secondary gain or reinforcement? And then finally, I would want to know more about his functioning as an individual. So things related to mood symptoms, anxiety symptoms, a trauma history. Is he engaging in any sort of rumination or catastrophization related to his pain? And what do his coping skills look like? Is he somebody who has a lot of cognitive and emotional flexibility? Is he somebody who is more rigid? What have these skillsets looked like before the onset of his pain? So then to wrap up, when we think about Tom's treatment plan and really any patient with chronic pain, we are going to be recruiting a multidisciplinary team for treatment. Thinking about Tom, he will absolutely be needing some physical therapy with a daily home exercise program. Seems like he would benefit from an accountability partner, whether that is a physical therapist, a trainer, teammates from baseball, friends, and working with his dad and other school staff or other training staff on a graded return to baseball. Making any referrals that are appropriate. And then finally thinking about how to best provide him with psychological intervention. Is that something that can be provided as part of multidisciplinary clinic visits? Does the team have somebody who is capable of doing that? And is that an appropriate level of intervention for him? Or has Tom sort of progressed so quickly that we need to be making an external referral, either within your institution or to somebody in the community, and always making sure that you are aware of pain management intensives that exist in your community and that are available to your patients. Thanks so much. Thank you, Whitney. That was wonderful. And then for our last speaker here, we have Dr. Mark Weyers, a vascular surgeon at Beth Israel. You may still be muted, but I do see your slides. Classic me. Okay. See if I can bring this home for everybody. Chris, thanks so much for the invitation to talk a little bit of a change of pace here. I'm going to give you my perspective as a vascular surgeon on some of these complex foot and ankle surgeries, and I think a lot of this, the intersection of what you guys do and what I do really comes together in the Limb Preservation Center, and we're fortunate to have a very busy Limb Preservation Center here, and so without further ado, I have no disclosures. So a lot of what I'll talk about is really identifying patients that are at highest risk for complications after these complex reconstructions. So it's really about identifying patients with existing peripheral arterial disease, and sometimes that's easier said than done, obviously, patients with diabetes and diabetic foot ulcers. Charcot foot is a big part, I think, of the intersection between vascular disease and the foot and ankle. Sometimes venous disease will play a little bit of a role, especially with respect to skin integrity, and I would say any time you have Sammy involved with complex plastic reconstructions, he may want to know what the vascular anatomy looks like as well. So those are the highest levels of limb salvage that we typically deal with. At the right there, you can kind of see some of the red flags, you know, issues with skin integrity, swelling, problems with glucose control, patient issues in terms of their ability to offload and have access to good wound care, patients with severe neuropathy, pre-existing infections, and renal failure patients are their own special category. So this is an example of what I think we're trying to prevent. This is a 64-year-old female with diabetes and pre-existing severe Charcot foot deformity who had a tailor fracture, very unstable ankle, and has, as you can see, some diminished ankle brachial indices on the left side there with an ABI of 0.5 and a toe pressure of 51. We'll talk more about those numbers in a little bit. But needed this arthroplasty, and when she came out of her cast a few weeks later, this is what her foot looked like. And so some extensive areas of full tissue loss, both at the access sites for her hardware and other places in the foot where she had pressure from within the cast. So this is what we're trying to avoid. It's not always that severe Charcot foot patient. However, there are, in the elderly patient populations, a lot of features about them make them behave like diabetics as well. So atherosclerosis as we age is much more prevalent so that in the 70-year and older population, 50% of patients will have some degree of significant atherosclerosis. They may have peripheral neuropathy unrelated to diabetes. The skin tends to thin over time, so skin integrity over pressure points is a real problem created by some of their foot deformities. So I would argue that some of these older patients are presenting as diabetic equivalents. This is just a snapshot of the initial importance of screening for vascular disease, especially in diabetics. This is a set of recommendations taken from the JVS as a practice guidelines, and it's recommended that all diabetics have baseline noninvasive vascular screening at 50 years of age. So even if you can feel a dorsalis pedis and posterior tibial pulse, that's probably good to have a set of baseline ABIs at that age range. And once it's recognized, that that be followed every year. So ABIs and PVRs done annually and that they undergo routine diabetic foot care. Prevention is everything for these patients. And then the hard indications for revascularization happen, you know, for most of our patients with peripheral arterial disease if they have an active foot ulcer or rest pain, things that are evidence of progression to chronic limb-threatening ischemia. So just a little bit more about ABIs, which can be ordered in almost any tertiary center with a functional vascular lab. This is a very reassuring set of ABIs with normal numbers. A normal ABI is in the 0.95 to 1.2 range, but it's more than just the number you can see from the Doppler waveforms there, beautiful triphasic-looking waveforms. And down at the toe level, doing a toe brachial index or an absolute toe pressure is also especially helpful for diabetics that may have calcification of the tibial vessels, which may make the ABI itself hard to interpret. I'll show you a little bit more about that in a couple slides. By comparison, this is an abnormal ABI, you know, mostly tibial disease on the left here where the triphasic waveforms are replaced by monophasic waveforms. And sorry, it's a little blurry, but the toe pressure, the absolute toe pressure is much lower. You know, the toe pressure of 44 here is kind of borderline to predict a healing response. And if you actually look at the—sorry, I lost my slides. Can you still see them? No, they fell off. You might have to unshare and then reshare. And you can also see on the right here, the toe PPG waveform is very depressed compared to the other side, so these are, you know, suggestive of somebody who would have a hard time healing, you know, even a relatively minor forefoot procedure. Not everybody with vascular disease needs a revascularization, you know, this is somebody with clearly abnormal Doppler waveforms in the lower leg, an arteriogram that instead of showing three-vessel runoff only has runoff via the perineal artery, but you can see fairly well-developed collaterals to the anterior and posterior circulation, so the foot itself is reasonably vascularized and further supported by this toe pressure of 65, which for something like this, which is an isolated toe amputation with reasonable skin at the base of the toe has a reasonable chance of healing. So not everybody with vascular disease needs me, they just need kind of a careful assessment of things and, you know, some thought to the actual procedure itself if there are options. This just highlights some of the problems with ankle brachial indices, especially in diabetic patients where you can see here their posterior tibial and dorsalis pedis arteries are heavily calcified and will not give you a reliable ABI reading. So in that situation, we tend to rely pretty heavily on toe pressures. The absolute toe pressure you can see here, even in diabetics, tends to cluster the same as it does for non-diabetics and that makes it a pretty good discriminator for patients in terms of their healing response. We talk about frequently when you order an ABI, you'll see a comment based on the ABI or the toe pressure that, you know, perfusion may be adequate to heal minor tissue loss and that's based on this toe pressure number of 30 millimeters of mercury. An absolute toe pressure of 30 suggests that there would be a good chance of healing. This is a meta-analysis that shows that, you know, for patients with greater than, a toe pressure greater than 30, that they have a five and a half fold increased chance of healing compared to patients with less than 30 millimeters of toe pressure. But I would suggest that it's not that absolute, it's not a binary thing. So the toe pressure of 30 is, I would say, you know, still fairly marginal because of all the other things that go into wound healing. A toe pressure of 30 kind of assumes that there is really no real infection, that this is an isolated forefoot issue, hindfoot issues, calcaneal issues are a totally different beast and require much more perfusion to heal. And it also assumes that this is a fairly superficial wound. So I would suggest that this is not quite an absolute number and it's more of a sliding scale. For a more granular kind of approach to this, this is the way we think about the intersection of the wound itself, how ischemic the leg is, and the presence or absence of infection. This is the SVS Wi-Fi grading system. I won't go into the details, but basically the wound, the level of ischemia and foot infection each get a score from 0 to 3, and it's put into kind of a decision-making matrix where it would predict, based on the intersection of those things, the risk of amputation at one year. So you can imagine that somebody with very ischemic foot with a large infected wound has a very high risk of amputation, contrasted with somebody with very little ischemia and lesser degrees of wound and infection has a low risk. But not 0. So in terms of the benefit of revascularization, this second grid kind of really outlines how we approach this. I mean, clearly, if somebody is very ischemic, almost all of those will require a revascularization, but this is kind of the nuanced portion of the decision-making. So even for milder or moderate degrees of ischemia, there are certainly factors that would favor an aggressive approach to ischemia, especially for deeper wounds. Wounds of the hind foot especially are in this category where I think you have to do better than that toe pressure of 30. So that kind of tells you how we think about approaching these kind of intermediate levels. The timing of surgery also affects results. If for more urgent or emergent cases, which are more likely to have an active ulcer or active infection, they have a much higher risk of failure, much higher risk of repeat ulceration, infections, or amputation risk. So obviously, in that setting, a more elective approach with less wound issues to start with will favor results in the end. So a lot of what we do, you know, for these complex reconstructions, it takes time to heal these things. I'd say short healing time is anywhere in the three- to six-week range. But some of these cases involve six and 12 months of multiple surgeries, reconstructions, and a reevaluation of the revascularization over that time period is important. So we think a little bit about how much of a revascularization is needed and for how long we expect it to be durable. And that helps us kind of decide between one type of revascularization or another. Like every specialty these days, we have minimally invasive options or maximally invasive options. And sometimes, we'll choose one or the other depending on how much time we expect it to heal. And these other mitigating features are really the things that go into this healing time. You know, I've talked about infection, wound size, and depth. But other challenges certainly are renal failure patients, you know, how compliant a patient is with offloading, what their access to good wound care is like. And then the size of the reconstruction itself. Here's an example of a pretty straightforward minimally invasive reconstruction, which all of it is required to really reestablish a palpable pulse here at the foot. Is a fairly straightforward angioplasty of the tibia peroneal trunk into the posterior tibial artery. Doing that here, you see the result with a palpable pulse at the ankle. And even a reasonably, you know, good-sized reconstruction via TMA was possible as long as this plantar circulation is adequate to support the plantar flap. A little bit about the type of revascularization. I mentioned that some, not all, revascularizations are created equal in terms of their longer term durability. And that applies especially to extensive tibial reconstruction. So here is an example of the tibial angioplasty, which gets the job done. But for these longer lesions, the task C and D criteria have a much higher failure rate. So if you're in for the long haul with a complex situation that takes a long time to heal, these need to be resurveilled periodically, and sometimes retreated, or sometimes even gone on to a more durable open revascularization. But I view both of these things as complementary. So there are certainly plenty of situations where we push the endovascular limits a bit. This is a complicated, heavily calcified popliteal artery occlusion that using a combination of both anterograde and retrograde access, we're able to cross and stent it open with a good result. But sometimes, you know, for patients that have adequate saphenous vein, then a more traditional operative bypass is always something that we can consider. Bypasses to the tibial level, even onto the dorsalis pedis or plantar artery are certainly possible and things that we do fairly routinely. And just one more bit, this is some of the best trial data, which is just one of the better randomized controlled trials, really one of the only randomized controlled trials to look at this issue of open surgery versus endovascular revascularizations. And as long as you have good saphenous vein conduit, that really kind of separates the people that do best with open bypass. For people with good saphenous conduit, you can see the blue line here. They have those open surgery patients have much lower major adverse limb events. They have many fewer reinterventions. And there's also a strong tendency towards fewer amputations over time. So saphenous vein to do these reconstructions is king. And I will wrap up by showing you what happened to that first patient that I started with. We actually started with an endovascular approach. We recanalized her SFA, and that provided enough stability to the foot to get things started in terms of the healing process and to reassure me that her fusion was actually going to take. That SFA stent eventually re-stenosed, was retreated once. And then after retreating it once, we actually did an anterior tibial artery bypass, which is still open. This is her foot about eight months after that first picture was taken. And she's two or three years out from that now, still walking well with an AFO. So even if the initial pictures don't look good, stick with it. And you can usually get these patients across the finish line. I will stop there. Mark, thanks so much. That was tremendous. And I know I certainly learned a lot from all these talks. If you don't mind unsharing the screen, we'll bring the panelists back up. Yep. Mark, since you're in the hot seat right now, I think part of my goal with this was to just get different perspectives on these issues. I think Sammy already answered this question. When should we call him? And he said yesterday. If you could summarize in one sentence or two, when do you want us to call our vascular person? And also maybe what is a common scenario that you might see, like, man, I really wish that those foot and ankle guys would just call us about this thing before they get into trouble. Well, I mean, I think my answer would be similar, if not the same. I'd much rather see a patient and say, hey, I think it's OK, go ahead, rather than have to kind of play catch up. A lot of this is about planning ahead of time. And that way, the same way Sammy was saying, you can strategize about the approach. If I can do even a simple tibial angioplasty to get it to a certain level of perfusion, and then if you're thinking about the same thing, whether you choose a minimally invasive approach versus an open reconstruction, I think those are all ways to kind of handle those borderline patients to right-size the operation for them. But I think the fundamental answer is sooner is better. I'd rather see somebody with a set of ABIs and may or may not do an arteriogram, but then give you some advice about, you know, what I think is possible. Yeah, absolutely. Chris, can I ask a follow-up to that? Of course. So Mark, I do, you know, I do a lot of minimally invasive forefoot surgery and, you know, I've even been burned on patients like that. And so for me, just following up on Chris's question, like, you know, look, I'm a dumb orthopedist. I check the pulses, I make sure the foot's perfused. I always look at the nails, because I think that when people have really bad nails, that's a sign of poor perfusion. But, you know, pre-op, do we reach out to vascular people before doing a surgery if we can't feel pulses or even before that? Like, what are the soft signs? Like, I'm not talking about like a huge TTC fusion, even for a small operation. Yeah, I mean, I think that if you can't feel a pulse, the next step is to get a set of ABIs and PVRs. And if those are kind of in that intermediate zone, then I'd be happy to see that patient. You know, those kinds of elective procedures, that's the way to kind of approach that, you know, and I think most patients would be fine, you know, we try to kind of streamline that evaluation for them, get them in so they can get on with the right procedure. Nice. Thank you. But Mark, if I can ask a follow-up question to that, as you mentioned earlier, age 50 and above diabetics with palpable pulses should be getting ABIs. Can you comment on that? Those are screening guidelines put forth by the American Podiatric Association and together with the SVS. And it's a screening baseline evaluation that kind of then determines how intensive their follow-up, because there's plenty of 50-year-old diabetics with palpable pulses, but kind of seeing, you know, if they have calcified vessels, all those kinds of things I think are helpful to kind of manage their risk factors. You know, not just, you know, not just me, not just the podiatrist, but how aggressive to be with their diabetes management, all of those kinds of things play a role in kind of the big picture management of those patients. Very nice. Whitney, I loved your talk. And we talked a little bit offline, but my wife is in mental health fields as well. And I talk a lot about this stuff with her. You know, I have 10 minutes with a patient, right? And on a good day, right? And I'm trying to get a lot of other stuff done. What's something that I can do in those, because it's going to be like two minutes of time that maybe if I think about it, I can address this. Like, what can I do as a, as Holly says, a dumb orthopedic surgeon that would maybe help normalize this, help them seek care, you know, sort of tee them up for somebody like you to step in and help out. I think in the best case scenario, you have somebody embedded within your team who's a psychologist or another mental health expert. The way that we operate at Scottish Rite, I'm actually in clinic. I am with the medical teams. So I get to go into the clinic rooms. I get to watch the exam, watch the conversation, and then watch the surgeon sort of introduce the idea that this is a primary pain problem rather than something else. And then it becomes a very warm handoff. They say, you know, here's the diagnosis. Thankfully, we've got folks who are here that are going to be able to help you with that. Here's our psychologist, and then here's our physical therapy team, things like that. That is the ideal. Can I just comment? I'm jealous that Jacob has that. Let me just make a comment. So, yeah, Whitney and her team have really sort of opened my eyes to this component of how we take care of patients. And at Scottish Rite, it's, I mean, it's like an orthopedic utopia. It's ridiculous. And we have everything and anything that we could possibly want there. And so, and many of the children's facilities have those sorts of resources. And so if you have a patient who's 18 and younger, this just goes to my point that I made two days ago, like be friends with one of your pediatric colleagues because I will just take patients right out of my private clinic and ship them over to Scottish Rite just so they can get set up with psychology. And it's so common in the, it's like, if you're like a high-functioning, straight A, well-to-do athletic female like who has like an ankle sprain, I feel like it's like this insane number of them that end up like unable to control the pain part of it. And it happens to the young men too. And it, I mean, it can happen to anybody, but it's, I just see it all the time. And to get it out of your hands and into the hands of the right person, sometimes it's just one visit or two visits with that person to get them back on track. And then as it, but you see it in the adults too. And someone had asked a question on the Q&A thing, what do we do when we don't have these resources in our clinics? And most of us don't. I certainly don't have this at my main clinic. First of all, the greatest thing is that Whitney and her colleagues, a lot of them have, do this online. So they'll do telehealth visits. So write down Whitney's name and Google her and utilize her and her friends, because a lot of, once again, a lot of the patients that develop this psychological pain, you'll, you start, when you start paying attention to it, you start noticing patterns. And a lot of them, they have means, like they are insured, they do have money, they're able to access this sort of care. And it just, I can't tell you how helpful it is. If you just sort of pay attention to it, they can be clinic-ending patients if you think you're gonna solve the problem in your clinic. You are not gonna solve the problem in your clinic. And so, anyway, just a comment. No, thank you. Holly, I was gonna say that I love your talks because it's, they're so intentional in your decisions about how to get people off opiates and make those transitions. And the fact that you're doing triples with no opiates, it just sounds amazing to me. And I wanna learn more from you. Are there handouts that people can, that I can find online that would help, that I can like use as guides for my own patients? What are the resources out there that we can use? I don't know if there's anything online. I'm always happy to share what I have. I've shared it with my service at HSS. I'm always happy to share my stuff. A lot of what I've learned came from David Ring, who really started changing the hand world back even before 2016. And I think that probably the most important part is just that literally two-minute discussion you have with your patient in the room and setting expectations for pain. And now, it's so much easier now because patients don't wanna take opioids. Most patients come in, they're not, they're saying to you, I don't wanna take opioids. What are my alternatives? And yet still, my 20-year-old son had surgery on his shoulder last year in Boston, and they were pushing the narcotics on him. And I was saying, he doesn't need narcotics. He's gonna be fine. And sure enough, he was completely fine without any narcotics, but there's still this push from the doctor's side, even when the patients don't wanna take it. So I think that you're obviously, when you're doing a huge ankle reconstruction that's open, those patients are gonna need some opioids. But I think that setting the expectations right from the beginning, telling them they're gonna be okay, telling them how many days they're gonna be in pain, how long their block's gonna last, write it all down for them so they have it, I just think it makes a huge difference. But I'm always happy to share my silly handouts. That's no problem. I had a joint replacement mentor surgeon in residency who would sit down, he was this really big Latvian guy with a deep voice, and he said, you have to hypnotize the patients. Ahead of time, he would just tell them, you're gonna be okay, and you're not gonna need the opiates. And they went in with that expectation, and lo and behold, if they go in with that expectation, more often than not, it's met. Yeah, and one more thing I do is I call my patients post-op. So I call every patient the day after surgery, and I reinforce the guidelines. You're gonna have pain. Oh, that's great, you've had X surgery. Don't worry, you have the pain you have right now, it's gonna get a little bit worse until about six o'clock, and then it's gonna get better. And again, you just set the expectations. But the set of phone calls that I make, it takes five minutes out of my day. It's a minute per patient, it makes a huge difference. Nice. And I think maybe one more question before the end, but Sammy, it's a pleasure seeing you again. Talk about the Achilles, because it's the bane of your existence. What's one principle thing that we can tell our membership to watch out for that drives you nuts? Gotta be careful what I say now. I think patient selection is key. I think patient selection and a really good closure. I think that's one of those cases where your closure needs to be perfect, whether it's a minimally invasive approach. Another thing I see a lot is some of the medical devices that are designed for MIS being used for open procedures. So I think straining plays is a problem as well. But I think the most important thing is patient selection. And it's one of those things that I'm trying to think of a comparison and plastics in my hand practice. I can't think of anything right now, but there are conditions which you can treat conservatively. And if you have a patient that's smoking, that some of these patients show up and they smell, their reek of smoke and other things, and they just don't look like they're gonna be compliant. If you don't have to fix the achilles, now I'm not a foot and ankle surgeon, I don't know, but if you don't have to, maybe don't operate. But then on the other hand, I've also had patients who've been treated in a cast with pressure ulcerations that have then gone on to infection. So I think it's a tough condition to treat. Well, thank you. And thank you, especially to this panel here. It was phenomenal. And in just sort of wrapping up the whole course, special thanks to my co-chairs, Dr. Jacob Zive and Elizabeth Cody. I'm really happy how this turned out. And I hope the panelists and the audience has gotten as much out of it as I have. And our goal at the beginning was to create a course that we wanted to sit through and listen to. And I think we, from my perspective, I think we did a really good job. And that's all to the panelists and thank you for making us look good. And this wraps up the 2024 Virtual Advanced Course. Thank you very much. Great job, Chris. Thanks, Chris. Great job, Chris. Thanks, Liz. Thanks, guys. Great talk to you guys.

surgery

pain management

vascular health

limb salvage

opioid reduction

multimodal strategies

patient education

orthoplastic approach

vascularized repair

chronic pain psychology

cognitive behavioral therapy

multidisciplinary teams

peripheral arterial disease

personalized treatment