Welcome to everybody on the webinar. It's an honor for us to be here. The collaboration between the British and American Foot and Ankle Society has been fun and growing. I think our virtual world has allowed it to expand and I hope it continues and that we see each other in person too. So this is just a really exciting endeavor for us to put together and it's even more exciting for me because in a way that for me this is getting my old gang back together. Two people that meant a lot to me and of course Callum who's put his talk together that we're going to hear first. I know a lot of the British members are going to have to join probably later because it's in the middle of the night but I hope you guys have a chance to see the webinar and learn a lot too. Caesar and Jonathan have kind of been my go-to colleagues. Jonathan's been my mentor for years and Caesar in a way you're my own mini mentor too. We've done so much and learned so much together and the point of tonight really is not to talk about everything we've learned about PCFD as we're now calling it but some of the newer techniques that we think will help and drive us forward and some of the new technology. So Callum is going to start. We're going to play his talk which is pre-recorded on using arthroresis technique in collapsing flat foot deformity. We are then turning it over to we said Caesar you next. What do we say? Yep yep. Caesar is going to talk about his Lapicotton technique and I'll let him obviously describe what that is. Jonathan who's been a pioneer in this whole field as everybody knows will talk about the latest and I guess I forgot to mention too a technique that you developed more recently too in spring and deltoid reconstruction and I'm going to finish off talking about the use of just isolated subtalar fusion in the treatment of flat foot. So please put questions in the chat room because we'd like it to be interactive or even raise your hand if you want to ask. Each talk will be about 10 minutes long. I'm going to then pause for questions after each because I think it'd be better to do that than wait till the end and I have some cases prepared for the panelists and so we can learn as well. So with that thank you everybody and I'm going to turn it over now. Jennifer you can put on Dr Clark's talk for us. Good evening and thank you for inviting me to talk on this topic. It's one of my pet topics in fact. I'm sorry I can't be there this evening. I've recorded this talk for you. Declaration is I'm paid speaker for Arthrex UK but the conflicts for those of you who don't know me I am an orthopaedic foot and ankle surgeon in the south of England. I work just the west of London here. I'm also a member of the education committee of AFS and I run the education committee at Bofas. I'm going to specifically talk about a certain type of flat foot not all flat feet. I'm talking about what used to be called tibialis posterior dysfunction or adult acquired flat foot. Traditionally there has been this view of the static and dynamic stabilizers of the medial arch and the main static stabilizer being the spring ligament or otherwise known as the supramedial band of the calcaneal ligament and the main dynamic stabilizer of course the tibialis posterior and we've had this condition which we used to call tibialis posterior dysfunction which passed through various stages of failure. And then perhaps also traditionally we've had what we in the UK sometimes call the all-american procedure which is a combination of the medial displacement calcaneal osteotomy and a tendon transfer usually the FDL into the tibialis posterior stump or the navicular and with or without a cotton osteotomy and these procedures would normally be done the combination together and as I say often the FDL transfer put through some kind of drill hole into the navicular bone. The trouble is for a long time we have known and Roger Mann showed here that although there were good clinical results and functional outcomes often the deformity correction was fair at best and not maintained over time. And we've also known that sometimes you do this procedure and you find a great big hole in the spring ligament, sometimes you find a spring ligament tear without any pathology to the tibialis posterior tendon so something's clearly going on here with the spring ligament and perhaps it was an error to call this tibialis posterior dysfunction on its own. Steve Rakin here previously showed what others have also found was if you repair the spring ligament in some way you could get as good results as those patients where the spring ligament was thought to be intact although some of us would feel that the spring ligament in this pathology was never completely intact anyway. So a lot of work has been done on the anatomy of the spring ligament and we now think of it in terms of the tibio spring or the tibio calcaneo navicular ligament. You'll hear more about this I think from the other speakers and here's a diagram if you look at the top left of this lovely calaveric specimen and that's the tibio calcaneo navicular ligament which is the biggest part of that sheet of white tissue you see when you're operating. So how do you repair it? Well as with all ligaments you can repair or you can reconstruct. The trouble with trying to repair the spring ligament is it's thin tissue, it's often attenuated, taking an ellipse or doing a pants over vest repair can be technically tricky and result in a relatively poor strength of repair. You can try intraosseous sutures sometimes but often it's a mid-portion tear in the ligament. So you can use the tibialis posterior stump to reinforce this repair locally, that's what I've always done, adds a little bit of strength to the repair. You can also loop your FDL tendon transfer back onto the spring ligament or back onto itself which adds a bit of strength. You're going to hear more I think from the other speakers about other techniques and you can augment this repair or reconstruct with autograft and there are techniques using different tendons and more recently the FHL. And you'll hear as I say more about this from some of the speakers who have been authors on more than one paper on this kind of technique with autograft and also allograft. The idea being that by passing the tendon tissue autograft or allograft through strategically placed tunnels you can reconstruct these failed ligaments. And then more recently there's been focus on fibre tape in particular which is obviously slightly easier to acquire than autograft or allograft and clinical papers are starting to come out relating to the use of this in repairing or augmenting the repair of a deltoid spring ligament. And the idea being that again there are very strategically placed tunnels but there's no consensus really on any of these procedures as to where you should place your tunnels or where you should pass your tape or your graft. So what about arthroresis which is really what I'm here to talk about? Well the Greek word oresis implies propping up or shoring up so this is the only real clinical use in the body of a technique where we prop up a joint. And this is not a new concept it's a very very old concept first described in 1946 and it's evolved over time. Initially there were bone block procedures and now implants and the implants have varied and evolved over time as well resulting in these sort of more modern implants which are effectively soft screws that you pass through the sinus tarsi into the tarsal canal. And the idea being that you prop up the sinus tarsal, you jack open the tarsal canal if you like and you stop this sinus tarsal impingement which we see in most of these patients with the adult acquired flat foot deformity. And here's a video, an interoperative video of the sinus tarsi and you can see that when you pronate and supinate the foot that it closes and opens. And when you put what was now an old-fashioned looking arthroresis screw in you can lock this joint and prop it open. More modern screws are inserted through smaller incisions using image intensified guidance and put in over a calculated system and you can more accurately cite these implants. And you can see that you shouldn't put the implant any further than about halfway across the tarsal canal. Now you can do it wrongly, thankfully I'd like to say that this is not my patient but you can have complications just like with any procedure. But in practice most of the technical errors are either over or under insertion can be fairly easily corrected and the commonest complication by far is irritation and pain from the screw which of course can be cured by removing the screw. Is there any evidence for this? Well most of the evidence is in the paediatric population and in the UK and I think in the US as well. Its use in this indication remains relatively controversial, it's certainly not a technique that's used widespread in the UK at all. But my interest has been in its use in this condition of adult acquired flat feet. And this is a series that we presented eight years ago now so we're looking this series up again so we'll have a long term follow up on them. But a small series of 23 feet where we did if you like the all American procedure and augmented it with an arthroresis screw. In all these patients the spring ligament was repaired and in all these patients the screw was removed at six months because routinely these large old fashioned type screws caused irritation and pain. And we had good follow up of three and a half years and good functional outcomes in these patients and a good radiographic improvement in the usual parameters which was maintained even after removal of the screws which of course was with all the patients. And there are other studies too so there are some systematic reviews coming out now. Most of these papers tend to be relatively old implants and some of the papers are a designer series. But there are a couple of these reviews and what they show is that there is level four evidence for support of the use of arthroresis screw in conjunction with other procedures. So not as an isolated procedure in this in this patient population but to support I would argue the ligament repair. And probably the best and most recent reasonable size clinical series is from Les Grugich in Sydney, Australia and he's used it in exactly this indication. He removed about 30% of the screws in his patients and over seven years he found the same thing as we did, which was that there is good good clinical results and he also feels that it's use is to support the spring ligament repair which is very much the angle I'm coming from. So you can use it to support your spring ligament repair. You can use it in those cases of adult accessory navicular pathology where there's a distal tendinopathy of the tibialis posterior and you do a kind of modified kidney procedure and you need something to support it. You can also use it in those traumatic deltoid ligament repairs, superficial deltoid ligament repairs I might add. But the rider is that there is a limit to this procedure and you'll hear more from the other authors, the other speakers tonight. It's generally thought that over 30% of Taylor head uncovering is a contraindication to performing a FDL transfer calcaneal osteotomy. And there are other joints that are involved often in the deformity more distal to the the Taylor navicular joint which have to be taken into consideration. It's interesting we might be revisiting what is a very very old concept. This is Jack's paper from 70 years ago where he described a procedure of fusing a navicular cannae joint and had an excellent series of results from using this as a as a sole procedure in correcting flat foot deformity. And we now call it progressive collapsing foot deformity which again you'll progressive collapsing foot deformity which again you'll hear more of. And I don't really want to talk any more about because several of the authors on this paper are speaking tonight. So in summary, my simple message is that if you're repairing the spring ligament in an adult acquired flat foot or PCFD, think about using an arthritis to screw to augment your repair even if it only stays in for six months. I would argue it supports your repair for long enough for it to to stiffen up and to become strong enough to maintain a correction long term. So thank you very much. Okay I hope Dr. Clark is fast asleep now and having pleasant dreams about this webinar. I'll open up there to I know he's not here to answer questions but I'll open up to the audience for for questions that we could pass on to our speakers here. And then I'll get ready to introduce our next speaker. Maybe while we're at it, Cesar, Jonathan, do you have any experience using arthroresis screw and you have any thoughts? I don't have experience in using it. You know Lu Shon had used it in in series and found I think that in maybe not the most severe deformities it was helpful. I am interested in the concept actually of using it with a spring repair or maybe even a spring reconstruction. That might make sense to me and in a not too severe deformity I think that could work along with a calcaneal osteotomy. So I'll be interested as more data comes out in the adult population. Yeah same for me. I mean I trained with you guys so you don't don't use but I trained Dr. Shon as well. So when I was there what he was doing for bilateral deformities and I think was very clever. He would do the reconstruction one side and he would put an arthroresis on the contralateral side just to hold the deformity because he found that people would put a lot of weight in the contralateral side during the recovery of the operated side and that the other side would become more symptomatic and progress more. He would put as a like a preventive thing and take it out after if patients did not develop significant symptoms. I think he was very happy with that. I think he's still doing it but not for complete treatment of severe deformities. Yeah one of the questions Dr. Zell thank you very much. Yes in patients where the screw is removed how is the deformity correction still maintained? Maybe I could take a first stab at that. I think what you heard from Callum too is that you don't just do this as an isolated procedure but you have to correct the deformity through your osteotomies and maybe Jonathan what you're getting at too is maybe it's an adjuvant where you put it in allow things to heal. Maybe it's in your case a ligament reconstruction and then at some point when everything's healed and stable if you take it out it wouldn't be as much of an issue. But it's a great point because it is temporary and by itself it's not going to be a solution permanently. Yeah I'd like to have clarification of okay so he was mentioning about his 30 percent. I believe he said that if it was a more severe deformity than that he really wasn't using it. So clearly this is in not the severe deformities. Just one extra thing Dr. Ailes is that after we started studying peritoneal subluxation I mean the screw does correct peritoneal subluxation if there's no significant instability in the subtalar joint if there's still residual interosteal ligament and things like that. So it does sound very clever as well to do what he's doing in terms of you do a repair you correct the peritoneal subluxation provisionally that will potentially put less stress in your repair. You wait for it to scar down and then you remove the screw and potentially that the repair will hold it in position. I think it's an interesting concept. I didn't love arterial screw before but after peritoneal subluxation I got more excited about the possibility of maybe using like that would be a good way to go. Okay one other question we'll get on to the new seizure. So Martin is VUGA. Yes isn't the screw more of a proprioceptive hindrance than a physical prop up? So if that's true you wouldn't need to put in so deep and it's a question. That's an interesting concept. I guess the thought is it kind of you feel when it's going to stop or maybe it gives you some feedback or I would maybe hesitate to say maybe it hurts a little bit and then you stop. I don't know the question. I mean I always thought is using it as a physical blocks probably not a good idea either because it's kind of like putting a door jam in a door and at some point it's going to wear away that bone. So I don't know we'd have to ask Callum. Okay Cesar you're next right? Yes I believe so. Yeah well you get your talk up. So Cesar is on faculty at the University of Iowa and he's been monumental putting together you know our knowledge about flatfoot. It's been a passion of his. We bring CAT scan. He's really pushing the limits on it and he's developed apart from many other things a first rate procedure which he's calling the lap of cotton which we'll get to. Well I'll let him get to but I'm so glad you joined us. Cesar's a fellow with us but we've learned so much from him. So Cesar go take it away. Thank you so much Dr. Ellis. Well it's a huge honor and pleasure to be here with all of you tonight especially with two of my main mentors and pretty much everything I know about this I learned from them. So I'll try to do my part here but it's a tough deal. So we talked about progressive collapsing foot deformity. I think you guys know that we recently recommended a new terminology for that. I want to touch in the point that I think it's important our brain is very lazy right. Our brain wants to think in 2D and 2D is very dangerous right. Like you can see Prince William here and you can think bad stuff about him and he's actually not doing anything bad. So you have the whole 3D you can you can get a better much better information there and I think for flat foot or PCFD is the same thing. So when we see this we see hindfoot valgus we want to do an MDCO right away. We don't even think about anything else. We just want to do the MDCO. We see an uncoverage of the tailor head like that. We want to do lateral column lampeny and we see a collapse and sag in the TMT like this. We see the sinus tarsing beam and we want to do something with the first ray. So we always try to think like let's correct this with that right and it doesn't work like this. So this is a video I think is very interesting. It's a video of a normal foot going into a progressive collapsing foot deformity where you can see that is there's a lot going on right. It's completely three dimension. You can see the external rotation, the peritoneal subluxation. And also, we don't have a medial view here, but you would see collapse of the longitudinal arc. So we have to think outside of the box. And I started thinking about the first ray when I was at HSS. So Dr. DeLand, Dr. Ellis, and also Dr. Dimitriokopoulos were very important for that. We know that the foot is a tripod and the ankle is sitting on this tripod. And that relationship is very important. And when we're doing total ankles, we would say at the end, we would always say, oh, let me see if I need a calcaneation. We started talking, maybe a first ray would be more important. First ray osteotomy would be more important than calcaneation osteotomy to protect the valgus ankle, for example. So we teach fellows and residents about forefoot-driven hindfoot varus, or cable varus. But we don't teach fellows and residents about forefoot-driven hindfoot valgus. That is what happens in the collapse in the forefoot or flat foot. When you have an unstable first ray, you put a big trust in valgus in your ankle. And so I always test these. I learned these with Dr. DeLand. We put your thumbs on the first ray and the lateral border of the foot, or the lateral rays. And what you want at the end of the surgery, you want your first ray to be back in the game like that. You want the first ray to be more planted in the fifth and the fourth ray. And so I was looking for options. I liked lapidus. I was trained to do lapidus. But I don't like the fact that there's average shortening and there might be transformation of our solid depending on how much you remove. I was also trained to do lateral column lymphenes. However, I do think it's a necessary evil that if we could avoid doing lateral columns, it would be a great thing. But when there's a lot of abduction, we feel compelled to do lateral column lymphenes. So the first thing I did when I was in Baltimore, we did a cadaver study, unfortunately it's not published yet. We compared calcaneal osteotomies and cotton osteotomies. We checked the pressures in the ankle joint. And we actually found that the calcaneal osteotomies did not change at all. These were normal ankles. They did not change the ankle pressures. But when you move the first rate or you combine calcaneal osteotomy with the first rate, then the pressures in the ankle joint would change significantly. Here's an important, then I did a cadaver study in Iowa that is about to be written where you can see here in this video, as you, this is isolated MDCO in cadavers. So you can see that when you do only MDCO, look how the foot derotate or rotate back into varus. And so we have that 2D mind where we think MDCO will only correct hind foot valgus. And that's completely wrong. The same for cotton. So we did different sizes of cottons and you can see how the foot is swinging back into position with isolated cotton. So you can see how the tail is or the tail navicular coverage angle is moving there. So you correct, you change one point of the tripod, you change everything. And they published the technique. So the idea was why not do a lapidus with a wedge? So pretty simple idea that was done before, but probably not for primary surgeries in a majority of the time. So we published this as a technical tip that was the lapidus with the wedge, thinking about going into a four foot driven hind foot varus. So you would derotate the deformity by plantar flexing the first range and also distress. I'll show a case here. These was actually a patient that came to me for Alex valgus deformity, not for flat foot, but she did have a mild collapse of the longitudinal arch. As you can see, she did not have any pain on the hind foot, but she did have some subluxation of the middle facet. She had a very low four foot arch angle. Her foot and ankle set was 6.35 and that is abnormal. The normal is up to 5.2. And then I did a lapidus and I started doing, I started trying to do lapidus with wedges. It's been one year and eight months that I don't do a lapidus without a wedge. And even for Alex valgus. So this is, I use it as a cutting guide for the lapidus. I usually put the trial in. I feel what Dr. Delane taught me how to do. So I feel where's the first ray, where's the lateral border of the foot. This is the wedge going in with an intramedullary extractor. In this case, I fixed with an intramedullary nail, but you can fix with whatever you want. I did a capsuloplasty. I put the nail in and you can see the final here. This is non-weight bearing x-rays with six weeks. This is the patient with 12 weeks back in the office. The hind foot alignment did get better. I'll show you some measurements here. Initially, I was worried about how much pressure you would put in a first MTP joint, if that would affect range of motion. You can see some weight bearing CT images here. There is an arch there now that there wasn't an arch before. You can see that in three months, it looks pretty much healed, the fusion side. You can see that the forefoot arch angle got significantly better. I did correct rotation in this case. You can see here the rotation and the foot and ankle offset went from 6.3 to 2.2 only with a lapidus procedure, no MDCO. In terms of thinking about, don't think 2D, think 3D. You bring the first ray down, everything is gonna change. Case two is more related to the progressive collapsing foot deformity. This patient came to me. She was very young, pain and deformity mostly on the left side. She had a very unstable first ray as we're showing there. You can see the asymmetric valgus of the left side. You can see sinus tarsing impingement here. You can see the amount of almost 50% on coverage of the tailor head. At that point, I was already just doing the lapicotens. You can see the weight bearing CT images. You can see the sinus tarsing impingement here again. 59% subluxation of the middle facet, a very low forefoot arch angle and a foot and ankle offset of 11. You can see that the tailors is completely medial to the tripod there. You can see in the MRI the sinus tarsing impingement. The posterior tip in this case was a bad. She actually had an injury that she felt a pop. But you can see the amount of swelling around the posterior tip. You can see the spring stretched out here. You can see the interosseous with some degeneration of the interosseous as well. In these cases for young patients, I always do an MRI to check fatty atrophy of the posterior tip. She did have some fatty atrophy. In that scenario, I decided to go for FDL tendon transfer. If there was no fatty atrophy, I would do an allograft reconstruction. We were showing, did an MDCO on her. Then I went immediately. You can always check as Dr. Ellis and Dr. Dilan showed and Conti that the heel needs to be aligned with the center of the leg. But then I went immediately. I found FDL. You guys know how to do this. Harvest FDL, prepared. The spring was intact. It was stretched, but it was intact. I always remove a little bit of the navicular there. I was ready for my FDL tendon transfer. I have been doing more and more augmentation. I don't correct the deformity with the spring ligament reconstruction augmentation, but I have been doing more and more. Here's the lapicotin going on. I don't fix my spring and my FDL until all the bony procedures are done. And then this is just showing, you can see here, I did like a triangle reconstruction of the, or augmentation, not a reconstruction of the FDL with a tape. Transfer my FDL, this is just showing the fluoroscopy for the surgery. Unfortunately, one of the screws you're gonna see that I put it out of the calc in the medial side. I actually had to take that screw out with one ear because it was bothering the patient immediately. Here is the fluoroscopy with that. And here's the lapicotin with the wedge. And this is a intracraniate form nail that I use as well. Here's the patient with 12 weeks, much better alignment. He was centered. There's an arch there that there wasn't before. She has good motion already with three months. She's trying to use her FDL. And you can see here, remember the sinus tarsing pene. You can see how the sinus tarsing is open. And this was, there's no lateral colon lengthening here. You can see how the fetal navicular cover jangling is significantly corrected with the lapicotin and MDCO and the augmentation of the spring. Here's some way parents to key images with three months. Was pretty much healed already with the wedge. You can see there initially, I was worried about non-union. Unfortunately, there's not gonna be enough time to show the data. We do have the data for all my cases. You can see that unfortunately that screw was out, was right at the system tackling. I had to take the screw out later. As I'm gonna show, here is her healed. And here, a comparison of four foot arch angle, stabilization of the medial facet and foot and ankle set. We were able to bring her from a 11 down to 2.3. This is the patient with six months still maintaining the correction. And this is the patient with one year with a fully healed lapicotin. And you can see a screw bothering me and bothering the patient as well. And we went there and took those screws out just because it was bad technique. Here, I just wanna show, this is the same patient, weight bearing CT before, weight bearing CT after. And you can see the derotation without any, look at the sinus tarsy opening without any lateral column lampening. So we have to stop with this idea that we have to do lateral column lampening to correct to a vicular bulbar jangle. We did publish our series. It's published in Archive of Orthopedic Trauma with a short term. I'm done with my time, I have to finish. And I would recommend you guys to take a look. But we did have only one symptomatic non-union out of 22 cases. And I'm happy to share with you guys this at some other time. We do have a follow-up study coming with 41 patients in 46 feet with lapicotins with different diagnoses. Alex valves and PCFD being the majority of them with an average follow-up of 11 months and an average wedge size of 8.8 millimeters going up to 19 millimeters in mid-foot arthritis. In summary, guys, please think 3D, think outside of the box. Remember that you bring the first rate down or you change the position of your heel, the whole tripod will move. Remember of this video, because I think it's very important. You don't need to do a lateral column lampening to correct all that. The necessary evil probably might be unnecessary. So if we can do that, it would be amazing. Thanks for the invitation, Dr. Alex. Sorry for going a little bit over. No, you did great. It's the first time I've ever seen you use a timer, Cesar. Yeah, well, if I don't use the time, then we would be here for the whole night. I know, because you love talking about, okay. So great, very thought-provoking too. And I know Dr. Delans talked to us for years about getting that first rate down. He's obsessed about it. Question from the Q&A, Jeremy Chang, great to hear from you. Hope you're doing well. So, and I was thinking about this question too, because what you're almost talking about is driving the foot in the opposite way we would do for a capoveris reconstruction. So he's asking, is there a equivalent to the Coleman block testing if the hind foot is valgus, is forefoot driven? Cesar, do you have a way to do that? Maybe on your exam, maybe on your weight-bearing CAT scans? How do we know that this is going to drive the hind foot in valgus? You showed those pictures how it does it afterwards, but is there a way to test it? I think we might've lost him. Can you hear me guys? Jonathan, can you hear me? Yeah, I can hear you. Okay. What do you think, Jonathan? Is there any way you can test if hind foot valgus is forefoot driven? I actually don't have an answer to that question. Now, obviously this is really based on Cesar's experience. I mean, I'd really like to ask him, are there cases where he thinks it's not appropriate, you know, and then try to identify it that way. You know, when does he not try to do this? And I guess he's mentioning that he does the spring as a, just as a support. In other words, he's not using the spring recon to get actual corrections. So it seems like he's getting a lot of his correction, obviously from the lappy cotton, which frankly is impressive. And it's something I think we need to look at because if it can contribute to the downfall of the lateral column lengthening, I'm all for it. I'm sorry, I had a problem here, Dr. Reyes. My earbuds, our battery is going down and I can't stop it. But I missed the question. I'm sorry. Did you hear that? Well, just, Jeremy Chan was asking, you know, we do a Coleman block to understand if a hind foot varus is forefoot driven. Can you do the opposite with the flat foot? Can you do a test before to understand whether your first ray bring it down is going to fix your hind foot valgus? That's a great question. I think, well, there is the reverse Coleman block test. I don't use it a lot, but we do have an idea of doing that in the weight-bearing CT and see if we can check that. And clinically, I might be too aggressive with this statement, but my opinion is progressive collapsing foot deformity with no first rate procedure is wrong. So I think that idea that you do the hind foot and then you check your forefoot, I know it was defended and supported for a long time, but I think it's a wrong concept, in my opinion. I think you always have to do something with the first rate. So you could do the reverse Coleman. I'm just not sure what would really add, because in my opinion, you have to do it anyways. Yeah. Okay, a couple more questions. Jay, great to hear from you too. Gurbani from UCLA. Do you have any current indications for a cotton osteotomy alone? Still, do you always do lapicotin? Because the other question I had that was similar in Jonathan does is, why can't you just bring the first rate down more through TMT? Because you can take a wedge. Do we have to always put the wedge in or can you do these cotton or plantar flexion first ray alone? You want to go first, Dr. DeLand? Yes, I think a particular problem is, you do have a problem with the first ray, is it all short? Okay, if you've got a short first ray, maybe to start, that's a great indication to do what Cesar's talking about. And I think if you have a long first ray, maybe bringing it down is enough. But I think what Cesar's doing is really different. He's actually not just bringing it down to, he's actually using it to get his hind foot correction, which is a fascinating concept. And I think we have to listen to his results and what he's able to do and look at the results and that that'll speak for themselves. Because I do think this is a strong concept and I agree with Cesar, you've got to always pay attention to the first ray. And I think this is a great new idea. Do you want to add something? Yeah, well, I still do cottons. Like I said, you have to do something with your first ray, right? And sometimes then a vicular cuneiform joint might be the one to blame if it's gapped or subluxated or something like that. So you could do the correction in any place of the medial column. I still do cottons when the first ray is not a super unstable and of course that's subjective. It's more in the feeling. And if I don't need a lot of correction, because I do feel that even though you could do a bigger cotton than eight millimeters, that is the maximum available. I do think that you could hinder or you could put in jeopardy the plantar cortex and then it would be an unstable osteotomy. So if I need more than eight millimeters to correct, I then I go to the TMT even if it's not a super unstable because I can do, like I said, I can do 12 millimeters correction in the TMT and I can't really do that in the cotton. And as Dr. Deland mentioned, I think it's not just bringing the first ray down, it's also distracting the first ray and retentioning the structures, including plantar fascia and all the structures that run on the plantar medial aspect of the medial column. So Cesar, in mild deformities, do you ever do a cotton and a very small lateral column lengthening or you just don't do lateral column lengthening it's hardly at all anymore? I haven't, I haven't done for a year and a half lateral column lengthening. I did one to be honest, and it's one of the case, unfortunately there was no time to show. I did have severe mid foot arthritis case that I did one, two, three, and I did all the NC fusions, not for progressive collapsing foot deform, but for mid foot arthritis. And I was able to salvage that patient. She healed everything, but she still had residual abduction. And then I went back and did, I didn't want to do a derotation osteotomy through the mid foot fusion, because it would be too much work. And she already underwent like a very big procedure. So then I went back and shifted her heel and did a lateral column lengthening just to gain a little bit more of the, correct the abduction. But that was a bad mid foot arthritis case. Not a progressive collapsing foot deforming. Okay, a few more things. Actually, Jorge Luis Castellini had the same exact question about cotton versus Lapicot. I think you answered that. Annie Sue here from the New York area. What type of wedge do you use for your Lapicot? Just briefly. I use allograft wedges available in the market from a specific company. I use most of them, but I don't like metal. I use allograft. You use a bone marrow aspirate or something? I use bone marrow aspirate with all my cases. Yes. Okay, yeah. Real quickly, Carlos Indica Ramirez. What's the order of the procedure? Do you calcane osteotomy, your tendon repair, spring, Lapicot? Which one do you do first? Which one do you do last? Great question. Yeah, I do like I've learned with Dr. Delane. So I do my provisional step first. So I do MDCO first. I do gastric first and MDCO. Then when I have been doing occasionally brevis to longer standard transfer. So then I do that. Then I go medially do my approach. Prepare everything for the, whatever you're gonna do with your posterior tib. And I already get ready for my spring ligament augmentation. Then I go to the TMT, do the Lapicot. Check the position of the heel. Check the position of the medial column. Fix it, and then come back for the soft tissue, including FTL, allograft, and spring. Okay, good. So Cesar, just quick question for Cesar. You don't use the spring procedure to give you any correction, really. You're using it to maintain correction. Just so you guys, I can't hear you anymore again because my earbuds went down. We'll go back to the, I have to log in again. All right, no problem. Okay, you go, Cesar. I'll, Jonathan, I can answer later. So Jonathan, let's have you do your talk. Sure, absolutely. Okay. Yeah, so those, Jonathan is a colleague of mine and has written a book on this. Okay, all right, can you see my talk there? Yep, go for it, Jonathan. Okay, here we go. So I'm going to talk about spring and deltoid reconstruction, past, present, and future. My disclosures are in the other literature. I'm not going to spend time on that. So the first thing is, in the past, does spring ligament really have a place? And I think it does. I think the spring ligament is something we're going to be reconstructing more and more over time. But I think for now, you should realize that when we have these midfoot deformities, well, I must say, after Cesar's talk, we have three choices now, right? Okay, so we have LCL, which is famous for lateral overload, very easy to get overcorrected. You're a millimeter, a couple of millimeters off, you can get overcorrected very fast, very problematic. Subtalar fusion, not that problem, but then you're fusing a major joint. And so now we have this lappy cotton, which we got to consider as well. But the spring ligament is involved here. And I think when you reconstruct the spring ligament, you can get some correction from it. So I think it does have a place. But I'm all for minimizing, or when you can, eliminating lateral column lengthening. So a spring ligament reconstruction that gives some correction can help do that. Obviously, the lappy cotton, as you just heard. And then this FHL, which was shown in the first talk, I'm going to show quickly in a slide, because I have used that in a few cases, and I've actually found it to be quite helpful. And when you have a very severe deformity, say one that you may have trouble even doing with a lappy cotton, Cesar would have to comment, then I'm interested in spring ligament reconstruction, maybe combined with a subtalar fusion if that's what you need to do in cases where the interosseous is out and you have subfibular impingement and you try to save the talonovico joint by getting some correction with the spring ligament reconstruction as well as a subtalar joint and save the talonovico joint. So I want to mention this procedure. I think it really bears looking at it. Published with Jae Young Kim and Woo Chung Lee in Korea. And I must admit I never would have thought of doing this. And having done it, I have to say it works, but I have only done maybe five, six cases. In the literature, there's an article with more cases than that. And I just saw two patients today back with it, six months and very happy. So I think it bears saying. And the interesting thing about this procedure is that it gives correction, not just at the talonovico joint, particularly in the sagittal plane, a little bit in the abduction plane as well, but also gives it at the navicular cuneiform joint and the first metatarsotarsal joint. And it'll even close a plantar gaps first metatarsotarsal joint. So really a pretty interesting procedure. Woo Chung Lee really developed it because he didn't like lateral column lengthening. So he doesn't use it with lateral column lengthening. And so he doesn't get into the problem of lateral overload. So I think this is something to look at for the future as well. And I'll be doing it more in finance place as well, getting into lapicotins. So for what's the literature in spring ligament reconstructions, I'm not the only one who's done this. Dr. O published a very good paper with 12 patients, showed correction. Also Dr. Neri did. And these were done without subtalar or talonovicular fusion. So it's possible to get correction with a spring ligament reconstruction, augmented with some bony work. Admittedly, these procedures were done with lateral column lengthenings as well. So they're for severe deformities. So that's a mixed picture. So you don't use it alone. I would use it with something else. My data, I've got long-term data now. So those studies are relatively small. I've got long-term data and what will be over 30 patients followed for six years. It was done with lateral column lengthenings, but in situations where I couldn't get enough correction from lateral column lengthening, I added the spring and got more correction. And I haven't had to go back in those severe cases. I've had no subsequent, I had to go back and fuse the talonovicular or subtalar joint. I did have one lateral column lengthening non-union. I would not use it when the lateral column didn't give at least half of the correction. So I was very careful. And there are cases like that. And in that kind of case, you might want to do a subtalar fusion as Dr. Ellis may show. So, and I got good radiographic correction, but that's really not the point. The point is how do people do functionally and are they happy with it? So I'm going to show you a case. There's a case actually of a 15-year-old with osteogenesis imperfecta. So interesting to deal with her bone, but very severe deformity. So even, you know, I would be worried just doing a lateral column lengthening alone and a talonovicular joint like this on the AP view, they would need some kind of augmentation. I didn't want to certainly fuse a subtalar joint in a 15-year-old. She's also obviously had very considerable hindfoot valgus. So the procedure that was done to go from this to this is she did have a lateral column lengthening, not a huge one, in the range of about six millimeters. And we added the spring ligament reconstruction, which actually goes from the plantar aspect of the medial navicular through this drill hole here, and it goes up the medial malleolus. So it's a kind of a reconstruction of the combined superficial deltoid spring. And that's the procedure that she had. She had an MCO, a bit of lateral column lengthening of this reconstruction. And here's the lateral showing correction. And, you know, most importantly, you know, the patient maintained good eversion. So I'm trying to demonstrate here, this patient still has good eversion motion yet had good alignment on the x-rays that we saw. And that's really what is helpful to make for a good result. If you do a lateral column lengthening and you really stiffen that lateral column, you got big problems. So, you know, I'll let the patient talk here a little bit. So this is her talking after the procedure. I've been playing three seasons, and every single season, I hurt my ankle. We asked Dr. Galan if I would be able to run after the surgery. He said, I'm not sure. I can play lacrosse. I can run. I can walk. So it's one of those cases where you could take a severe deformity and actually get somebody back to athletics. So it's, and you certainly can't do this in every case, but it's, it is possible. So here's an example from the OR. This type of you may see, here's this slide on the left. I've done my lateral column lengthening, but the talus is, the tailor head is still escaping from the navicular, not enough correction. And I added on the spring limb reconstruction in the OR, and it helped relocate it. And that was maintained post-operatively. So I think spring limb reconstructions do have a place. It takes time to do them. I generally have done them with allograft, sometimes autograft tendons, but usually allograft. And it would be nice to get a quicker technique, I must say, but I think you'll be, it'd be more in people's armamentarium in the future, especially if we can make it faster. So now, now we'll go to the deltoid. So in, in the past that the, you know, so this, now we're talking PCFD stage one, and there's lots, lots else going on in the hind foot as is, as is in a class A, B, C, D, and it's the previous stage four, but it's, it's, it's this, and so this is for flexible deformity of the ankle. In other words, that you can actually reduce it. So I'll do a stress x-ray, making sure that I can correct the valgus tilt passively before I go to the OR. Prior view of deltoid reconstructions was that it really couldn't be done, that, that, you know, that they would fail. People had tried to refit and, and, but there was a few studies where they had some success. Dr. Meyerson, Haddad, myself, Dr. Ellis, worked on this and, and, but the studies were small. So it's, it's say, you know, can you get, can you reproduce in a larger study? And I'll just show you my technique quickly. I, I don't do a deltoid reconstruction as Dr. Ellis will tell you, unless I have full correction of the heel. I have to have full correction of the heel. Here's, thanks for Cesar for emphasizing this, the first metatarsal must be mildly plantar flexed, however you want to do it. I do not leave the first ray up. I, anything, I make it more, a little more plantar flexed than normal. And I, I will do, the standard will be a deep deltoid going from the tailor body up into the medial malleolus. If that's not giving me enough correction, or if there's flat foot deformity that I need more correction in, I can, I can add a, my, what, what is my, so this, this was my spring ligament reconstruction in that earlier case going from the navicular up here. And I, I'll use this as a superficial deltoid and add on to the deep deltoid in ankles that I'm not getting full correction with a deep deltoid in, in the, in the OR. I do have a, a long series on this that I've, I'm going to hopefully be submitting for publication this year. So this is an average 10 year follow-up, as you can see. Age, it ranged from five years to 18 years, so minimum was like point, was like a 4.5 year follow-up. And it doesn't necessarily correct it every time all the way, certainly not. My, so my average correction was four. I still had four millimeters or, I mean, excuse me, four degrees or five degrees left. So there were some that had more than that. And obviously some that were a few, but the real lesson here is that, is that there was correction. I, I got good correction and that in these patients followed over a long period of time, average 10 years, I, I did not have to go back. I had two failures. One, one, which I did have to go back was a mistake from the beginning. And another one, which was infection, but in those other patients, in the 20 other patients, I have not had to go back and do any subsequent procedure on the ankle, such as an ankle fusion or an ankle replacement. So I think it has a place and I'll just go, I'll show you a few, a couple of examples. So here's one 15 year follow-up here. You can see the big valgus deformity in this ankle. 15 years later, he's maintained his correction. He does have some medial gutter OA, but he can play basketball with his kids. I don't think he could be a professional athlete, but he's, he's happy and he hasn't had to have an ankle fusion, which you would think would have had or T or ankle replacement given this pre-op x-ray. Here's, and I like to do them in cases where there is some joint space remaining laterally. I don't, I, this kind of patient, I would tell, tell them you're going to need it. You got to need a total ankle replacement. But I want to give you a good deltoid for your total ankle replacement. If you don't need it for a while, we push that down the road all the better. And so this is a bit of a, kind of an amazing case. So I followed this patient for 10 years. This patient has pain level of two out of 10 and has maintained really pretty good correction. So, so this is possible is the point. It, it is possible. I think we can probably get better at it by paying equal attention to the foot. And, and so, so I think it definitely has a place and you can do your patient's service by, by saving, by saving their ankle for at least a good period of time, if not for the rest of their life. So what's the future? I think the future really beat would be to have a faster procedure. So it's particularly problematic making these big drill holes. So my drill hole in the medial malleolus can be seven, eight millimeters, and certainly you're not going to want to do that. At the same time, you're doing a total ankle replacement. So that's a problem. It'd be nice to have something you can put in faster than, than fashioning your, your allograft tendon or autograft tendon. Cause that takes time. And so there is this material called Ardavan. I'm not associated with the company. I must say I've only tried it in a few cases. But I, I wanted to show a case and thank Patrick Bull whose case this is where, where he used this in a total ankle replacement and, and, and used it to give a good deltoid and did not use an allograft tendon of any kind, just use this this Ardavan, which is a unique material because it has some elasticity to it. Not as stiff, like the, the internal, you know, the internal brace. And, and so here we go, here's the pre-op. So he did a double bottle spring reconstruction, just using the Ardavan. He did it in stage. So he actually did a cement spacer, did the reconstruction at that procedure, did a subtalar fusion, a medial slide, FDL transfer, and an NC fusion. So he's correcting the foot a lot appropriately in preparation for the ankle. And here's, he had it with a subtalar fusion and there's the cement spacer. And he's, he's, he's not using screws to tie it down to. He has these little screws in the, in the, in the much smaller holes that Ardavan can use. And here's this patient a year out with obviously good alignment of their medial cover, gutter, no tilt and these weight bearing x-rays at a year. So a nice result in when you can reconstruct the deltoid in a, in a total ankle patient without creating a big hole. So I think we need more data on the Ardavan and some of these other materials to really say, okay, what is their longer term results? Like I'm not advertising that people should go do this right now because they, there's no series of, of, of Ardavan deltoid reconstructions or either in springs that I've seen with a significant follow-up period. So I, I think we have to await, but I think this is an area of the future and deserves mention and further development. So thank you all for listening and, and happy to answer any questions. All right, John, thank you. Thanks for always pushing the limit here. I may run out of time and not be able to give my talk, but the truth is we've covered a lot of it because I was going to mention just isolated subtelic fusion. I think at the end of the day, it's a, it's a good technique. You've mentioned it, Cesar's mentioned it, can correct more than just hindfoot valgus. It is good in some cases where you have either severe deformity or some of these major subluxations where you're, we're seeing on weight bearing CAT scan or lateral impingement. So and it corrects more parameters, like I said, than just hindfoot valgus. We have a couple of questions through the chat room, Jonathan, Dr. Rajiv Shah, good to hear, good to see you too. He is saying, when you do a fusion for a DIPL, do you always do a deltoid reconstruction or do you always avoid a fusion? So I guess the question is, you know, when you fuse all those joints, the ankle can tilt. You just avoid the fusion, Jonathan, or do you ever just do a deltoid reconstruction? I, well, I have to adhere to the criteria that I mentioned. In other words, I would do the fusion if I do, if I need to, to maintain correction at the subtalar joint. If I don't need to do that and, and can do a small lateral column lengthening, or maybe we would do a lappy cotton. I would prefer that, but I, I'm going to do whatever I need to do to get that heel straight and, and have a stable midfoot. I think it's the way to answer that question. Yeah, and then a follow-up question he asked too, you're talking about using allograft, but are there situations in, you know, maybe it's in India where, Dr. Shah, you are, but if you don't have allograft available, are there other options to use other than just allograft? Uh, well, I think, I think allograft. I, I think that if, if I was, if I was there, um, and I, I, I needed, I would, I would use a hamstring tendon. Yeah, hamstring for the same person. Yeah. Well, and Jonathan, just a question about the technique of the, um, FHL. How are you, um, bringing that through the base of the first metatarsal? Um, so, uh, that is, um, I can see, I can go right to the slide. The, the, um, you, you, you, you know, you go, uh, let's see. I'm sorry, it's gotten there. So, um, you, uh, you, you just create a drill hole and, you know, you, you've cut the FHL here and you make an incision and then you just bring it up through this drill hole and you, you actually plantar flex the first ray, Cesar, as you, as you, uh, you, you, you put the ankle in about just 45 degrees of plantar flexion because you don't want to over tighten it at the ankle, but then you forcibly plantar flex the first ray, you pull up on the tendon, uh, and fairly maximally, um, with the, with the foot and ankle in that position and then drive in your biotinesis group. Good. Okay. Um, Dr. Wang, thank you for this question. So do you have a weight limit for your FDL transfer with spring ligament repair? And maybe I'll preface it by saying in my talk, I was going to mention that in some heavier patients, and I'm not sure what BMI to put on it, but maybe 40 or so, uh, sometimes a subtalar fusion, and we're not talking again, we're trying to not fuse the tail ligament joint, but a subtalar fusion can be perhaps a more predictable way in those heavier patients to correct hind foot and get it to stay. Although we did remember, John, and look up our patients with flatfoot reconstructions and find that, um, BMI actually wasn't a factor of whether they did well or not. It was really a matter of, did you correct the deformity, but what would you say for you? Yeah, I, I, I would, I would say what you just said is true, uh, uh, Scott is that I don't think it's driven, um, by weight, although I do get a little more nervous and I would say certainly if I felt that I was on the border of not getting enough correction and the patient's heavy, then I would definitely be worried and, and, and, and fuse the subtalar joint. I also would be, you know, a fuser of the subtalar joint in, um, in more, in, in patients with lower activity levels and higher age, you know, you get somebody, uh, you know, in their, in their seventies or something, or not so active individual in their sixties. And, um, uh, and maybe we'll go more to lappy cottons and things like, uh, like, like this, but I would, uh, but if it's a really heavy person, uh, and I'm having borderline correction, or they're just minimally active, uh, I don't think a subtalar fusion is a bad operation. Okay. So maybe just last question for you guys, and we'll close, um, Cesar and Jonathan, what do you think that, that both of you mentioned summits, what do you think that the next steps are to treat this better, this condition better surgically? What do we got? Well, for me, I would love to have another material other than autograft or allograft tendon. Um, that, that would be a huge step. So, uh, whether it's going to be Ardalan or something else, if we can develop something like that, um, it would, it would be terrific. It would make the surgery faster. Uh, and so, and, and Cesar's done, has used Ardalan, so he can comment. He's got more cases of it than I do. Uh, so, but if we had a material that would really work with that, I think it would be terrific. Cesar, what do you say? Yeah, well, I have been using Ardalan for at least a year, uh, year and a half, um, for my spring deltoids, um, and I'm pretty happy with it. It's, it's, it's working as good as, uh, before with, uh, internal brace or allograft. Uh, I wouldn't do for potentially, if you really have a tailored tooth, like a bad tailored tooth, like those cases that Dr. Dilan showed, I would, I would still be, because there's no data, I would feel, uh, you know, uh, bad about using Ardalan for those cases. Um, so for that, I would still learn, do what Dr. Dilan, um, what I learned with Dr. Dilan with the Achilles tendon allograft, uh, just a more robust, uh, tendon. Uh, that being said, the next steps, I do think this is a rotational deformity, peritoneal subluxation, until you have your ligaments to be in, uh, relatively competent, uh, you could still derotate the deformity. So, I, I think ideally, in a ideal world, uh, derotating the deformity and re-augmenting ligaments would be the perfect scenario. Uh, I, I'm not sure we're going to be able to get there. I, I'm not sure I trust that we will be able to do isolated soft tissue procedures without bony correction, because I just think it's a, it's a, it's a bad, it's a bad problem. Uh, so, I'm not sure we're going to be able to get rid of MDCOs, uh, in first-rate procedures. Uh, but if we can avoid a lateral colon lampheny and subtalar joint fusions, in my opinion, it's already a big deal. So, that's where I, I think we should focus. Yep, I agree. All right, thank you both. Great session. I, I even learned a lot. So, um, it's amazing this, this, uh, subfield, right, just, um, how far we've come and how far we have to go. Yep, you got a future. Okay, um, Jennifer, Julie, I'll turn it over to you. I don't think there's any final, um, housekeeper closing items. I, I see, uh, Jennifer set out a survey for CME credit, but anything else you need to add in closing? And thank you, everybody, all the people we know, uh, for attending, and, um, those we don't look forward to working with you or seeing you. Thank you so much. Thanks for an invitation. Thanks for being here. Thanks for everybody. Thank you, Dr. Ellis. Jennifer, anything else you need to do? Uh, no, we are good. Thank you very much, everyone. Okay, good night. Bye-bye. Bye-bye.

surgical techniques

flat foot deformity

spring ligament

deltoid ligament

arthroresis technique

lapicot technique

four-foot-driven hind foot valgus

ligament reconstruction

autologous tendons

allografts