the 12th webinar of the 2021 Foot and Ankle Focus Series. Tonight's program, MIS, that's applicable to your practice away from the bunion, will be moderated by Dr. Holly Johnson. Joining Dr. Johnson are doctors, Rebecca Serrato, Oliver Schipper, and Christopher Miller. You could find their full biographies and disclosures in the program document posted in the chat box and the PRC. The 2021 webinars are provided free to AOFAS members and orthopedic residents and fellows with funding from the Orthopedic Foot and Ankle Foundation, supported by grants from Arthrex, Inc. and Stryker. I'd like to run through a few housekeeping items before we kick off the presentations. For technical difficulties, please try closing your browser and logging back in the same way you did the first time. Registered physician attendees may earn one hour of AMA PRA Category 1 CME credit by completing an evaluation and CME claim form at the end of the webinar. You can find the link to claim CME in the chat tab, and we will follow up with an email following the conclusion of this broadcast. This webinar is being recorded and will be available for on-demand viewing on the Physician Resource Center at www.aofas.org slash PRC in approximately one week. We encourage you to ask questions during the presentations. To send your questions to the faculty, click on the Q&A tab on your navigation column. I will now turn the program over to Dr. Johnson to begin. Thank you. Okay, well, welcome everybody. Hang on one sec. Thank you so much for spending your evening with us to discuss MIS again. Tonight, we're gonna talk about procedures that you can do through small incisions beyond the bunion. And as much as I love the percutaneous hallux valvus correction, I do understand that not everybody has bought in yet, but I still think that there are significant advantages to using the scope and the percutaneous burr whenever possible in order to limit patient, limit exposure and decrease pain, less wound issues overall, the benefits are endless. So these are gonna be techniques that aren't necessarily more difficult and hopefully more accessible to the average user. So here are our experts today. And when I was asked by Joe Park to give this, to host this webinar, I picked the three people who've had the greatest impact in the United States on my practice. Becky Serrato, of course, is an absolute master arthroscopist and percutaneous surgeon. Chris Miller continues to blow my mind with his scope skills. And Oliver also teaches me something new every single week. And I'm excited to share what they know with all of you. So Becky, you are gonna start and tell us all about MIS techniques for Charcot. Well, thank you, Holly. I'm honored to be invited by you to participate in tonight's lecture. And I agree with you. I think this is a great topic to talk about where surgeons that are interested in introducing this, comfortable with the burr, maybe not necessarily what else can I do other than a bunion surgery, this is gonna be a great topic for them. So I'm gonna talk about something that we're gonna take the challenging percutaneous, I've just learned something new and combine it with the challenging Charcot arthropathy. So why would this be something that you would wanna do early in your practice? But I would argue if there's anything that using the burr can be a tool that you should introduce very early in your practice, it's with these very challenging patients. So here's my outline disclosures. And I do wanna highlight, I am a consultant for Stryker and specifically in the MIS line of equipment. But that being said, none of this topic tonight is gonna be percutaneous to one particular company. So as we know, when we talk about surgical challenges, although there are several disease processes that are associated with Charcot deformities, the most common cause in the US is diabetes, as we know. The aim of surgery is to stabilize and align your foot and ankle and to make it amenable to wearing appropriate either braces or footwear. Surgery for foot and ankle is replete with many technical challenges, as well as assumed post-operative complications, as we can see. These are high-risk patients. These patients have cardiac, renal compromise, they're malnourished, despite the fact that many of them are obese and they have immunodeficiency. So many of us are really nervous about these patients than when they get wheeled into our doors. Open surgery carries, like we talked about, significant risk of poor wound complication and severe infections, as you can see. So I would make the argument, why not consider minimally invasive surgery for diabetic foot complications and even Charcot? One, this allows the surgeon to perform deformity corrections through small incisions. You have less soft tissue trauma and you're gonna have a reduced frequency of what you can see over here, which is one of my patients, a bad soft tissue complication. So I'm gonna talk to you a little bit about where we can apply the BRRRR in complicated neuropathic and Charcot patients. So let's start with the forefoot. So patients with neuropathy, most likely from diabetes, are gonna come in most frequently with claw deformities. And we know this is an imbalance between the extrinsics, which are strong, and the atrophic intrinsics, which have gotten weak. And you get a resultant flexion deformity at your PIP and DIP joints. And you have this hyperextension at the MTP joints. And these patients oftentimes ulcerate on the top of the toe or at the tips of the toes. And so some of these patients come in, they have poor blood flow, they have terrible skin. The idea of making any kind of incision, putting pins in these patients, is just not something that we're looking forward to doing. Well, this is where we can start looking at maybe some MIS approaches to correcting these. So this is just kind of like a really whirlwind approach, but it really is a sort of blue plate, look at the patient's deformity and look at ways to correct it. So if we're looking at a claw toe deformity, you can do these flexion releases, both releasing the FDB release at the PIP joint, or even the FDL at the DIP joint. You could release the plantar releases. And you can see from that top right-hand side, you can do this with a beaver blade without making a large incision. And so you've released some of the soft tissue deformers. And then at this point, you can look at doing correction of bony alignment through tiny incisions where you're doing corrective osteotomies. It can be a closing wedge osteotomy. And I think I'll show this on a slide that follows this to help correct the extension of the toe. And even at this point, we'll talk about moving on to the correction of the MTP extension, either with soft tissue releases, including the EDL and EDB like tenotomies, or even shortening osteotomies like the DMMO procedures. So real briefly, how do you do a proximal phalanx osteotomy? And again, this isn't the scope of this, but this is just to show you guys techniques that we use to help make these corrections. So this is an example, how we would go ahead and do a closing wedge osteotomy of P1 using the birth. So you're making a tiny incision either on the dorsal side coming inward, or more commonly on the plantar aspect. And we're doing this closing wedge osteotomy, leaving the dorsal cortex intact. And then when that is performed and the toe is plantar flexed, you can see this correction. Again, all of this is performed with these safer tiny percutaneous incisions. The DMMO, which stands for distal metatarsal minimally invasive osteotomy, can be a really powerful tool to be able to correct metatarsalgia or load across multiple metatarsals. These are performed extra capsular using a cutting burr, as you can see here. We typically perform this at a 45 degree angle, and this is outside the joint. But sometimes we wanna modify this type of osteotomy. And there has been the technique described as the DMDO, which is a distal metatarsal diaphysial osteotomy. So this osteotomy is similar to the DMMO, but we're making this a little more vertical and proximal to what we would consider the DMMO. When you do this, you're gonna have greater potential for that metatarsal head to elevate. And again, for patients who are having diabetic ulcerations on the metatarsal heads, this is what you wanna look for. And so this has been described and reported in the literature. So let's move on to other areas of the foot. So if we're thinking about midfoot deformities, one of the things that some of us might be able to use for patients is an exostectomy. And again, this is something that you guys can do through an MIS incision and using the burrs. So an exostectomy is indicated for patients who have bony prominences secondary to joint dislocation or subluxation. But I think the caveat you have to be able to confirm, this is a patient who has a stable midfoot or hindfoot. So the example here is a patient that I think years ago, I had done a triple arthrodesis on her for a Charcot hindfoot deformity. And she came in overall doing well, but you can see she has this plantar exostosis on the plantar aspect. With this, I made a small little stab incision, was able to introduce either a 3.1 or 4.1 millimeter wedge burr. And through a small incision, I was able to just mill away that bone spur without making an incision for this patient. You can excrude the bone paste, irrigate it, and you're done. And I think that can be a very simple, low risk procedure for patients. If we flip now to the patients who have more unstable deformities, now you're looking at patients that require midfoot or hindfoot arthrodesis procedures. Again, the indications are patients that do not have plantar grade foot alignment. They failed non-operative treatment with joint instability or recurrent ulceration. And if we look at this slide, this is what we put up for the reasons to consider surgery for Charcot. But I can make the argument, okay, well, let's look at it. Is this patient somebody that we can consider using our MIS skills and techniques for? So major corrections can be obtained in patients with high risk deformities and high risk patients. So this is an example from one of my colleagues, Dr. Younger, who you can see a patient who had a collapse at the midfoot, rocker bottom deformity, very severe diabetes, and also peripheral vascular disease. So this isn't a patient that anybody's looking forward to making large incisions and making correction and putting large internal fixation in. And so you can see there's a lot of fixation in place in this patient. But as you can see with the correction and the placement of the fixation, this is all performed through small incisions, and you're introducing much less risk to these patients despite being able to correct the deformity that they had. So I'm gonna walk through sort of kind of ABC, a little bit of a recipe on how to do a midfoot correction using MIS technique. So typically what I'll do, and some of the videos are provided by my colleague, Dr. Miller, who is over in Scotland, and I wanna thank her for some of these. But what we'll do is I'll place my patient's foot over the edge of the table, and I bring my mini CRM in under the foot. And that's gonna, again, guide me no different than a lot of my corrective forefoot procedures like bunion. If the patient has a tight Achilles tendon, I'll perform a percutaneous lengthening before it. I'll place two K wires as you can see here on this X-ray that will act as a guide as my plantar medial closing wedge osteotomy. And then what we're gonna do is you're gonna use typically a cutting burr in the beginning, usually a two by 20 millimeter cutting burr, and you're gonna introduce this between these wires to start creating those osteotomies along the distal as well as proximal K wires. And so you can see that on that video that Dr. Miller is showing you. Okay, so again, as you can see, instead of making this large incision and taking this large wedge out, we're making tiny incisions through this whole thing. Once we've created these cuts, both at the distal wire and the proximal wire, I'm gonna replace it with the wedge burrs to be able to mill the bone. And so here's looking a video, and you can see the example. We're in that small incision, X-rays there, it's guiding me through this whole thing, and I'm just milling across this area that I'm gonna wanna resect anyway. Once we've accomplished that, then you can see you can excrude a lot of bone paste. So you can see all of that. It's a lot that you're able to accomplish through that. And again, a lot of surgeons are worried about, in the beginning, am I in the right location with my burr? And I would argue this is the perfect place to start because, again, this anatomy isn't normal, you're resecting it anyway, and so the burr is really safe within this tissue. And then if you look at this video here, once you've been able to accomplish it, you can start looking at the mobility that you get to be able to correct your deformity. So once you feel like you've resected enough of that deformity, then typically I'll put K-wires again on either side of the wedge resection, and I'll use this to help close my deformity. As you can see, both in these videos, we're correcting that abduction deformity, you can correct that rocker-bottom deformity as well. So once you've been able to do this, mobilize the deformity, then fixation's no different than what we've all started to learn to do with Charcot deformities, particularly at the midfoot. Again, if we look at internal fixation for this, intramedullary screws, nails, they limit the risk of wound complications as they can be placed percutaneously. So they complement MIS surgery very well. And you can see these are multiple examples of both screws or the bolts that we talk about from multiple companies. Here's an example of a medial column nail fixation that's used for this kind of rocker-bottom collapse that happened basically at the nivigal cuneiform joint. And the same sort of principles can be applied to the hindfoot and the correction as well. So again, you have a patient with a bad deformity, you can use burr debridement to debride the joints, mobilize the joints, and again, using a TTC nail complements that idea of minimal fixation. So what are some of the outcomes of these techniques? Well, there's not many publications on it. Most of them are level four. As I had mentioned, Dr. Miller provided the video and she had actually published in FAO in 2018, her experience on 16 patients that she did her triplanar MIS correction. And she followed these 16 patients anywhere from three months to three years. And no different than a lot of Charcot patients, she saw some complications, four deep infections, one that had broken hardware, one that developed a hindfoot deformity from their midfoot and needed a nail from there. But importantly, not a single one of these patients needed an amputation after this procedure. Bradley Lamb published his results on a MIS approach where he would do osseous realignment that he would achieve through mini incisions, osseotomies, he'd put an external fixer as you can see, so it was two staged, and he would gradually correct the deformity as you can see through the X-Fix that was placed on here. And then once this was corrected, he would then place his internal fixation. And he published on a small group, eight patients, had a couple of complications including broken half pins and wires, pin track infections, but again, no deep infections, no recurrent ulcerations, and more importantly, no amputations. So I would argue, again, this is something to think about, diabetic prophylactic surgery being more aggressive plays an important role in establishing better outcomes for our patients, preventing and treating foot ulcerations. I think we all know that. Charcot reconstruction we also have seen has gained a lot of increasing popularity due to the fact that we know it improves long-term limb salvage. Initial results adding MIS neuropathic surgeries are there to suggest that they may offer even better surgical outcomes, including less risk infection potential, decreased vascular complications and increased healing problems. So again, I wanna thank Dr. Miller for some of the videos and I wanna thank Holly for the invitation to speak on this interesting topic tonight. All right, Becky, thank you so much. You made it look really easy, but I think for the debridement, it just makes a ton of sense to use the burr as opposed to make large decisions to put a saw in there for an osteotomy. So to me, at the most basic level, doing debridement with the burr is kind of a no-brainer. So we're gonna switch gears a little bit here to some slick arthroscopic surgery for Achilles. And Chris Miller will talk to us about that. Okay, well, thank you so much for having me, Holly. I really appreciate it and just, I think we all learn as much from you as from everybody and thank you for being a leader on all of this stuff. And so I'm gonna talk about endoscopic-assisted insertional Achilles reconstruction. These are my disclosures. I do, this is all related to MIS and I will show some arthritic stuff, but it's certainly applicable to any of the companies. So the first question is, I think why think about doing it endoscopically? Open techniques are classic. You can do a double row, you can do a single row repair. The outcomes are good and it allows easy access to the pathology. And this has been a standard of mine that I do frequently. And I love this, how I learned to do it and it's how I was taught in residency and fellowship. So why change? And I think one of the things that you'll hear from anybody that doesn't love MIS is that you change because you get something like this. You get a wound, you have to call your plastic surgeon for help and you take somebody who has what should be a slam dunk case and now they're just off to the races and I think many of us have had cases like this. And so, and also I would say that if you wanna be an MIS surgeon and explore what your options are, like here's a somewhat out of the box option for you and to try thinking about how else can I explore this and see if I can benefit my patients with it. So why endoscopic? For me, I have less wound issues that I worry about, and less wounds in general at the posterior heel. If I have someone who's very active, I might worry about a tendon evulsion if I'm doing a single row repair, less nerve injuries, stiffness. And so I wanted to say like, can we find something that's reliable that would work here? So I like to try and find sort of a same surgery or similar surgery to what we have. And I'm really looking forward to Oliver's talk here. And I'm very interested in this data technique and I'm looking forward to your talk, Oliver, so convince me. But if you're not comfortable with it, this is a way that we can still limit the wounds, faster recovery, and we can turn that into this, which most people are gonna be familiar with looking at the open approach. So how do you do it? I'm gonna walk you through. So first you start in a prone position and you wanna bring the C-arm in. Now, this is how I started. Do not do this. This was a big pain for me and I learned better. So the way I do it is actually bring the C-arm in from the top. And if anybody's starting, even if you're doing open techniques, think about bringing the CRM in from the top, because then you're not working over the arms. So that's just a little technique for anybody. So I'm right-handed. I need to get my burr in on the right side. So I'm always going to leave the emitter further from the foot. And so I'll bring the CRM in from the right, and then my scope tower will come in from the left. So these are the incisions, and I learned this from one of my fellows, to start the incisions a little bit more on the outside or medial-lateral aspects of the tuberosity. So if we're doing it open, I'll expose, I'll come in, I'll put my drills tunnels pretty directly in line. With these, my portals are going to be a little bit more on the side, and that's because I want to be able to get my burr in, and then sweep down the line and resect all of that bone that we see, and I'll show you some pictures of that in a second. But I try to center the, or spread the portals around the four corners around the spur. And this is going to be where I put the anchors through as well. So this is the planned debridement that I'm going to try to achieve. And so my first initial part of this is going to all be fluoroscopic with the burr. So I'll use a 4.3 millimeter wedge burr, and I'll come in through the portal, I'll elevate the tendon off, get into that retrocalcaneal space, and then I'll start up right above that Hagelin's bump, and I'll just get right into the bone and start undermining it. So I think one of the things, as you get into MIS, is you often want to stay in the bone and then work out, because it's always safer that way. And the same thing here. So I'm going to get into the bone and then work my way up, and then eventually I'll sort of detach that. I can usually fish it out with a snap or something through the portal, or get it with a scope later. And again, I can use, actually what I was going to say is up above, if all your pain is at the Hagelin's, you can just take that down and then you're done. Put the scope in, resect, but you don't have to detach the tendon. And for some of my runners, that's a nice technique. If they're having pain down at the insertional spur, and I want to get that as well, I can just keep rotating my hand around, come down the spur. And as I do that, I'm going to elevate the footprint of the Achilles, but you can get right down to the spur, as you can see here. And that's going to create my working space for the scope at the next step. Again, I'll use all of my portals to get around, and it's a lot of feel. So I'll feel where it's high, where the, if there's a bone spur, if there's a high part of the bone and I want to file it down with the burn, I'll do that now. And I'll look at it with the scope as well. My goal is to create that sort of front of the VW bug, which is what Dr. Reed showed me at Yale when I was a resident. So I still try to do the same thing. I'm just doing it with the burn, the scope. Okay. So now we have this, we have a big bone, we've done the resection, but we have all the bone slurry still in there. So now I'll flush it out or I'll take the scope. And in this case, I usually use a large joint scope because I have better visualization. I get more flow through the area. One issue with the smaller scope I find is that because the portals are pretty close together, the fluid just comes out a little too fast. So with the larger scope lets me keep, keep to insufflate it a little bit better. I'll use a four or five shaver with or without teeth. And then we just take out all the, all the debris first. And now we're going to visualize from the bottom, I'll look up the slope and I'll take the shaver from the top or really from any of the scope portals that I need to work through. And I can use that to remove any of the sort of retrocalcaneal bursa that might be in shape that might be inflamed. And then I'll look up at the tendon and I'll remove any sort of damaged tendinopathy on the anterior surface of the Achilles. So I will always get an MRI of these. And so I try and see how much of the tendon looks bad on the MRI. And I try to take that much out. It's certainly a little bit of a guessing game. My resident has often said that he feels like it's like decompressing the acromion. So that can be a nice sort of analogy to help get your orientation because we're not spending that much time, unless you're doing this, scoping right underneath the Achilles tendon. So it can be a little disorienting at first, but I try to debride the anterior surface. And sometimes I'll actually take the scope out and under x-ray, I can actually feel where the shaver is. I'll just push down the tendon to help get a little bit more resection of the tendon if I have to. And as you do that and you get more experience, you can feel how much tendon you have left. And I usually try and take about 50% of the thickness, depending on how thick it is. Okay, so now we've decompressed our, we've removed the bone, we've decompressed the retrocalcaneal bursa. You can even come up and do a little bit work in the back of the ankle if you wanted to. We've elevated our tendon and now I want to repair it and hold it back down. So now you have, you see the drill coming through the proximal scope portal. So we're looking up the slope from the bottom. I'll drill, I'll tap, I'll put the anchors in and the sutures coming out the two portals. I'll take a free needle, I'll pass it through the portal, through the tendon and out posteriorly through the skin. So if anybody's ever done like an arthrobrostrum, now you have to retrieve the sutures from above the tendon, superficial to the tendon, but under the skin. So I make a little subcutaneous pocket there, take a crochet hook or a arthroscopic hook and just reach in and pull them out. So I'm back through my portals, but I'm through the tendon. I'll take a straight micro suture lasso. I pass it sort of through the tendon distally and I, to each of the two proximal portals and I grab one suture from each of them. I like to pull it slightly through the tendon. I feel like I had one patient who maybe had some irritation from the fiber tape just under the skin. And so by pulling it just slightly through the tendon, I hope to avoid that. But I'm trying to make that same speed bridge type repair that you do with the open with one limb going to each of the two distal portals. Okay. And then we drill, we tap. And just like with the open, you're going to tension both of them, put the anchor where you want it, market, back it up and impact it into place so that you flatten the tendon down on top of the resected bone. And so this is the same picture I showed earlier, but this is the pattern we're trying to do. We're just doing it all through the endoscopic approach. And so this is the final result here for this patient, two weeks, really no pain. She'd already been walking on this in a boot for about 10 days at this point. And you can see up above, we also did a endoscopic strayer as well. So this is my post-op protocol. They're usually in a boot for four to six weeks. I give them partial weight bearing for about a week and then weight bearing is tolerated. And they're usually out of the boot by six weeks and starting PT at the two to three week mark. So why augment the repair? So we have a double row. We know it's better than single row. This was a biomechanical study. So immediate implant, two to three X peak load to failure with the double row compared to single row. And then a shout out to my former fellow here, Max Mikulski, who's in LA at Cedars. He did a great study looking at open single row repairs versus an endoscopic repair. And I was just talking to him about this yesterday to make sure I got the story right. In this case, they did elevate the tendon and then they evaluated it and it was actually three times higher peak load to failure than with the open. And some of their theories was that you leave some of the investing soft tissue attachments and you probably don't elevate as much of the edges of the tendon as you do and the most distal part of the tendon as you do with the open approach. So with the double row repair plus the added strength and endoscopic repair, I feel very comfortable letting these people walk pretty early on. So who's the right person to start this with? I think a smaller spur, somebody with more mild to moderate tendinopathy on MRI. My goal is I don't want to have to debride too much of the tendon where I'm worried about fixation or getting the double row fixation to hold down. I think it's a great option for that isolated Hagelin's pain patients or some of my runners who just having pain at the retrocalcaneal bursa, large Hagelin's, I'll take that down, scope and debride the area. And that's a very efficient way. And then you don't have to repair the tendon either. So Dr. Jordi Vega, one of the true masters in the whole world on these techniques has published his series about 15 patients looking at a similar but single row repair with very good outcomes in his patients here. And a recent meta-analysis, certainly a number of problems with this, and it was mostly level three and four studies, but it did have 1200 ankles in total. So they showed for the open, it was 87 final mean of AOFA score 87 versus 90 for the endoscopic and then lower complications and actually a faster return to both ADLs and sport. So I think a very interesting study, interestingly, most of these endoscopic cases from what I was able to glean did not involve repair of the tendon. They did include Dr. Vega's study, and that was one of the only ones that did. So that's where you start. What do you do if you have something like this? And this is courtesy of my friend, Jim McWilliam. So if you have somebody with a lot of tendinosis, a lot of calcification, you're going to debride the whole area, but this is going to result in a large debridement of the tendon. And I would be worried about fixation as well. So in this case, he augmented with an FHL tendon transfer. And so you can see here, he used two additional scope portals at the ankle to go get the tendon itself. And this is one of my cases I did for a chronic Achilles rupture, but you can retrieve it through one of the portals, whip stitch it, and then you just drill through the other portal just as if you were doing an open one. And again, Dr. Vega here has beaten us to the punch and published a series on this. So this is the equipment that I use for the case. You can take a picture of this or save it for later. Please remember, bring the CRM in from the top, it makes your life a lot easier. And I thank you very much for listening. And I hope you guys all learn something and join us in the MIS world because it's wonderful. Chris, that was an awesome talk. It's such a great technique. And it is really challenging. I have tried it. I think that starting with something, you know, with a patient who has a little less significant tendinopathy is probably better. I just have one quick question. Do you try to take the whole tendon off? Or are you, you know, especially in the plantar side, like it looked like it on the images that you showed on those scope images, is that your goal? Or is that just if you need to, you do it? If I need to, I do it. If they're having pain right at the spur, I usually go, I try and go down and get it. And I think in the process of that, I'm probably elevating most of the tendon. I'm probably, I'm probably, I don't open to check, but I doubt that I'm getting the plantar medial and lateral aspects of it. So I'm probably mostly elevating the central part of it. Cool. Oliver is going to show us another way of treating Achilles insertional tendinopathy. That's also pretty exciting. Oliver, you're on. Great. Well, let me tell you guys, MIS has been an incredible journey, and it's been obviously incredibly fun to do this with Holly and very rewarding, so I appreciate the opportunity to speak. Let's see if this advances here. Here we go. Here are my disclosures. So I'll go through background. We'll discuss indications. I'll go through the technique, and then I'll show a few cases to kind of go through this. So why not open? I think Chris already alluded to this, but, you know, especially for insertional reconstruction, these patients definitely have an extended recovery. Even in younger patients, I think, especially if you include a gastrocnemius recession, you know, they can sometimes take 6 to 12 months to kind of get back to where they were preoperatively in terms of sport and activity. You know, it's always unclear how much tendon do you take. You know, sometimes a lot of it looks like crab meat. You know, you're trying to remove as much as you can, but are you really getting all of it, especially far medial, far lateral? I already discussed these patients can take a while to return to sport, sometimes as late as a year. Knee problems, that's been discussed already. You know, these patients always, always, always have waxing pain or pain and swelling. Around the 2 to 3-month mark, as they start to recondition their Achilles after getting out of the boot, definitely can see seral nerve issues occasionally. And then again, this is really not, it's not ideal for athletes with this extended recovery. So again, I was looking for something more. So I mean, I think this is so cool, right? So Dr. Zadek, who's pictured here, you know, this technique is actually first been described back in 1939. He's an American orthopedic surgeon. You know, he was obviously a general orthopedist at that time, but this is just a very cool article. If you haven't read it, these historical articles are always interesting. You know, he states here at the beginning, it's most frequently seen in women and was directly influenced by the pressure of the upper quarter of a shoe, really a heel, posteriorly since women's shoes are necessarily more cupped to keep them on their feet. So again, he was a little bit off there, but he was definitely onto something with the Zadek osteotomy as an option for Achilles insertional tendonitis. So in terms of literature, there's actually been a fair number of papers published on the open Zadek procedure. This first paper shown here had 52 athletes. And again, in Europe, this is done frequently for soccer players as a way to get them back to sports sooner compared to the open technique. This paper had a minimum three-year follow-up, again, a high level of good to excellent results. Return to sport on average was 21 weeks, and again, plus minus eight weeks. So the earliest was around two months. There was one revision for displacement of the Zadek osteotomy. And this technique in this case did include a Haglund excision as well. So it wasn't just that dorsal flexion closing or that dorsal closing by the osteotomy. It also included a retrocalcaneal exostectomy. And again, that was the open technique. So there was a few superficial wound infections, one incidence of soral nerve neuropraxia that resolved over time, again, but that was the open technique. So this lower paper here was performed by Dr. Ettore Fulcano and his colleagues. This is really the only percutaneous Zadek osteotomy study in the literature, it was published recently. It included 26 patients. Again, it was an early follow-up, early experience, minimum six-month follow-up, but mean 12-month follow-up. Showed significant improvement in pain function scores, including FFI and BAS. There was one revision for nonunion, and that one nonunion occurred, per the author, believed secondary to breaking the plantar hinge, and so that allowed some slight displacement of the osteotomy. And then finally, there was one patient who just did not improve clinically, although that patient was excluded because they also did not improve with an open traditional Achilles reconstruction, so the thought was maybe their source of their pain was maybe from their lumbar spine or other cause. So this is just a great paper if you've not read it. Dr. Torm from Europe, he has published a lot and discussed the open Zadek osteotomy extensively, but he was able to describe why this technique is so different biomechanically and why patients improve with the Zadek osteotomy. He basically scientifically explained it, explained kind of what we were seeing in our post-op patients. So a few key points here. So number one, when I started doing this, I would do a silver skull test before and after the Zadek osteotomy, and I couldn't believe how much they improved in ankle dorsiflexion with the knee straight, and here he is showing there was actually a mean improvement in ankle dorsiflexion of 7.27 degrees. So it definitely, you know, decompresses or removes tension from the Achilles complex. Also, the calcaneal pitch decreased from 28.95 degrees to 19.77 degrees. And finally, the mean XY ratio, and I'll show you what that is in a second, improved from 2.18 to 2.75. So really, Dr. Torm describes this as the ideal technique for patients with what he calls the posterior cavus, very kind of high arch foot. He believes these patients have a higher risk of kind of mechanical irritation of that posterior superior corner of the calcaneal tuberosity on the Achilles insertion. So, you know, again, if you're looking for an ideal patient to do this in, that posterior cavus calcaneus, we call the long calcaneus, or really typically a cavus appearing foot on the lateral, that may be your ideal patient to do this in as a first patient. So this is taken from his paper, and this really kind of describes what we were just looking at here. So he's referring to PAR1 as the calcaneal pitch here. You can see the Zadek osteotomy or the dorsal wedge that's removed, and here's the XY ratio. And so typically in patients who are symptomatic, they often have an XY ratio less than 2.5. And with the Zadek osteotomy, that will actually improve. So, you know, again, the ideal patient to perform this in is typically a higher arch patient with posterior cavus. That being said, I've done this in patients with a more neutral or even flat arch, and they've done great as well. So even though I think the ideal patient probably is a cavus foot, you know, again, I've done this in people with a reduced calcaneal pitch, and they've still done great. So indications, again, these are typical patients with insertional tendinosis, so that constellation of either Hagelin deformity, calcific metaplasia at the insertion, partial tearing, retrocalcaneal bursitis, obviously they failed conservative management, and then again, ideally they've got an XY ratio less than 2.5. So what about setup, right? So these patients are, for me, on beanbag lateral. I think if you're ever doing isolated calcaneal osteotomy or isolated percutaneous subtalar arthrodesis, beanbag lateral is great, very easy to throw your screw once you're finished. And the entire operative foot in this case is off the table, resting on the mini C-arm. I put two blue towels beneath it, so I don't, you know, go along with the bur or puncture beneath or puncture the plastic over the C-arm drape. I have the contralateral leg flexed out of the field, so I don't have to deal with it with the C-arm. I'm not obstructing my view or obstructing my ability to work with the operative heel. I use the three by 30 millimeter Shannon bur. This may vary by the company you prefer, but the key here, so some companies have a three by 20 Shannon bur. The key though is that you use the 10 centimeter calcaneal bur, and again, most of them, some companies just have a seven centimeter bur. Again, you want the 10 centimeter, especially for a larger patient with a wider calcaneus. If you just use the kind of stock seven centimeter burr, you may end up hubbing the hand piece on the skin or have to pull it out and then it could become loose. And this is typically done with a four in one reducer. So that means the torque is about four times the speed and that's to reduce heat generation. For my calcaneus osteotomies, I use 6,000 RPMs for speed. And you can use a three millimeter wedge burr to widen the osteotomy dorsally. Although I would tell you this can all be done with a three by 30 millimeter Shannon burr. I never use a tourniquet for my minimally invasive procedures with the burr. And the reason being, especially for the calcaneus, obviously secondary to the width of the bone, even if you're irrigating at the skin portal, it's very hard to cool the burr buried deep in the bone, especially with a longer calcaneal burr. So again, I want that slow ooze of blood to further prevent thermal injury to the calcaneus, which could put you at risk for non-union or delayed union. And in keeping with that, I always use copious irrigation with chilled or refrigerated saline through a bulb syringe. I don't really feel like the small spout that comes out of some of the hand pieces is adequate for irrigation, especially when you're using 6,000 RPMs on the calcaneus. So these images are courtesy of Ettore. Just in the short time period, I had to put this talk together. I didn't have a case to get these pictures, but the incision is made down at the apex of the osteotomy plantarly. And again, you're on the lateral calcaneus over here, obviously to stay away from the nerve bundle medially. So your incision, it's about an eight millimeter incision at the apex. I make it about five millimeters dorsal to my plantar hinge. And you always wanna maintain a five to eight millimeter cortical bridge plantarly. Again, that will give the osteotomy stability and reduces your risk of a non-union or displacement of your calcaneal osteotomy. Ideally, you're taking a seven to 10 millimeter wedge of bone dorsally. If you go below that, you risk under correcting, and the patient could have continued symptoms. Obviously, if you go beyond that, you could significantly tension the plantar fascia plantarly. You could significantly flatten the arch. So again, it's a fine balance here, seven to 10 millimeters is what's recommended. And I will mark out on the skin my wedge. So I can follow that line with the burr, obviously in opposite as I complete my osteotomy. So typically when we do calcaneal osteotomies for medial lateral slide or Dwyer, we separate the four quadrants. For me, for the Zadek, I separated the three quadrants. So again, we're entering the calcaneus plantar and lateral. And what I do is we've got here as shown, we've got the medial plantar third, we've got the dorsal third, and then we've got the lateral plantar third. So what I will do is go in with my burr at the junction of the medial plantar third and the dorsal third. And then with an underhand grip on the burr, drop my hand to basically remove all the bone from the dorsal third, all the way back to the lateral plantar third, because it's a very ergonomic maneuver. Then I'll go back to where I started and move and complete my osteotomy plantarly then on the medial third. And then finally, I'll use that three millimeter burr to widen the osteotomy dorsally and take my full dorsal wedge of typically around for me, eight to 10 or seven to 10 millimeters. You don't need to widen the osteotomy significantly plantarly. It's really dorsally where you need to widen the osteotomy. And so here's what it looks like. And the beauty of this is once you're finished, you dorsiflex the ankle in order to close down the osteotomy. And I'll run this video here. And the great part about this is then, post-operatively you put these patients in a short cam boot and that keeps them dorsiflexed to again, protect your correction. But here you can see I've dorsiflexed the ankle. And this is definitely an example of that posterior cavus calcaneus here. So you can see how the osteotomy closes down nicely with dorsiflexion. So here's just a pre and post, again, showing my dorsal wedge. And then once it's closed down with, I typically use a seven millimeter headless cannulated screw. I know some people who use two screws just to give added fixation. I think if you're gonna wait bare these people at two weeks, which you can do, maybe two screws would be better just to allow you to sleep at night. I don't have literature by mechanics because it's for one or the other. But again, I typically use one seven millimeter screw and you can see here a small Eichmann deformity was left in place. Another teaching point, ideally your osteotomy, the apex is right at the level of the plantar fascia origin. You just need to keep in mind, the more distal you go to that, the more you may tension the plantar fascia and reduce the calcaneal pitch. So again, something to keep in mind. And this is what it looks like when you're done, right? It's a fairly quick osteotomy. It doesn't take that long to do, usually about 20 to 30 minutes out the door, especially once you become fast on with it. And it's just these two small incisions. So there's no splint needed, just put them in a short cam boot off the bat with a small soft dressing. And so post-operatively, as I mentioned, you can do two or four weeks non-weight-bearing and short cam boot. I certainly started with four weeks. When I initially started doing this, I've kind of moved to do more two weeks. If you have any concern about your plantar hinge, you can obviously be more conservative and do up to six weeks non-weight-bearing. I keep the patient in the boot for six weeks total. I allow them to start driving between four and six weeks in a regular shoe. They start physical therapy in four to six weeks, and then they're okay for full activity as tolerated at eight weeks post-op. So again, it's a fairly different recovery here compared to an open reconstruction. So I'll go through a couple of cases now. And so here's a preoperative radiograph. You can see there's some obliteration of Hager's fat pad. You can see significant soft tissue swelling at the insertion. There's a small little obstacle of calcium metaplasia there at the insertion. You know, this is a relatively flatter calcaneal pitch in this patient who's got some slight sag of the ventricular cuneiform joint. And here's an MRI. So when I first started doing these cases, my first patient I did this on, he was a young runner, wanted to get back to running, had very mild changes on the MRI. But then I said, okay, he did really well. Let me try this on kind of a patient who's a disaster. And so my second one was a rheumatoid patient. She had just significant pain, could barely walk, high grade partial pain at the insertion. And again, did great. Her Achilles insertional pain was gone by two weeks. And again, that's fairly typically what we see. What we do tell patients is that they may have some vague kind of heel pain for about six weeks to three months. Again, it tends to resolve over time. But here you can see on this MRI, clear partial insertional tearing, retrocalcaneal bursitis. You can see some signal within the Achilles insertional tissue. And here's what they look like when they're finished. And again, she came in two weeks, her pain was gone. It's just, it's surprising how quickly the Achilles insertional pain goes away when you change the biomechanics. Here's another patient. Again, you can see in this case, you can see a little more calcific amyloplasia at the insertion. Definitely a Hagelin deformity here. You can see here, this patient has even more signal at their distal Achilles tendon, distal midsubstance. Partial tearing again. Again, doesn't look great on the MRI. And again, with the Zadek, no pain in two weeks and has done great. So this is one, again, I've been doing a lot of Zadeks. I thought, hey, there's something to this. These patients are doing really well. This patient five years prior had an open insertional reconstruction at an outside institution. He's a Home Depot supervisor on his feet. He works nights. Came to me, could barely walk secondary to insertional pain. And he said, look, I went through that insertional recon before. You can see he's got calcific metaplasia, heterotopic ossification here at the insertion from the Z's tendon. You know, he hasn't had recurrence of a major Hagelin deformity here. You can see there's clear Achilles insertional tendinosis. You can see the thickening of the tendon. He told me, look, I really don't want an insertional reconstruction. Took me forever to get through this. I said, hey, look, I can try this. You know, we'll see how you do. This would be kind of pushing the envelope for this technique. And here he is, here's his MRI. You can see some edema in the bone of the insertion. You can see some edema surrounding that area of heterotopic ossification of the tendon. You can see clear thickening. But again, did a Hagelin procedure and he was back to work by six weeks. Again, his insertional pain was gone. He was walking without an assistive device. So again, you know, this can also be used to revise open procedures. And I think you say, well, why does this work? You know, in this case, most likely a large part of it is secondary to that reduced tension, that increased ankle dorsiflexion, you know, working in his favor here to improve this patient. But again, you know, an indication that may be pushing the envelope here, but this guy did great after surgery. And so again, it's not like I've totally flipped the lid and, you know, this is the absolute treatment for all Achilles insertional disease. You know, I still will open from time to time. Here you can see, there's just so much calcific metaplasia here, heterotopic ossification. You can see the tendons totally thickened, complete obliteration of Kager's fat pad. You know, this is still someone I would open and do your traditional Achilles insertional recon with. So in terms of complications, again, I've already discussed most of this, you know, nonunion is always a complication. Really the keys are don't break your plantar hinge, if at all possible. If you do use two screws, you want to avoid thermal injury from the burr. You know, I typically, with all my, whenever I'm doing an osteotomy with the burr, I pause about every 10 seconds. I'll often clean out the flutes, clean the bone out of the flutes. I will use copious irrigation, as we discussed, even refrigerated saline. I've gotten to that extent. I never use tourniquet, right? Those are all the things you keep in mind when you do this, especially in your learning curve, when you're still getting a feel for the burr. You know, a lot of people, when they first started using the burr, they kind of jerk the burr and force the burr. You really want to let the burr do the work. And as you kind of force it and push it more or jerk it, you know, it puts you at risk for breaking the burr or generating more heat. So again, you always want to let the burr do the work. And these tips will hopefully help you, or help protect you in your learning curve. As I mentioned, I have seen some plantar fasciitis in the post-op period, but it's always been mild. I've seen in my series, two cases of it, both resolved with physical therapy. And I think that, you know, it makes sense biomechanically why you may see that. As I already discussed, you could see displacement of the calcaneal osteotomy. It was described in Ettore's paper. I have not seen it personally in my series. But again, I think the keys are really keep that plantar calcaneal hinge intact. And you know, the deal is, right? So if you dorsiflex the ankle and the osteotomy just doesn't close down, you just feather the remaining plantar hinge a little bit, take another millimeter or two, right? And then try again, and you do that until it goes. And then the other key is you just, throughout the rest of the wedge, sometimes you leave a little bone bridge on the far medial side. There's a lot of feel to doing a calcaneal osteotomy. Just use that burr tip to take a feel, or you can use a Fourier elevator if you prefer, because it's less sharp. And make sure you've gotten all those little bone bridges. There's definitely a feel to using the burr. So in summary, use copious irrigation. Always try and maintain a five to eight millimeter plantar cortical bridge. Remove a seven to 10 millimeter dorsal wedge. That seems to be the sweet spot. Ideally, the apex is at the level of the plantar fascia origin. Again, you could go distal to that in the true posterior cavus foot. I wouldn't go much distal to it in more of a reduced calcaneal pitch patient or flat foot. And then for longevity of the clinical outcome, there may be some role to excising the haglund with a three millimeter wedge burr or the calcaneal burr at the same time. I can tell you in the short and medium term, you don't need to do this. But for the longterm, there may be benefit to doing it. I certainly wouldn't fault anyone for doing that. But again, we need further clinical studies to determine if really that's necessary or not. So again, thank you so much, Holly, for the opportunity. This is something near and dear to my heart. I also have to give a shout out to Ettore. He's done certainly a nice paper on this and really got going early on the percutaneous technique for this. So again, thanks to all. Great. Oliver, thank you so much. That was fantastic. There was a couple of questions. One question was, let me read it. We want to avoid taking too much bone and causing too much lengthening of the Achilles or causing varus or valgus malalignment. Would you consider the Zadig for a patient with a normal silver skull? Definitely, if they have Achilles insertional disease. Yeah, I mean, I don't let the silver skull be the dictation or dictate what I'm doing this in. What I have not seen, Chris and I were actually talking about this before we started the webinar, but I think another study that would be very interesting to do is, especially compared to say a gastroc recession, do you see the same amount of functional weakness after a Zadig as you do with a gastrocnemius recession? Because what I can tell you anecdotally is these patients seem to return much faster than they do with the open procedure. So again, that's not dictated. This really doesn't necessarily change the varus or valgus alignment of the heel, but it does change the calcaneal pitch as I discussed in the talk. So again, varus or valgus doesn't so much matter, but hypothetically, valgus, you could say, well, it's most likely associated with a flat foot. And so, yeah, you want to be mindful of where the vertex of your osteotomy is or the apex of it to make sure you don't dramatically reduce the calcaneal pitch. Although I can tell you again, in the patients I've done this in, they've still improved clinically after Zadig. Great. Do you have any absolute contraindications? I mean, I would say a severe flat foot where their whole medial column, they're basically walking on the medial column of their foot. That would be one. I showed that one image there of just a severe calcitic metaplasia, the insertion. I mean, that's not going to go away with doing a Zadig, right? You got to address that open. You know, a prior failed Zadig, I'm not going to go back and revise that with another Zadig. I actually had a patient who was done, it came to me, had been done about eight to 10 years ago. He was an elite tennis player, just had recurrence of symptoms about a year ago. And again, I'm going to take him for an open reconstruction. It wouldn't make sense to do a Zadig again. Got it. And then Chris, in your arthroscopic approach or endoscopic approach, do you have any absolute contraindications? I haven't gotten quite as aggressive as Dr. McWilliam in taking out. I think sort of the same. If somebody had as much calcification as Oliver showed, I probably would do that open. I think that, you know, I've seen some people come back who've had a partial endoscopic. I would go open in that case also. But, you know, I think I've done most of them this way and I've been pretty happy with it. Great. And then Beck, question for you. Do you find, I mean, I think intuitively, it seems like you'd be able to weight bear the Charcot patients faster based on the fact that, you know, ideally the bone heals faster and you're using smaller incisions and things like that. But have you seen that clinically or is there any publication that demonstrates that? No, I don't think there's a publication that supports we're healed faster, you know, unlike, you know, an arthroscopic ankle fusion versus an open. I don't change my weight bearing protocol per se, an MIS approach to debriding the joints versus an open. It's staying prolonged approach with it. Again, I just feel like this affords me the ability to do what I was doing open, but they come back in that two week post-op visit when you look at them, you're not walking in there with like, you know, like a pit in your stomach because you're just expecting that incision to look bad. But that doesn't necessarily accelerate my weight bearing on them. And again, there are no studies at this moment that say, just because you performed it percutaneous, which may prove out to be, but there are none right now, that they heal faster. Got it, okay. Have either of you guys seen that? Oliver, it seems like you weight bear the Zadig probably faster than we would a calcaneal osteotomy. Do you find that the bone healing is faster than in your former life where you open things up? I would say doing an MIS, I think you see bony bridging more quickly. I mean, the key with the Zadig is, you know, you're keeping the plantar cortex intact. So again, with weight bearing in a boot, it's also dorsiflexing to actually close it down. I mean, I think that's the difference between a typical slide where there's no intact cortex. That gives you a little bit of leeway there. You know, I've only recently started allowing them to weight bear at two weeks if I'm confident I've got a good plantar cortex that's intact. X-rays always allow them to weight bear at two weeks. I initially, when I started doing this, started at four weeks. So again, I've become more aggressive over time, but I think it's whatever you want. You know, everyone always typically starts more conservative when they begin. I think that's the right thing to do. But I would tell you on a bony bridging side, I think doing an MIS, especially because all that bone paste kind of stays in there as bone graft, you know, it's very different. I don't try, for an osteotomy, I don't try and extrude all that. I try and leave it in there. I will irrigate some, but I don't try and flush it all out for an osteotomy just because I want that as kind of biologic bone paste to stimulate healing. Got it. And then Chris, I know you showed us how quickly your patients get back. It's unbelievable thinking about how I feel like in my open patients at three months, we're still struggling to get them into a shoe at that point. So that's, I mean, the endoscopic approach is worlds faster. I have one last question for you though. There's a lot of talk at HSS specifically by Marty O'Malley that he feels that a lot of, putting a lot of anchor material in the calcaneus causes issues. And so most of the guys at HSS, I still use the SpeedBridge sometimes, but most here have really gotten away from the SpeedBridge because they worry about, or whatever brand you use for using that double row technique because they feel like there's this edema that forms and kind of chronic heel pain from all the, I don't know, some sort of inflammatory reaction. Have you seen that at all? Yeah, so I would have said no, but I recently have seen that. I did have to take one of my patients back and I, who was having pain right at the scar and I got an MRI and there was some of the edema, some of the distal things. I opened it up and I sort of drilled out where it was and then cleaned it up and she got better pretty quickly. So I've seen it once with the endoscopic. I've also seen it with the open once there as well. I haven't seen as much as some of maybe they've seen, but I would say, you know, Dr. Vega has a nice, you know, paper showing how to do it with a single row repair as well. And with the added sort of soft tissue restraints that you have when you do it endoscopically, maybe that's enough and something to look at. Got it. So I don't see it too often, but I would like to say never, but I have seen it once. Yeah, okay, sounds good. Well, thank you all so much. Thanks to Oliver, Chris and Becky for amazing talks. Once again, I come out of here knowing so much more than where I started. So thank you guys and thanks to everyone listening. We will end the broadcast now and hopefully everybody gleaned some more skills after hearing our experts. Bye-bye, good night.

minimally invasive surgery

foot and ankle conditions

bunions

Achilles insertional tendinopathy

arthroscopy

corrective osteotomies

Zadig osteotomy

patient selection

surgical approaches

improved patient outcomes