Okay, hello, thanks for joining this evening. I'm Chris Miller, one of the foot and ankle surgeons in Boston. And we're here with a really great panel tonight to talk about some advanced concepts in minimally invasive surgery. So I just want to welcome all of our panelists today and I'll introduce everybody before their talk. But I'm going to start today with Dr. Miki del Mal Pastor. He's joining us from Barcelona and the University of Barcelona where he's an associate professor and one of the head anatomists for the MEPHIS by Gretmik group, which is an international minimally invasive foot and ankle society. So he's going to be highlighting his work on anatomic dissections and principles of foot and ankle. And I'm really excited to have him because he's an excellent researcher and educator. And I think his work really blurs the line between science and art. So with that, Miki, please take it away. Thank you, Chris. And hello everyone. I'm just going to share my screen now. So yeah, thank you. As Chris said, I'm an associate professor at the University of Barcelona and I also work as an anatomist of the MEPHIS group. And I would like to thank the organization and to Dr. Miller for its kind invitation to today's webinar about advanced minimally invasive surgery for the hind foot and ankle. I think it's a very, very good webinar what we're going to have today. And it's especially interesting to have it directed to the American public. Those who have been working in minimally invasive surgery for a few days, especially at MEPHIS used to present these techniques as a new thing. But I think now it's 2022 and the scientific background behind these minimally invasive or percutaneous surgeries in the foot, scientific basis is going big. We have also many, many publications in American journals supporting the use of these techniques, especially because when they are compared to the open surgery, they usually show a shortening of the post-surgical recovery also shortening of the duration of the surgery and normally a lower rate of complications that is after you climb the learning curve of these techniques, which we know it can be quite a learning curve and anatomy is behind it because we know in this minimally invasive surgery, there is no direct exposure of the structures to operate on. So this means you're gonna need three things to perform these techniques. Two of them, which are the X-ray control and how to use this X-ray control and also the specific instruments you need to perform it. This is something which cannot be taught online. Of course, you need to go to a hands-on to an instructional course, but then you have a third requirement, which is a deep anatomical knowledge because you will not be seeing the anatomy. So you won't be seeing the nerve so you can avoid it. That's mean you need to know this deep anatomical knowledge before you start to perform these techniques. So today, I'm going to show you a little bit of a mixture of anatomy of the related topics of the webinar. And I'm gonna start with the ankle. The ankle joint, of course, we all know that is formed by the taller articular surfaces, a medial comma-shaped articular surface and a triangular lateral articular surface with the vertex located plantarly. These two articular surfaces will articulate with the medial and lateral malleolus. And of course, then we have the dorsal articular surface, which is the thaladome that will articulate with the inferior epiphysis of tibia and fibula. Now, to be noticed, the anterior part of the thaladome, as you can see in this image, is wider than the posterior part. So that means that even if the thaladome and the whole talus will be embedded within the tibia-fibula mortis, the degree of inclusion of the thaladome will be different in neutral or dorsal position and in plantar flexion. So that's one of the principles for ankle arthroscopy, as Dr. Nofeld will explain later, especially when you are working in a no-distraction technique. Now, we also know that for ankle arthroscopy, before you can have an intra-articular view of the anatomy of the ankle, you need to perform your incisions and to establish your portals. Normally, we work with an anterior and anterior portal because the anterocentral portal is nowadays not so much recommended. The anterior portal is located just medial to tibia's anterior tendon in a soft spot, quite easy to locate, which will put at some risk two of the structures we can find here, which are the greater saphenous vein and the saphenous nerve. Usually, the branches of the saphenous nerve are quite small, so really the risk is minimal. And on the other hand, on the anterolateral portal, which is located just lateral to the peroneal stratum tendon, there we will have the superficial peroneal nerve, which is going to be at risk, and it's very much at risk, as it is the main cause of complications for ankle arthroscopy. And in order to decrease the amount of complications, a fourth toe sign was developed, which consists in setting up your ankle inversion and in a fourth toe flexion, which really, in most of the cases, will allow you to visualize that branch of the superficial peroneal nerve. Now, we have this study also saying that if you do the marking of the nerve on the skin during ankle inversion, you need to go back to a natural position to establish your portal. Where is the nerve gonna go with this movement? Well, we know between inversion and neutral position, the nerve will always displace laterally, and you can see this on this video. You can see the nerve here and how it displaces laterally when the ankle moves to neutral position. So if you go on the skin marking, your approach will be safe. This is quite the same. You can see in this cross-section of the ankle. You can see how we cut the thaladon just here. You can see how the anteromedial portal for ankle orthostope is located just medial to anterior tibialis nerve, tendon, sorry. You can see how the anterolateral portal is located lateral to the tendon, but medial to that superficial peroneal nerve. And you can also see how I highlight the anterior tibialis neurovascular bundle, where we will find the deep peroneal nerve and anterior tibialis artery, which is why normally the anterocentral portal is not recommended. Now, next thing you want to do is to create your anterior working area, which is possible because as you can see in this image, there is quite a large recess on the anterior ankle joint. And in this video, I can show you how I insufflate with air the anterior ankle joint capsule, and you will see how this capsule expands anteriorly, which is exactly the same that will happen with the serum when you do it on your patient. And after you have this anterior working area, the approach to arthroscopy will be different if you're using a no distraction and dose inflection approach as you can see on the left, or a distraction approach, as you can see in the right image. So as you know, the no distraction and dose inflection approach, it was made popular by Nick Van Dyke from the Amsterdam School. It's much used in Europe, in US. Normally, I think it's more used the distraction approach. We think that it is important for the evolution of ankle arthroscopy to be able at least to use both of them. And I would like just to remind this editorial commentary from Rick Farrell in 2016, where he said, okay, correct portals and distraction are the keys to success in ankle arthroscopy. We think it would be fun to reply to it. So we did. Jody Vega and me are saying, okay, we think that for ankle arthroscopy, no distraction and dose inflection technique is the key for ankle arthroscopy evolution. To which he replied, and okay, he wasn't very happy about our reply, but we still answered back saying that no distraction and dose inflection allows for advanced techniques in ankle arthroscopy. And this is mainly because if we take a look at the literature, we can see how the overall complication rate using dose inflection approach is less than half to the distraction approach. We also performed recently a study in which we compared the arthroscopic view in distraction on the left and dose inflection on the right. So it is true that with distraction, you can see more of the central compartment. You can even reach the posterior compartment, but you cannot explore the medial lateral gutters, which you can beautifully do in dose inflection. And that's why you can explore, you can diagnose, you can treat the lateral and medial ankle ligaments, which is also why we published this seven point step-by-step ankle examination, where you can see all the anatomy of the anterior compartment, including these ligaments. Interesting also to mention that we recently published this redefining anterior ankle arthroscopic anatomy, in where, in this study, what we did was to make an arthroscopic suture of the tissue on the lateral and medial side of the ankle joint, which was believed to be just ankle capsule. But with this study, we proved that both the medial and lateral ankle ligaments can be effectively sutured and repaired doing ankle arthroscopy, if you use dose inflection technique. But we already knew, because in 2013, the first ankle ligament repair using a full or a complete arthroscopic approach was published. And it is also interesting to see how this technique was described as a new technique in 2013, and how in 2021, we are already talking about how the arthroscopic treatment of ankle instability is the emerging gold standard. That means it's not the gold standard yet, but we think that is coming. And I will finish with the ankle, because it's not possible for me to cover everything, but I'd like just to highlight a few of our recent papers. We recently published a new classification of the different types of injury of ATFL's superior fascicle, which is the fascicle we find intra-articularly, which is inside the ankle joint. So four types of injuries, including ankle micro instability. Also, not so recent paper, 2018, about this new core ligament complex we found in the lateral ankle ligament complex, which is the connecting fibers between the ATFL inferior fascicle and the CFL, which we also performed a study, paying attention on the tension of these fibers to see how a CFL repair can be achieved by an ATFL repair, because these connecting fibers are pushing one ligament. Also, another publication talking about how the three ankle ligaments, ATFL, CFL, PTFL, these three lateral ligaments, they are all connected, which as you can see in this image, from ATFL superior fascicles, from ATFL inferior fascicle, CFL and PTFL, they are connecting medial intra-articular fibers between these ligaments, which you can also see in this video, where I'm pulling from different bundles of ATFL, you can see how the rest of the ankle ligaments, PTFL and CFL are moving, so these ligaments are all connected. And this is just a brief overlook to these publications, which you can find all of them in a special issue of the KESTA, which is the official journal of the ESCA, that was published in 2020, where both Joe DiBega and John Kalsman, Gino Percoso and myself were guest editors, and you can find most of these papers in this special issue. Now, if we move to the rest of the anatomy, I'm gonna talk a little bit about the calcaneus, which is probably the calcaneal osteotomy. It's one of the best indications for percutaneous surgery. You can see the size of the approach is quite different, as under the risk of complications will also be reduced. So the calcaneus, as you know, we'll articulate with the taller bone, the calcaneus is the largest bone on the foot, and you will usually find it with an upward tilt of 15 to 30 degrees. Few things to say about the lateral side of the calcaneus, which you know, it's a superficial lateral cortex, which is easy to access during surgery. Two main points of interest, one of them is the insertion site for the CFL, the calcaneal fibroligament. Also, we have the peroneal trochlea, peroneal trochlea being the point where both peroneal tendons separate. So peroneal brevis will be docile to the peroneal trochlea while it goes in the direction of the fifth metatarsal, and the peroneal longus will be planted to the peroneal trochlea, trying to reach the cuboid and torn plantar. On the medial side of the calcaneus, which we know it's a concave medial site, we have the sustentaculum tully, which creates a path for the FHL, flexor hallucis longus. You can see this in this frontal cross-section of the calcaneus where you can see here sustentaculum tully, and in the right image with the zoom, you can see sustentaculum tully, and just immediately beneath it, you can see the tendon of FHL. You can also see a muscle belly right here. You can see the posterior tibialis, neurovascular bundle, and another muscle belly here. So let's play around with this cross-section here. This, as you can see, we have a large calcaneus. This means we are on the rear foot. That's why calcaneus is so big. And we find here muscle belly, which maybe when I asked, I get a few of the response saying, this is the adductor hallucis, which is not because the muscle belly in contact with the medial cortex of the calcaneus is always the medial head of the quadratus plantae muscle. And pay attention to this neurovascular bundle. So if we move a little bit anteriorly, we are going to find that we continue to see the quadratus plantae here. We can see the neurovascular bundle, and then we can see the muscle belly of the adductor hallucis. So it's important to remember the position of this medial head of the quadratus plantae because it's in contact with the neurovascular bundle medially, but it will protect this neurovascular bundle when you perform your lateral approach to perform your calcaneus theromy, as you will to reduce your burr laterally. And when you reach the medial cortex, you don't have to worry immediately for the neurovascular bundle because you have that muscle belly, which is protecting it. And I'm gonna also divulgate a little on the morphology of the calcaneus, just to talk a little bit about the calcaneus spur, which you as orthopedic surgeons know very well. You know, it has been taught as being responsible for the plantar heel pain, but once we check the literature, we can doubt about the involvement of this plantar spur in the heel pain because we have publications saying, okay, this spur is not caused by traction of the plantar aconrosis. It is rather caused by a compressive load. Other publications are saying, okay, our findings support this spur is an adaptive response to vertical compression of the heel. And we find further publications going beyond that and saying this spur might be an skeletal response to protect the calcaneus against the development of micro fractures. And this together to the fact, this calcaneus spur can be found in up to 90% of asymptomatic volunteers, probably make us think that it's not so bad to have a spur. Maybe it is okay because we have these publications or maybe that is, you need to think of this before resecting that spur because it's possible that it is not the origin of the patient's pain. Now, if we go back to the percutaneous calcaneal osteotomy, where you are performing a lateral incision, which will put at risk the sural nerve and in a minor degree, the lesser sphenous vein. Let's just quickly remember to finish my presentation that the sural nerve is normally found and it's normally originated between the both heads of the gastrocnemius muscle coming from one branch of the tibial nerve and one branch from the colon peroneal nerve. That's where the sural nerve is formed. From there, it will descend to the lateral retromodular space where we will find this sural nerve as giving some several lateral calcaneal branches all over the lateral border of the foot as well. And we will have normally two terminal branches for the fifth and fourth toe. Of course, if you ask me, I would say this sural nerve is in much high risk during the performance of an open calcaneal osteotomy than if you perform a percutaneous approach. Also, our surgeons tend to ask whether there is a safe zone for these lateral approaches to the calcaneus. We have two papers here, but the one I like the most is this one, which says, surgical approaches to the calcaneus and the sural nerve, there is no safe zone. So it's quite a clear message. The anatomical variations of the sural nerve are so many that it is not possible to describe a safe zone. Just keep your approach to minimal and that will be safer for the patient. And finally, if you decide to go for a medial approach for this calcaneal osteotomy, you can also do it. Normally you would think, okay, this puts at risk the tibial nerve and the medial calcaneal branches, which is if we very quickly describe the anatomy, you know, on the medial side, you have the flexor adenaculum, which if we open, we can see this tibial nerve with several of the medial calcaneal branches. Then we have this tibial nerve, which will divide on a medial plantar nerve, on a lateral plantar nerve. And you can see here off the right, how we have a branch, which is branching off this lateral plantar nerve. This is the inferior calcaneal nerve or Baxter nerve, which you can better see here, how it branches off from the tibial nerve and it will direct to the lateral side of the foot to reach the abductor digiti minima. So as you can see, if we compare the incision and the distribution of the nerve, it should be safe also to perform this medial portal. And with this, I finished my presentation. I know it was quite a lot of information in a short time, but I would also like to let you know that we will have a course in Washington, DC in November 11th and 12th this year. You can see we have a tremendous faculty team with us. The course will be directed by Dr. Rebecca Serrato and Dr. Stephen Neufeld, which is another one of the speakers today. And I welcome you to visit us at myfas.org. And with this, I thank you for your attention and I give the floor back to our moderator, Dr. Miller. Thanks, Miki. Amazing talks and really impressive dissections there. I've always just in awe of the work you're doing there. But moving on, I'll have some questions at the end if possible, but to Dr. Lorena Bejarano-Pineda. So she's our newest foot and ankle colleague in the Boston area, fellowship trained in sports and foot and ankle, and then International MIS Fellowship with Dr. Renwell, another one of the speakers today. So she's now at MGH in Boston and doing some really great work over there. So Lorena, the floor is all yours. Thank you, Chris, for the invitation. I'm very excited to be here with all the panelists. Very excited to see some of my mentors here. Let's just start here. Let me share my screen. Of course, this talk is not gonna be as pretty as Miki's talk. I don't have those beautiful dissections that he has, so I'll do my best. So we're gonna talk about minimally invasive techniques for a cavivirus food and beyond the cow's life. So that's totally prohibited for this talk. I don't have disclosures relevant to this talk. The agenda for the talk will be introduction, talking a little bit about algorithms for treatment, mention some of the substantial procedures that are mentioned to be doing percutaneously or minimally invasive, and then finally talking a little bit about arthrodesis. So the true prevalence of cavivirus food is unknown, but it's concerned that about one fifth of the population can have at some point some cavivirus deformity, and that includes the pediatric population. Back in the days, maybe in the 50s, 60s, we believe this was more prevalent with patients having sequela from poliomyelitis, and now it's still present, but it's not as strong as it was before. We definitely know that a high proportion of these patients have some type of neuromuscular disease, and we have found that about 78% of patients that have a lot of cavivirus food deformity have some degree of Charcot-Marie-Tooth disease. It's also prevalent in patients with diabetic elitist, where about up to 25% of those have some sort of cavivirus deformity. When we talk about prognosis, it's a combination of factors that can affect this, and mainly age of presentation, the severity of the deformity, flexible versus rigid, and the underlying pathology. In those patients with having an underlying neuropathy or tend to be more severe, and those with idiopathic that include subtle cavivirus deformity, or patients with rheumatoid arthritis have some degree of deformity, but they tend to be more flexible. And we lastly have patients with post-traumatic cavivirus deformity as well. What we know for sure is that has a wide spectrum deformity is a challenging problem, and often is under-corrected. There are studies that have shown that up to 60% of patients with surgery for cavivirus deformity are under-corrected when they look at the axial alignment and the alignment in CT scans. So when we talk about treatment, we can divide this into types of deformity, and of course it is flexible or rigid. So when we talk about flexible deformity, we talk about mild, moderate, and rigid. And when we talk about mild, usually we approach these with the calcineal astatomy as the main body procedure to correct the height of the deformity. And we do some soft tissue procedures as plantar fascia release and transfer the peroneal longus to the pelvis. The first metatarsal astatomy is performed at the end or after we correct the height of the deformity and is done in the majority of the patients. However, there are some authors that argue that doing the first metatarsal astatomy for dorsiflexion is not addressing the epics of the deformity. And when we started going through more severe cases that we go through moderate and rigid, they advocate that addressing the deformity in the midfoot on the epics of the deformity that is usually at the TNT joints or even at the navicular or talopuniform joint, talonavicular joint, will achieve a better correction. So when we're talking about moderate deformities, we usually address more the midfoot, and even we can consider the first metatarsal astatomy thinking about tarsal metatarsal astatomies or a closed-in wedge astatomy of the midfoot can again, a better correction. Now, when we talk about the severe of the spectrum that we're talking about rigid deformity, triple arthrodesis will be the best approach to correct the height of the deformity and we will address the midfoot and the forefoot deformity after. So in terms of flexible deformities, the first thing that we had that has been described for over probably two decades now is a plantar fascia relief that can be done endoscopically. As we see here, usually it's preferred doing two small incisions at about one centimeter each, and this is being commonly described. We can use an arthroscope to support and to verify and visualize our release of the plantar fascia. When we talk about patients with calvar deformity, the recommendation is to do a complete release of the plantar fascia. Benefits of this can be gain a major displacement when we're doing the calcineal astatomy. And when we're doing a correction, the midfoot with the plantar flexed first ray, we can gain more elevation if we do this plantar fascia release. However, the recommendation is not to do it by itself or isolate it. And it will also always have to be done and or simultaneously with other type of corrections, mainly calcineal astatomy and metatarsal dorsiflexion astatomy of the first ray. Then we will have the lateralizing calcineal astatomy that I'm not allowed to talk in this talk. So I will defer that for later discussion. And then we talk about tendons transfers. There's not much about percutaneous tendons transfers for calvar deformity in the literature or not that I'm aware of. There is some description in terms of what we can do mini open or minimally invasive. And this is an article that talks about how we can address these patients. And this usually are teenagers when the deformity is very mild or less severe but the deformity is totally flexible and does not affect any of the forefoot in terms of there's no development of bowel deformities. And this is mainly to prevent that deformity and address those deforming forces that these type of patients are gonna end up because of the imbalance caused by the disease. So as we can see here in the first image, the C represents the incision for posterior lungus transfer to the posterior prebis tendon. And now we can see here on the dorsum of the foot, the incision that corresponds to the letter D. It's mainly to do a hip tendon transfer which is mainly transferred the EDL to the lateral acune form to increase that power for dorsiflexion. Try to avoid that weakness that eventually pedialis anterior tendon develops. I can argue here in this technique that surgeon with a level of expertise for percutaneous surgery can be done the release of the tendons distally by percutaneous technique and avoid those incisions over the dorsum of the forefoot. Results of these type of technique, it is only a few case reports and they talk about mainly how these can decrease or delayed more biggest or salvage procedures as a triple arthrodosis or the development of severe deformity. These patients technically, when they compare, they have some patients that have these type of surgery in one foot and in the other one, they just didn't have it and they delay surgical procedures in terms of salvage procedures for up to 10 years. Now, when we talk about a rigid deformity which is encountered in many cases with these patients, we have the indications for triple arthrodosis percutaneously and the indications for these are usually mild to moderate deformity. It's ideal for patients with significant comorbidities and remember that these technique allow us to treat patients with arterial problems, diabetes or with some sort of immunodeficiency that we have a high risk of potential complications mainly when complications are infection and finally, those patients that have a previous procedure that might entail skin problems or very thin skin that we also worry about big incisions. Contraindications for this technique, severe bone loss that requires bone graft. Also, if the patient has previous surgery that requires hardware removal, it will be another contraindication for this technique and two relative contraindications for this technique is severe fixed deformity. We can argue that it's totally correlated to the level of expertise of the surgeon. So, the recommendation is to start with mild to moderate cases and by the time that you achieve better corrections and you feel confident about it, you can address severe deformities with this technique as well. Preoperative planning is important even in open procedures but I believe in percutaneous procedures it's significantly more important because you won't be able to appreciate a lot of the things that you will be doing there because of the percutaneous technique itself. So, when you're addressing these patients in the preoperative planning, make sure you address if they have a good bone quality or if you are facing a patient with bone loss, the degree of the deformity to estimate the amount of correction that you need and if the deformity is reducible or not. When I have these type of patients, my workup plan usually includes with varying x-rays of the ankle, of the foot. We can use the Salton's view. I'm a little bit spoiled where I am. So, I use a with varying CT to calculate my amount of deformity. And finally, if we don't have a with varying CT, I recommend having a standard CT mainly to address or to assess any sort of bone loss or bone quality. When we talk about a patient position in semilateral or what we call a slopilateral, as we can see here, this is a procedure that I feel confident doing. I mean, it's CR, but there are people that feel more confident using the big C-arm as we can see in this picture and has been described in a few articles. The foot should be always at the end of the bed. So, we keep the same principle for minimally invasive surgery. Some people use thigh tourniquet, but you can just place it without inflate it. And again, I think this is a technique that can be done with the mini C-arm and avoid exposure to big radiation with the standard C-arm. So, usually we start with a sutular arthrodesis. We can, there are people that only do one portal on the anterolateral portal, which is similar to the portal that has been described for arthroscopic arthrodesis of the sutular joint through the anterolateral approach. We do an incision of about five millimeters at the sinus tarsae. The lumbars are usually keeping the fibula. We go one centimeter distal and 1.5 centimeters anteriorly. And we do a dissection of the tissue and then with the vertebrae, as we can see in some of the pictures here. We can also, and I think it's very useful to use a post-anterolateral approach, but we have to be aware that the only caveat of using this portal is that we have a risk of injuring the surrounding. So, to do the post-anterolateral portal or approach, we made longitudinal incision about one centimeter above the tip of the fibula, between the border of the posterior fibula and the Achilles tendon, trying to be more towards the lateral border of the Achilles tendon. We separate the tissues with a hemostat and then we put our birth. And this will allow us to remove bone of the posterior facet even better. The main reason of this is always to have an asymmetric surface preparation. Usually we tend to remove more bone laterally than medially. In this case, we can use that on our benefit, but if we're using this type of technique to create a post-plantal deformity, that totally can harm our results. In terms of, we usually use a wedge birth, but I have found that if we start with a shining birth to open a little bit that space and then change the wedge birth, the procedure goes easier and faster because you slowly open that space between the subdullar joint. The calcaneous-cuboid arteriosclerosis probably is the easiest to approach, just a simple one internalization at the level of the C-C joint. When we use, we can even go through the same sinusoidal approach. We will have to remove that spike or like that little portion of the anterior process of the calcaneus, and then we immediately fall into the C-C joint. I find that it's much easier to do a small incision laterally on the hind foot at the level of the C-C joint, and we just remove the bone there. One thing with this joint is that it's a high risk of excessive bone resection, given the soft kind of the bone here, even the calcaneus and the cuboid are very soft bones. So we tend to create a lot of resection and that can shorten the lateral column and eventually can cause an abduction in the mid foot. And finally, the tonic-lavicular arthritis is probably the most challenging one, given the shape of the joint itself. So the portal that has been described, as we can see here, a medial portal, which is just medial to the tibialis anterior tendon, and we can access the joint. We can also, and I think it's very useful to you, a more dorsal approach that is done between the tibialis anterior tendon and the ES shell. We usually locate the portal, we have to do the incision is slightly bigger, two separate features here, and then we go into the joint. When we use this portal, and the recommendation is to avoid medial column shortening, is we go and we place the vertebrae from plantar lateral to dorsal medial, and almost like a windshield movement to avoid and to go like around the shape of the talus neck. Probably a lot of fluoroscopy in this part of the procedure, because we don't want to short the medial column. Some people use a medial accessory portal, which is then just above the posterior tibialis tendon, in case you want to achieve a better resection of your cartilage or you have some doubts on the plantar aspect. Fixations that we can see here, usually a disabled joint can use one or two screws, and the calcaneic tubule joint usually with one cantilever screw is sufficient. And for the talon vicular joint, we usually use one or two screws. The one of the screws is probably different than the open approaches, but we can see here, we use that incision that we used to do the posterior lateral approach of the sutular joint. So we use the same, exactly the same portal, but we just direct the K wire from the neck of the, sorry, from the body of the talus posteriorly towards the navicular, so we can see in these pictures. I feel that screw provides a very good construct for the fixation, besides the typical retrograde screw that we use from the navicular to the talus talon. For the bariatric protocol, usually the recommendation is in a wet bearing for six weeks, so you can place the patient in a boot or in a cast, and progressive wet bearing start in a boot in about week six. So the recovery of the patients and the possibility of putting a wet bearing definitely increases or is shorter when we do the percutaneous techniques. If you follow this technique, please check for a flare areas in any of the images that you have done before to anticipate where the use of the burr will be more difficult during your resection of the bone. The risk of asymmetric surface preparation, especially over the lateral aspect of the sutular joint, excessive bone resection of the calcaneus joint because of the quality of the bone, or insufficient joint preparation that something can be happened mainly in the talon navicular joint, given the shape. Preliminary results of this technique, as any other minimally invasive technique, decreased postpartum pain, decreased hospital stay, or even patients can go home the same day, less wound complications, lower rate of infection. Some authors mentioned that it's less repetitive time in consuming compared to otoscopic techniques. I think this might be the case for a surgeon that has a lot of experience with percutaneous techniques, but initially I will say it's the same as consuming as any otoscopic technique. Joel can argue that definitely not, but in my level of experience, I think it will be very similar. Unfortunately, no much bullish in terms of Calvary's results, but I decided to brought this paper because even if they're addressing, or they're looking at the results in patients with flat foot deformity, they did a minimally invasive technique with percutaneous double arthrodesis. As we can see here in terms of what this paper can provide value for this talk is that the non-union rate is about 10%, which is very similar to the rates of open techniques, no wound complications, no major AVN of the talus in 67 cases, significant improvement in terms of patient clinical outcomes. The office score went up to a 27 to 81. And mainly we can see here in this table, the amount of correction, and we can see how we were able to correct in every single angle that we measure, we're having significant correction of the deformity. So deformity is a technique that can offer correction of the deformity, something that we can also see if we do this in calvary deformity, we just need a little bit more time to see these results published. This is one of the cases that I did while I was a fellow with Joel, and this is a 78 year old female with a history of amyloidular ankle fracture back in the 90s. She presented with severe pain over the left ankle and foot for the last four or five years, and the patient ultimately needed a cane for ambulation. As we can see here in the picture, the calvary deformity, and a little bit on the corners, it was fairly rigid with subluxation in the midst of it that was not reductible. And we can see here some of her playing films. And these are some of the images from her CT. As we can see here, almost complete luxation of the thalamicular joint with also severe subluxation in the subthalar joint as well. So as we have described, so these are some of the pictures that are how we approach this case. Patient was in lateral decubitus, as we can see in the first picture, and this is how we address the deformity. So we start correcting the midfoot deformity, and Joel decided to take a huge wedge from the midfoot, and we can see here these K wires were placed to guide the amount of restriction that we were going to take in the midfoot. We were to take a big opening wedge immediately, as we can see here, to correct that deformity. And what we did is we placed the K wires, and finally we started with a Shannon Burr. Remember, when we're doing these procedures, because we are not able to appreciate sometimes what we're doing because it's percutaneously, we should be very methodical with our Burrs. So we usually start at one edge of the two K wires. We start with a Shannon Burr to open a little bit of space, and then we switch to the wedge Burr, and we remove the entire big wedge to correct the deformity. And then, as we can see here in the next picture, we move our attention to the subthalar joint. We start with, Joel started with the posterior lateral portal first. He addressed the posterior facet of the subthalar joint, and then he used a sinusoidal approach to totally finish the subthalar joint resection. And we started with the fixation of the calcaneal fluid joint first, and then subsequently with the talonomicular joint, and finally with the subthalar joint. This is some of the pictures of the patient six months after surgery, but the fusions are almost healed. So the patient was one of the screws at the back of the heels, we can see in the image while bothering her. So those were, she was taking back the work to remove those screws from the back. The patient is ambulating in a booth. Sometimes she feels a little bit of instability, and she's walking. She doesn't need a cane anymore. So in conclusion, there is not much out there in terms of deformities besides the calcite, but I think we have been seeing results with percutaneous arthrodesis, including triple and subthalar joint, and we can use this, especially in those patients that have a high risk of complications related to wound and infection. Advantages of minimally invasive techniques are across all segments of the foot and only to the forefoot that is how we start using these techniques. We have less pain, less wound complications, faster recovery, patients tend to wait on it significantly faster compared to an open technique. We need to be cautious and avoid excessive over-section during these percutaneous techniques. Always keeping in mind the degree of the correction and what are the deforming forces that we're addressing. I start with mild to moderate deformities and then go big, as Joel, for big deformities, but after a few years of doing this. Even the state of rigid deformities, I think considering doing some combination of soft tissue procedures to compensate for those joints that are not being infused, something that we all consider, especially for patients with neuropathy, as Charcot-Marie-Tooth, so something that we can address some part of the deformity, but eventually the deficit that this patient had in terms of muscular function is gonna end up having a recurrence or increased pain affecting other joints. This is something very personal that I have seen that I think I always try to do two screws for a fixation of the talon vicular joint because when we see the results for triple arthropodesis, percutaneously or open, the joint that has a higher rate of nonunion are the talon vicular joint. So in my personal opinion, always try to use two screws for fixation. Thank you. Thanks, Lorena. Great talk. Next up, we have Dr. Steve Neufeld. He's hailing from outside Washington, D.C. He's the fellowship director at the Orthopedic Foot and Ankle Center in Washington, and he'll be one of the co-chairs for the upcoming MIFAS course in D.C. in November. So he'll be talking about hindfoot and ankle fusions. So Steve, why don't you take it away? Great, thanks a lot, Chris. I appreciate the invitation. Oh, let's see if we got a clear share. All right, can you guys hear me? Yep, perfect. Awesome, well, good. Thank you for the invitation. I'll start off by saying that I have been in practice now for over two decades. And when I learned from Joelle and Redford and all the guys over in Europe about minimally invasive techniques about four or five years ago, it has completely revolutionized my practice. And my practice now is completely different than it ever has been and ever I was trained. And I would encourage anybody who's watching this webinar to hopefully get inspired by our talks and attend courses and really get into it because it's really a terrific thing. My disclosures, I do some consulting work with some of the companies that make some MIS stuff. And again, I am the course chairman for the U.S. MIFAS division. So let's sort of cruise through these beginning slides. Ankle fusion indications are for malalignment and arthritis, infections, TTC fusions, especially for severe deformities, infections in the subtalar joint. We use external fixators, we use cement spacers, and eventually when the joint is destroyed, they need to be fused. In certain cases of Charcot, that is non-plantigrade feet fusions, either TTC mid-foots or ankle fusions are necessary, either using external fixation or internal fixation, depending on the case. And TTC fusions are indicated in terms of bone loss where replacements can be used, avascular necrosis. It's difficult to get in growth into replacements, neuromuscular problems, and when there's subtalar and tibiotalar involvement, in certain cases, we would do a TTC fusion as well. So the goals of any fusions, whether it's high foot, mid foot, or forefoot in general are removing the cartilage, penetrate the subchondral bone to get a bleeding surface, reducing the joints, reducing the deformity, adding biologics or bone graft if necessary, holding that ankle or subtalar joint in neutral position, obtaining provisional fixation, whether you use the wires from the cannulated screws, which you'll then replace with screws, or if you're gonna use an IM nail for a TTC fusion, you could use guide pins to reduce and hold your correction in that point, or just use 62K wires. But the key is really to get provisional fixation first, then check your fixation and finally put in your screws. This is a tried and true technique for your ankle fusion screws. If you're gonna use percutaneous techniques, the number one screw I tend to put in is, we call it a home run screw, I learned in fellowship. It goes from the back of the tibia down into the tailor neck and the tailor head. And if you can get this screw in first, it's very, very secure and you're gonna feel very good about your fixation. I find if I can get the screw in a good position, I've had very few problems in terms of healing. It's a nice rigid screw. And then you can use your second screw from the medial aspect of the tibia into the tailors and finally a third screw from the lateral aspect as well. I've done it with two screws, but I think three screws is great for rotation and for compression. These are partially threaded screws as well. The optimal position of an ankle fusion, typically it's neutral dorsiflexion plantar flexion, a combination of roughly zero to five degrees of valgus between the hind foot and the ankle. You wanna compare your rotation to the other side and try to be symmetric if possible and a slight posterior displacement to help with the angle of the moment arm. So this would be an ideal position for ankle fusion. So why do we do, why are we even having this discussion? All of us have done ankle and TTC fusions for many years. And really it comes down to this picture right over here. We wanna reduce our wound complication rate. When I started with MIS surgery in the forefoot and in the midfoot, I was shocked about my complication rate. It dramatically went down. And now as I'm moving towards the hind foot and the ankle, I'm finding the same exact thing. You have reduced swelling, you have less pain, you have faster healing. This is just an angiogram of an ankle and you'll see the blood supply. Well, if you'd imagine when you open up the ankle and you do an incision on the right, you're really stripping a lot of this blood flow. You're stripping the periosteum. And in cases that are high risk, especially where the blood supply is disrupted or is compromised, then you're really asking for trouble when you have a big incision like this. So we really, the whole reason why I have this talk is you wanna avoid this slide right over here. If you never see this picture in your practice, you'll be a very happy surgeon through 20 years of practice. So that's why we're talking this talk here. MIS fusion techniques, the way when I started thinking about this, well, we were taught to use burrs and in most cases we can use burrs, but there's three different approaches. You can look at mini arthrotomies. And I would suggest when you start MIS techniques for the hind foot and the ankle, to start with the mini arthrotomy technique. Arthroscopic, I think is extremely valuable and a very, very useful way to do these techniques. As we saw previously, the subtalar joint can be fused through a scope as well as the ankle. And then finally, when you get to a much better skills level and you're comfortable with a burr and you're comfortable with the anatomy, then you can even do these percutaneously without a scope. There are MIS specific burrs. There are large joint shivers that we need to use. And for open cases or mini arthrotomy cases, you can use a regular burr as well. Let's start with the mini arthrotomy technique. And this is just an extension of an arthroscopy technique as we were instructed a few minutes ago. But you just extend your arthroscopy incision. So there's two incisions, roughly two centimeters. Through these small incisions, believe it or not, you can have excellent exposure. You use things like laminate spreaders to hold open your joint. And through these small incisions, it's very little soft tissue stripping. There were results all the way back to the 90s with Meyerson that showed good results after this technique with ankle fusion. So the days of making large anterior incisions or large lateral incisions, which is how I was taught, are really unnecessary with this technique as well. So again, the idea is you make these small incisions. You work from both sides, medium laterally, using fluoroscopy or using either an MIS burr or a standard round burr. Small chisels, small osteotomes, you want to wash out the joint. And you can really achieve the same results, if not better, through these small incisions without actually visualizing it through an open technique. Here's a case of a seven-year-old diabetic male with significant neuropathy. He had an ankle fracture, shows up six years after his injury. At his baseline, he had limited mobility. So this would be a perfect case for a fusion as opposed to an RAF or a ankle replacement, especially since his skin was poor. It was swollen. He was deformed. He was not plantigrade. He did have pulses, but he had delayed CAP refill. So this should raise all kinds of red flags. If you're going to make a large anterior incision and try to fuse it, or a large lateral incision where you're trying to approach the joint, you will potentially run into some troubles with wound problems. And this is a great patient-to-MIS approach. So in this case, we did a mini arthrotomy, made a small lateral incision, made a small medial incision. Oops, let me go back. In this case, we used a standard large burr and a drill to debris the joint, packed with some bone graft, and did our standard fixation through the small little incisions. Aligning it in the sessatum coronal plane is fairly straightforward. We used provisional fixation and put some screws. In this case, we did a TTC fusion on this patient. So again, through mini arthrotomy incisions, and it's fine. There's their incisions, very, very small little tiny incisions, and luckily we had no wound problems. Now, once you become comfortable with the mini arthrotomy technique, you can move toward the arthroscopic technique. And I would advocate for this technique for most everybody at this point. This is very, we're all comfortable doing, we're doing scopes. This has been described a while ago in the 1980s. Lots of literature to support high fusion rates. Infection rates are lower than with open techniques. It's relatively easy to perform, and has a relatively rapid rate of arthrodesis. You use the arthroscope and the burrs to remove the cartilage, but you use the fluoroscopy to assist in the screw fixation. And I would say in the last probably 10 years or so, I've gone primarily to just arthroscopic ankle fusions. I find the results are much, much better. Mickey did a nice job of talking about using a distractor or a non-distractor. I would say if you're going to try to get to the back of the joint for a fusion, a distractor is a very helpful thing to have. I position them on a thigh holder. We tend to use pumps to keep the fluid flowing. I tend to use larger instruments like a 4-0 scope as opposed to a 2-7 scope. And you can either use MIS burrs or standard burrs. And this is a typical setup of what it looks like. The reason I like it up on the thigh holder is because sometimes you need to make a posterolateral portal, either for washing out the joint or to get into the back of the joint. But typically in a position like this with distraction and plantar flexion, you could really reach the entire joint through those anterior portals. The advantages of this technique is that there is much, much less reduced morbidity. You have two small little incisions and a few percutaneous little incisions for your screws. You can put that home run screw from the back, as I showed you in the earlier slides, once the joint's debrided, you have access to it with the leg hanging up in the air. Better cosmesis, and I do believe there's much less complication rates. And this video is just using a standard knee shaver, aggressive full radius shaver, and it just takes away all the cartilage very, very nicely. You can do the surgery relatively quickly at bleeding surfaces without disrupting all the blood flow and have very fast low complication rates. Here's an example of one of our patients in the office, 65-year-old who had a hunting accident. As you can see, his skin is in poor condition. His bone was shattered. He presented years later with post-traumatic ankle arthritis. This is a perfect case to do an arthroscopic or minimally invasive approach to effusion. In this case, you can also make accessory portals. You can do a small portal inferior to the lateral malleolus, one inferior to the medial malleolus, where you can get to the gutters. Sometimes in these post-traumatic cases, the ankles are very stiff and it's difficult to get into the gutters. And this is a nice little technique to help with that as well. Here's an example of intra-op. You can see that this joint on the left is pre-debriment. It's really pretty much destroyed. This is using a large MIS side-cutting burr, and I penetrate the surface with an awl and with a drill hole, and you achieve a nice result in six weeks with no skin complications, no wound complications, very satisfactory, happy result. Let's look at another case, number three. This is an avascular necrosis in a pro-snowmobile patient snowmobiler. The approach was an MIS minimally invasive fusion using a scope. This time, you scope the ankle and the subtalar joint because you have an avascular talus. You're trying to get bleeding surfaces. We all know the blood supply to the talus is as tenuous as it is. So if you're stripping the soft tissues to get to an open approach, you're gonna compromise whatever soft tissue, whatever blood supply there is anyway. So an arthroscopic or minimally invasive approach is really an ideal way to approach this. There are studies that have a nice series of these as well. This patient by six weeks had a full fusion with no pain and he was full weight-bearing and had a good result through vascularization of his talus. Here's his incision. As you can see, there's no wound problems. There's no complications, a very good result using small minimally invasive techniques. Let's go on to case four, more challenging. The 61-year-old type two diabetic with neuropathy. As you can tell, this is a challenging case. Chronic atraumatic ankle deformity, non-healing lateral foot ulcers. He's already undergone a partial fifth-ray resection and this was done using MIS techniques without the scope. So using a burr, the surgeon removed the lateral malleolus, removed the medial malleolus percutaneously, which allowed reduction of the joints. Used an MIS burr to prepare the joints, as you can see, through different approaches. As we talked about how to approach the subtalar joint, it's how to approach the ankle joint. And then once the joints are prepared, they're aligned just like they would be opened, provisionally fixed them, and this was fixed with a TTC now. Again, very nice technique with minimal soft tissue and blood supply corrections, getting yourself a nice approach and a nice result. So in summary, MIS ankle and TTC fusions are safe. They are effective. I think there are three approaches and it's depending on the surgeon's techniques that he's preferred, he or she prefers, and your learning curve. You can start with a mini arthrodomy technique, small incisions, move to an arthroscopic technique, and in some cases you can actually do it just using MIS burrs as well. Large deformities can be corrected as your skill level gets better. And with practice, joint preparation is equivalent or better than open. Dr. Miller, our moderator, just had a paper that came out this past month in FAI. I would encourage everybody to read that. And he showed very clearly that MIS agreements are just as effective as opened agreements. So this can be done. And even rigid deformities can be corrected with MIS only techniques. As we talked about, there are soft tissue constraints that may need to be released, but they can be done fairly effectively as well. Tips to avoid complications, in my opinion, get experience in open surgery. So really understand your anatomy, review Mickey's lecture, know where the safe zones are. Please make sure you stay away from the nerves and the arteries. I would recommend training in a cadaver lab or at various courses. The companies now have low speed, high torque burrs. I would use irrigation or sometimes no tourniquets at all. So that keeps your burrs cool. You don't want to burn the bone and that will lead to problems. And obviously this is very dependent on a C-arm. I use mini C-arms whenever possible. Full C-arms are good as well. So thanks everybody. I would acknowledge these contributors for their cases, Dr. Patrick McGill Miller and Dr. Younger. So thank you, Chris. Thanks so much, Dave. Great talk. So our last panelist is Dr. Joël Renoir from Paris. And he's, you know, I'm really looking forward to this talk. He's a surgical innovator and one of the real driving forces in the world for MIS and a past president of MIFAS by Gretmich. So thank you for joining, Joël. It's always a pleasure to hear you talk about this and your passion really comes through. So I think Charcot cases are some of the toughest cases we deal with. I'm really looking forward to learn what we should be doing about it. So thank you so much. Thank you. Okay. Thank you very much for the invitation. And I'm following my friend and colleague about their topics. MIS Charcot foot is exactly the same. We are looking to perform something better with less complication. That's my disclosure. Right medical and extremity medical. First, talk about the Charcot. You know probably better the Charcot than us in France. Even if it's a French guy that will describe the Charcot with the syphilis. The Charcot foot deformity diabetics become more and more important today. And we are looking at this patient more and more often. According to Sander, Charcot foot principal localization are the least from the Chopard. We are not surprised as it is where the constraint are the most important. We have problem on you all talk about this problem before. Vascular problem, healing, infection. When the deformity is not too important a medical treatment can be enough. But when the deformity is responsible of complication the treatment is surgical. And then the complication. Whatever is used external fixator or internal fixator, fixation. The correction requires two or three extensive approach. This approach can be responsible of complication. My colleagues talk about this earlier and that's all our concern. The complication with our surgery. Can we do surgery if there is high risk of complication? Such as necrotic evolution which is a perfect situation to develop a sepsis. But can it be simple? How to have a local problem? How to manage with previous surgery without doing an extensive approach? I say yes. And my colleagues show it already with percutaneous surgery and the use of birth. Why? Because of a long experience of incredible bone remodeling with percutaneous technique. And because we have techniques to obtain reproductible osteotomy. I have only an elective practice. That is why the Charcot fit I see in my clinic looks typically like this one. The complaint of the patient is mainly a plantar is mainly plantar with a null cell tried for a few months locally but also some lateral impeachment. Here, the deformity is complex and an isolated shaving of the spur would be useless. The correction must be global. Sometimes a simple exhaustive ectomy can be done in simple case. Here, with a medial open approach, personally, it would be percutaneously. Like in this case, a 75-year-old patient whose only complaint is a painful plantar ulcer secondary to this large plantar spur. The complex reconstruction was a bad idea. And I decided just to shave this plantar spur with a simple wedge spur. If we go back to this initial case, we have to correct it. We need to reduce the luxation and to create an arch. The plan is simple. We need to perform a complete osteotomy of the midfoot followed by a plantar closing wedge osteotomy. So it is a 3D correction. It is a 3D correction. If we want to avoid local complication, we must minimize our scar. So that's a percutaneous approach. We must minimize the blood flow, the decrease of the blood flow. How? No tonicane. We must minimize the blood loss with safe zone and a high-level technique. And last, we need to shorten our operating time while we optimize the correction. For that, percutaneous surgery is the key. Thanks to the use of the burr, with variable diameter and length. The fixation is then performed with large tools. I like to come from posterior because of arthroscopy, but whatever you use, anterior-posterior approach is fine. Here, it's one of my first cases. Now, I fuse systematically the subtoner joint. I want to make you thinking about this osteotomy and to look at your feet and think, can I do it percutaneously? What can I do? How can I do it? It's not so simple. First, which kind of osteotomy do you need to do? Well, you have to do it because of the fixation. I want it precise. I want it reproductible. How to do it and how to fix it? If you can answer it today, let's start. If not, I recommend to come to some course. The first course we've done on high-foot, mid-foot was in 2015. That was the second one. And let's take a simple case. And I want to show you how to manage with this really simple case of deformity. Fixed deformity here with a valgus on a collapse of the heart. There's many way to think of it. First, okay, you now have to recreate the heart. So a plantar closing wedge. With this valgus, you may be able to do an open wedge osteotomy. Or you can decide to do a medial closing wedge osteotomy. I prefer this technique as I can control and fix it immediately. The lateral opening wedge can be used with external fixator, like my friend Harry Aran, for progressive correction. Now, how to do the exact wedge? To perform a complex osteotomy free-hand is difficult. And your learning curve will be too long. The key is to position two K-lines, which will determine your wedge. Then, with a small dorsal approach, so usually you use two, one medial, one lateral approach of five millimeter. Always use a clip to disease the soft tissue before you put your burr in. And you have to know, as soon as your burr, the cutting part is in the bone, you can't damage anything. So you just introduce your burr, and you push your burr against one of the K-lines. I like to start with a long channel of 20 by three millimeter that allow me to do my first cut. And it's a rotation. Then you can rotate and move it to the other K-line, and follow, with a rotation, your K-line and perform your wedge osteotomy. When you arrive on the lateral side, your burr is locked by the two K-lines. And if you want to finish your osteotomy completely, you need to remove one of the K-lines. Usually, as soon as your osteotomy is done, the K-line can be pulled out easily by hand. The position of your two horizontal K-lines will determine your plantar wedge. On this picture, I put my two K-lines in the middle of the burr. That, at this level, determines a plantar wedge. But if you put your K-line more dorsally, the plantar wedge will be bigger. So when you put your K-line, it's not, I just put two K-lines with an AP view. You have to think of the lateral view, because this lateral view will determine the size of your wedge. When you have obtained the wedge, it will be able to simply close it. Because you keep the soft tissue intact, the correction dictated by your 3D osteotomy will be easy to obtain. Last, the fixation, after preparation, of course, of the subtalar joint with the burr, like Lorena or Steven showed to you. I like the Parisian approach, retromalleolar, lateral retromalleolar, and the sinus dorsal. By this way, I can shave all the subtalar joints. I always start with the calcaneocuboid joint, and then the talon avicular, if I need it, and the subtalar joint. There is not a lot of paper. A few years ago, I went to work, after I developed this technique, with Rose Miller in Glasgow to help her with lots of charcoal foods. The result is this paper she published a few years ago. Whatever is the deformity, and my colleague showed it to you today, the challenge is the same. You have a 3D correction to do. The KY, or the position of your KY, will be the good choice, and that will help you to obtain the perfect correction. For a long-term result, for me, the key is the fusion of the subtalar joint in the charcoal food. To conclude, perkinose surgery with the use of specific burr allows us to treat charcoal feet while we are reducing the risk of classic open approach. Thanks, Joel, so much for joining. That was awesome. I think just listening to you talk about all that is, it's amazing what you're able to do with just, you know, it's like you and your burr, and you just go to town on that stuff, but I'm just always in awe of seeing your cases and how easy you make it look. We all know that it's not easy. So with that, I think we'll wrap up this session. I'm going to turn it over to my colleague, we'll wrap up this session. Thank you again, and I'm really looking forward to more talks in the future. Thanks, yes, of course.

minimally invasive foot and ankle surgery

ankle arthroscopy

calcaneal osteotomy

ankle ligament repair

cavus varus foot deformity

plantar fascia release

percutaneous triple arthrodesis

preoperative planning

medial accessory portals

recovery protocols

Charcot foot deformities