On behalf of AOFAS, I want to welcome you to tonight's program, Managing the Neuropathic Ankle and Foot. It'll be moderated by Dr. W. Hodges Davis. Joining him is Dr. Carol Jones, Dr. Adam Schipp, Dr. Angad Halim, and Dr. Michael Anerni. You can find their full biographies and disclosures in the program document posted in the chat box and on the On Demand Education Center. The 2023 webinars are provided free to AOFAS members and orthopedic resident 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 presentation. 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 clicking on the evaluation and CME claim form at the end of the webinar. You can find the link to the CME claim form in the chat tab, and we'll also follow up with an email after the broadcast. This webinar is being recorded and will be available for on-demand viewing on the On Demand Education Center content library in 24 hours. We encourage you to ask questions during the presentation. You can send your questions by clicking on the Q&A tab in your navigation bar. If we cannot get to your questions during the live broadcast, the faculty will reach out to you following the broadcast to respond to your question. I will now turn the program over to Dr. Davis to begin. Thank you. Thank you, Julie. I'm super excited about moderating this seminar. I am in particular excited that for the faculty, these are all folks that I've been on programs with before, and I know that this particular issue, which is complications of neuropathy, is something that each and every one have a passion for and believe that we need to be raising our game to do better than we have done historically. So with that, I'm going to introduce Carroll Jones. Carroll is my partner in Charlotte and always loved being on a program with him, and he's going to talk about fundamentals of treatment of Charcot using internal fixation. Carroll. Thanks, Hodges, and good evening. I appreciate the opportunity to speak tonight on a topic that I've spent really the majority of my career trying to understand, which is certainly no easy task, and I think you have faculty here that probably have the same experience. And we know that Charcot, if untreated, can progress to deformity, ulcer, infection, and ultimately amputation, and it's critical that we recognize and treat it as early as possible so that we can sort of avoid this cascade. And I mean, I think we all know how to do that with non-operative techniques. I think you'll probably notice through the lectures tonight that maybe a more important strategy in many cases is a surgical approach to avoid the progression to amputation. So surgical indications, deformity at high risk for ulceration, which many have defined as a Mary's line worse than negative 30 degrees on a weight-bearing lateral x-ray, unstable and unbraceable foot and ankle deformities, painful deformities. We see a significant percentage of Charcot patients that have mechanical weight-bearing pain really unrelated to the neuropathy, typically when the Charcot fails to consolidate and they progress to kind of a non-union type of situation. We've also seen patients that have recurrent ulceration despite offloading, and of course those that haven't established a deep infection. This is just an example of a patient of mine with a persistent mid-foot ulcer despite many months of casting. You can see there on the left, and clinically, you can appreciate just how unstable that mid-foot is. So his x-ray may not look necessarily that bad, but this just highlights the importance of the clinical exam, and certainly one indication is just the gross instability that can occur. Basic principles for whether you're doing infix or exfix in terms of treating mid-foot and ankle and hindfoot Charcot. Acute deformity is correct, is achieved by arthrodesis and bone resection. External fixations indicate if there is an established deep infection, limited to bone work with or as a hybrid construct with infix. This is what I'm going to focus on. Internal fixation is really reserved for what I consider clean cases, and a clean case by my definition is ideally one that is ulcer and certainly infection-free. You can argue that a patient with a small superficial clean ulcer, maybe you can get away with infix, but I would still consider that a relative contraindication. And for those patients, at least, I'll try and cast them until I can get the ulcer to heal and then jump in and do the infix when we know they've got a completely healed soft tissue envelope. And just important to know, particularly for infix, that ideally you want their A1C to be less than 8. Even for a clean case, if the A1C is higher than that, there's still a very, very high risk for a deep infection. Dane Wukich described what we call a super construct, which is fusing well beyond the conflict of region to improve fixation. For example, for the midfoot, that's going all the way from the posterior talus all the way to the infusion point level. Deformity resection to decrease skin tension, using the strongest implant tolerated by surrounding tissues, and device positioning with optimal biomechanical effects. And as you go through this list, modern-day beaming really fits all these bullet points. I thought this was a pretty cool example. This is a case that I did not too long ago. This is a midfoot Charcot after we correct the deformity, and there was a pretty sizable plantar ulcer, obviously under tension, before we fixed the deformity. And you can see here how redundant that is after the deformity correction. And we were, in fact, able to completely resect that and close the ulcer. So one of the Wukich principles of shorting the foot, resecting the deformity, and then decreasing the skin tension. And using those principles for midfoot Charcot, fixation techniques have really evolved from large plates to beaming. The beams have a much lower profile, obviously, than the plates do, and in my opinion, a lot more powerful for obtaining and maintaining the deformity correction. Beams have evolved to include many IM nails, and there are several on the market now. Most surgeons for midfoot Charcot cases have gone to an extended trip for arthrodesis. I'll show you some examples of that. Here's just one example of a midfoot nail. It's typically applied retrograde through the first metatarsal, across the midfoot, and into the talus. For this particular device, there's a distal interlock screw, and then an internal set screw that's advanced against the interlock, and you can really get some significant compression, obviously, in addition to the stability. So that's just an example of what the midfoot mini IM nails look like. Here's my technique, again, whether I'm doing infix or exfix, just in terms of correcting the deformity for a midfoot Charcot. Start with a medial approach, and really prep the entire medial column, including the T end joint, and that often includes cutting and reflecting the anterior tibial tendon, which can be repaired later after you finish, or as you're closing the case. I'll typically prepare the lateral column through a separate lateral incision, usually focusing on the calcaneicuboid joint. Rarely do I address the lateral TMT joints. Doing that incision just a bit proximally, and also including the subtalar joint, and if it's a really sloppy, unstable Charcot, you can just sort of go through every single joint, one by one, kind of an incisory prep. If it's a rigid deformity, it often requires a closing wedge osteotomy, and whether, and in some cases, you'll use a little bit of both. You may do an osteotomy in one location, and then do an incisory prep in other locations, this really just depends on kind of what the foot gives you. You can, I think you can get an idea of your game plan ahead of time. Here's a great example of a case that is ideal for infix, and the classic rocker bottom midfoot Charcot, and you can see how prominent the soft tissues are plantarly, although in this case, he's not had an ulcer, and obviously has no infection, so really the ideal kind of quote clean quote case, and the bones quite consolidated, both on this lateral x-ray, and if you look at the AP x-ray on the right, and then when you examine this gentleman, unlike the one I showed earlier, this is a very, very stable midfoot, so our plan here was surgery, because he has this impending ulcer on the bottom of his foot, but we were planning an osteotomy just based on the rigid nature of his Charcot, and in fact, that's what we did. You see, here's a medial incision, which really doesn't have to be that long, particularly with the evolution away from plates, because you're really just using your exposure for the joint prep. Medial incision from the base of the first metatarsal to the tailor head. In this case, we're able to kind of peel and lift up the intertibial tendon rather than fully cutting it, and we fully expose the entire medial column. I always add an Achilles tendon lengthening. In these cases, I think the easiest way to do this is through just a triple hemisection technique, and as you see in this video, I'll often put a chance pin in the calcaneus just as a joystick to really pull that ankle out of Aquinas, which can be hard to do, at least in my hands, when you don't have the chance pin and you have a really sloppy foot you're trying to pull on. So, we've done our TAL, we've done our medial exposure. In this case, my plan was to do an osteotomy to the midfoot, but then separately prepare the TN joint. So, here we prepare the TN joint, and I used x-ray to kind of find the joint, which can sometimes be a little tricky. So, we prepare the TN joint just using osteotomes. Then we placed a couple of K-wires here to guide our osteotomy, and as you can see here, it's a plantar medial closing wedge. Really simple to do. I don't honestly think it needs a lot of preoperative planning. This can be done during surgery. You find the apex of your deformity, throw in a couple of K-wires, and get a general result of how much wedge you want to take out. And of course, if you're, you know, cheat on taking less rather than more, and then you can always go back and take more if you need to. So, we put in our K-wires under fluoro, then I'll use either a small or wide saw blade, depending on the size of the patient, and you can literally just run the saw right across those K-wires or Steinman pins. And once you've done that, you can see how easy it is just to pull that section of bone out, and you really get a nice correction of the deformity. This is before we've done anything laterally or to the subtalar joint. So, that's the medial side. We then went lateral, as you see on the left, a relatively small incision here. We use a centermeter tractor to expose and prepare the subtalar joint, and then extended it this way to the CC joint. This is how we do the bone graft. I'll take iliac crest aspiration and concentrate it, and I usually mix it with BMCs as well, or sorry, mesenchymal stem cells, as well as PDGF, and make a nice little slurry there, and then pack it into all the arthrodesis sites. And when we're done, now we're ready for fixation. I mean, just very generally speaking, for the midfoot, it's going to be a medial column nail, a lateral column screw, and a subtalar screw. I think the second two parts of fixation, the order probably doesn't matter a whole lot. I do always start with the medial column nail. I think that's the most important part of getting your correction and the stability of the entire construct. So you can see in this fluoro, we've made an incision, dorsal to the haloxin P joint, and we've thrown our K wire retrograde. This is almost the whole, I mean, this is the most important part of the case by far, is just making sure that wire is, I like the lower third of the talus on the lateral view, and then sort of down the pipe on an AP view. And then pick your poison in terms of whether you're going to do a big screw or a nail. I think most of us have gone to sort of the mini IM nail, which you see we inserted there, kind of the dorsal part of the fluoro shot. And then we placed a lateral column screw, which you can go from front to back or back to front. I usually use a fully threaded screw just to optimize the fixation. You can use partially threaded if you need to get compression. And then lastly, throwing a subtalar screw in. This is the final construct, which has kind of a triangle appearance, getting multiple x-rays here and just making sure that the correction is adequate in all the views. Here's another case, which just shows better follow-up. A 56-year-old school teacher, and she unfortunately had a bilateral shark head that was painful. She didn't have any ulcers or history of infection, but we just couldn't get her out of the walking boots. Left side was the most symptomatic, and that's the one we tackled first. And this was really one of the first times I'd kind of evolved to this triangle-type construct. You can see the medial column nail and then the two additional screws. And this is a two-year follow-up and really has a solid fusion and a nice stable planar grade foot. If you get a little bit of sag or even prominence, it's usually laterally of the cuboid, you can always sort of shave that down after you throw in your screws. But I'll try and lift up that lateral column of the cuboid when we're putting in the lateral column fixation. So post-op, if I'm doing all infix and they're relatively compliant, it's non-weight-bearing for 10 to 12 weeks. Bone simulator, if we can get it approved, calcium and vitamin D. After three months in the cast, a walking boot for another couple of months, and then hopefully transition them into an in-depth-type shoe. You know, timing of surgery is, in my opinion, very dependent on the deformity. And there are cases that you just can't sit on. And even if their A1C is high, even if they're swollen, even if they're poor surgical candidates, you know, I can't emphasize enough that there are certain situations, and they're not that common necessarily, but you probably need to move quickly, even if that means just a temporizing frame. And this is one example. There are a couple patterns that I see. This is a real common one, the complete transversal dislocation. And the ankle and talus goes into almost a vertical configuration. And that's just a really high risk for eroding through the skin plantarly. Similarly, but a different kind of pattern is this midfoot, when it's sort of anarchy across the lisfranc articulation. And not uncommonly, that medial cuneiform will spit out immediately, and then you get a really prominent area that's almost tending the skin. So whether you go in and just take out the cuneiform, or you go in and put a frame, I think at least do something early, and then you can always go back and do the more complex reconstruction once the soft tissues settle down. Just a few final slides on the ankle and hindfoot. I actually think it's a much easier task in terms of obtaining your deformity correction. High-end foot and ankle charcot is much less common than midfoot, but it's also less stable, harder to brace, and far more likely to require surgery. So I keep a much closer eye on the, particularly the ankle charcots than I will the midfoot. Particularly they have that coronal pain instability. You know, varus and valgus is just very, very sloppy. It's really hard to cast without getting an ulcer. It's hard to brace for the same reason. And honestly, in my experience, I think they rarely stiffen up, so to speak. So if they have a lot of coronal pain instability, I would consider moving on surgery sooner rather than later. And CT can be very helpful to assess bone quality. And that applies to the midfoot as well. I think it's particularly helpful in the ankle because sometimes we're not sure what we're gonna do with the talus. And on that note, if it's a pure ankle hind foot, I mean, really your two options are a tibial calcaneal fusion or tibial talocalcaneal fusion. Same principles as the midfoot. If it's a clean case, I will do a rod plus minus an X-fix. If it's infected, then obviously we'll just do the external fixture alone. We often get asked, you know, should we extend the ankle hind foot fusion to the midfoot? It's very tempting to do so so that you have a completely stable plantar grade foot. I just think it's not, honestly, not really necessary. I think it's nice for them to have a motion segment somewhere. I think if the midfoot's just way out of line, you can kind of pull it down and pin it temporarily or pin it in your frame. I don't think you need to do a formal fusion into the midfoot because probably that's gonna break down at some point. I almost always use a transfibular approach and just cut and resect the distal fibula. You can morselize it for autograft if it's not infected. I'll flat cut the distal tibia and do a little anterior chamfer cut, which I'll show you in a second. If the talus has good bone stock, and sometimes a CT can help guide this, then I'll flat cut the top of the talus and just correct underneath it, the subcutaneous joint. If the talus is bad, I have kind of a low threshold for just taking it out and then doing a little carpentry and matching your distal tibia to your calcaneus. So, and sometimes you can kind of figure that, figure this out going into it. And sometimes, honestly, it's just a game time decision. Just a couple of examples here. Like this gentleman has a painful ankle hindfoot charcot, mainly in the ankle, not a lot of deformity, but we couldn't get him weight-bearing comfortably out of a boot or brace. And so we did a TTC fusion with a nail. We ended up doing that kind of chamfer cut on the distal tibia. We left part of the tailor head, but the majority of the talus we had to resect because it had kind of collapsed and was fragmented. And if you don't have a lot of fixation in the calcaneus with your nail, I have a low threshold for adding a screw parallel to that just for additional fixation and some rotation stability as well. Here's just a better example of a chamfer cut. Here, the talus is completely gone. We got no talus to work with. Nice chamfer cut on the tibia. And the reason, I think the reason to do that is just so it nestles into the foot easier. I mean, you don't necessarily have to do the chamfer cuts, but when I don't do the chamfer cuts, I end up fighting either the soft tissue or the midfoot anteriorly or the calcaneus posteriorly. So I'm just, I kind of do this routinely off the bat. Then I kind of match it on the calcaneus. In this case, I just use this as an example of the cuts here. We used a frame because the, we had almost no calcaneus to work with. And see, we just did a frame here rather than index. Last case to show you, you know, I'm not afraid of what I call extreme nailing. I do love the nail, even if you have to back it up with a frame. You know, here's a case where it's really hard to tell how much talus you have to work with. Probably not much, right? And the calcaneus is way lateral to the tibia. So it's going to require a lot of, probably medial lateral dissection, soft tissue release. We did get a CT scan, but it just shows a tremendous amount of fragmentation and deformity. But we were able to get the calcaneus into the tibia and we did those chamfer cuts there. And in this case, we used a couple of accessory screws. I did not back this up with a frame, but it certainly would not be a bad idea. But you can, it's surprising, at least in my opinion, how much stability you can get, even with a relatively small amount of calcaneus if you just get creative with your infects. Closing thoughts, I mean, we obviously, we only have an hour here to cover a lot of content. It's okay to be conservative, but here we're kind of focusing on surgical treatment. You know, if they meet any of those indications for surgery I mentioned, and they have clean soft tissues and A1C is reasonable, I think it's important to kind of press ahead. And aggressive is okay. And I think sort of the mantra is moving from, not only is it okay, it's really preferred in a lot of cases. Midfoot nails are becoming the gold standard. I feel strongly about that. It's really improved the stability over just the cannulated screws. And big fan of the nails for TTC, but low threshold for backing it up with an X-Fix if you don't have the stability that you necessarily need, or maybe they can't be compliant and they need to wait there sooner. So thank you for your attention on N-Fix. And I'll turn it back over to Hodges. And I think the next one is gonna be on X-Fix. So thank you. Carol, thank you so much, Adam, while you're getting your stuff up. There's one question on the chat, Carol, asking in that two-year case with the, in Charlotte, we call that the triangle of life, then in Midfoot with the, did you do an osteotomy or were you able to do it separately through the joints and then bring it all together? I think, honestly, I think she was really unstable. I can't, I don't remember exactly. I think we kind of went joint by joint and just did it right inside you. And I think that's a good answer. I think you and I have talked about this a lot more we're going to that because the nail kind of brings everything together. So you don't have to do so many of the big whacks anymore. Yeah, and I think, I mean, I mean, I know you know, I mean, a lot of times you feel like you got a good correction and you're putting a wire in for your medial column nail and maybe things aren't lining up well, that's okay. I mean, just take your saw and do a little carpentry and get things, I mean, you're really just trying to get the first metatarsal lined up with the talus. And I really don't worry a whole lot about what's going on in between. Okay, all right, Adam. Adam's going to talk about external fixation which at his home institution in my belief in many ways have defined treatment for these patients using external fixation. So Adam acute correction with external fixation. Thank you, Hodges. Thanks everyone for joining us tonight. These are my disclosures but perhaps the most important disclosures Hodges mentioned is that I am a disciple of Mickey Pinzer who I think has shaped all of what we think about external fixation, myself included. So, so much of what I know and believe has come from Dr. Pinzer, right or wrong. My ideas of external fixation come from basically what we've learned in trauma and that's the idea of damage control orthopedics. This is a traumatic case, a non-Charcot case but I think any of us look at this gruesome picture and potentially gruesome x-rays and think, you know what are we able to do? And we don't know what to do. External fixation has really come in the trauma world as that next step. And I think that's absolutely true in the world of Charcot as well. We don't know what to do. X-Fix is always a good answer. These patients have poor bone quality or soft tissue envelope. Many have an active infection and that leads us to a lot of problems acutely with the idea of internal fixation or casting or anything else. Carol spoke a lot about what the indications for surgery are. We try to keep it very simple at our institution. Basically, if you have a non-plantigrade foot or an unstable foot or ankle it's basically an indication for surgical reconstruction. I mean, leaving these patients with poor alignment and a non-plantigrade foot is essentially a setup for ulceration, infection, amputation. And many of these patients who have their Charcot and they go through this deformity phase they don't necessarily heal all their joints all that well. And so even if they're well aligned then painful non-union, Carol showed one of those ankle cases as not a lot of deformity but lots of pain even though they have neuropathy, they're painful. That itself is an indication for surgical reconstruction as well. The goals of reconstruction are pretty straightforward. First, getting a plantigrade foot and it doesn't have to be the prettiest foot. There needs to be overall alignment so that their first ray in their heel or their first ray in their tails are aligned pretty well. What happens in the middle as long as it's not plantar sagging is fine. So a nice plantigrade foot and the idea is first realign it to reduce it and then maintain that reduction. And that's where an external fixation really comes in. The other goals obviously are to have the infection free. We're not doing our patients any good if they have active infections and then obviously allowing them to ambulate afterwards whether it's in a commercial available shoe, a custom brace, but a lot for independent ambulation. Limb salvage is really the key for success here as much as possible. So these patients have lots of problems. Obesity and osteoporosis, multiple comorbidities. They're unable to stay off it. And I think we've all had these patients that we recommend non-weight-bearing to, but they can't do it. Whether they consciously or unconsciously put weight on their foot, they have neuropathy, they don't realize they're weight-bearing. And so it's too much to ask them to stay off it completely. We have to embrace the fact that they're going to walk on it. And then obviously most of them are, many of them are infected or have had an infection. Maybe the ulcer closes, but once that bone has been contaminated, it certainly could be bacterial lurking, which sets them up for a risk of infection. And so, you know, in our practice, essentially if someone's had an ulcer before, we consider that they have some sort of infection or contamination at that time. The idea obviously is they have a non-plantigrade foot and we have to somehow make a plantigrade. This is probably one of the more extreme examples, which Dr. Pender is able to turn into a saw bone for us to demonstrate. So this is sort of the classic deformity, the abduction through the midfoot or tenovicular joint midfoot somewhere in there. And then this rocker bottom they develop as well. And so the first thing, as Carol talked about, is get this reduced as best we can. And in our hands, this is a biplanar wedge osteotomy. So we would take essentially sections out, much larger plantar than dorsal and larger medial than lateral. And that would allow it for a correction. Now, if the deformity doesn't look like this, it's sometimes taking it other ways. For some that only have rocker bottom and don't have this abduction, it might be taking out more of a rectangle of bone on the AP view. So it's actually shortening the foot, but still larger plantar than dorsal in order to get that position back. And this is essentially what that correction would look like if we were able to make it. Regardless of internal fixation, external fixation, however you want to approach this, the deforming needs to be corrected. And that's the mainstay of this. And once that's corrected, provisional fixation, and then we strongly believe external fixation is a great option for many of these patients, particularly those who have an infection or who are going to walk on it immediately anyway. And this is typically how we sort of do it with a static circular fixator. There's a couple of pearls to external fixation that I think make this very simple. And for those who don't do a lot of thin wire external fixation, it seems like a very daunting task, but it doesn't have to be. So first, like we showed, provisional fixation of the correction, like correct the deformity, pin it in place. At that point, we close the wounds, the pins are outside of the wounds, and then the deformity correction part is over, and then it's about going on to the fixator. We pre-build our external fixators on the back table, or you can even build them ahead of time and sterilize them, but essentially this is our normal static external fixator, two tibial rings, a foot ring, and then an arch to sort of lock everything down. So you pre-build the fixator based on size of the patient. It's important, there's going to be a lot of swelling. The soft tissues around the posterior calf seem to always get bigger and bigger over time. And so I prefer these rings to be a little bit big, especially approximately, so that you don't have irritation on the rings themselves. Once it's pre-built, slide the fixator just like this over the foot and use lots of towels to help position where you want the foot to be, and then essentially place your wires. I use the calcaneus and the foot ring to sort of set the height of the fixator. The foot is going to hang off the bottom of the fixation, or the bottom of the fixator. You like the calcaneus rings to be slightly above the foot, and then you can attach it using, some companies have rockers to them. Other times we attach a post-operative shoe to the bottom so that their foot isn't on the floor itself. But the key is to sort of set the height based on the foot ring. I've also gone to having much shorter distance between those tibial blocks. A lot of our patients using these scooters, even our neuropaths try to use these scooters from time to time. If you make that proximal ring not too high, can really give them the ability to get around on a knee scooter or something similar without compromising that. And then I'd point out all of these are done in our hands with thin wires and not half pins, especially in neuropathic bone. It's really a setup for a stress fracture with half pins in the tibia. And so all tension thin wires, much lower stress fracture risk, and pretty straightforward to put on long-term. We're able to publish these results with our deformity correction. It had pretty good success in terms of limb salvage and avoiding amputation. This is an example of what the fixer would look like once it's on. As I mentioned, the foot sits below the level of the fixator that lets you get your thin wires in metatarsals as well as in the calcaneus. An example is one of Dr. Pinder's patients, but someone who's obviously been operated on numerous times, missing many toes and a very large sort of ladder plantar ulcer with deformity. And I think you can see the various deformity here. It clearly rotational, it's not well aligned. And here's the X-ray showing that rocker bottom and hard to tell what's happening on the AP, but essentially some abduction deformity here as well. This is that patient that we put into a paper, but acute correction, placed the external fixator and we debrided the ulcer. You can see even with the correction, that ulcer was large enough that we weren't able to close it acutely. I think with internal fixation, it's something you really wanna try to get closed right away. One of the advantages of the X-Fix is that you don't have to. These can stay open and their time in the fixator is kind of, it helps offload. It's kind of that special sauce to help them do this. And then here they are once the fixator is off, ulcer is completely healed and a much more well-aligned plantar grade foot as patients are able to ambulate in a commercially available shoe with a custom orthotic. And so that's a huge success with a deformity like this. A couple of sort of pearls of X-Fix. As Carol mentioned earlier, the definition of a super construct, right? The idea of immobilizing other joints and it's for a midfoot Charcot, if you're doing internal fixation, you often have to extend sub-tailor joint lateral fixation as well. One of the sort of secrets of the external fixator is it is the definition of a super construct. It immobilizes all the other joints. And so if you're a deformity correctionist through the midfoot, with once you place the external fixator, you're immobilizing the sub-tailor joint, you're immobilizing the ankle joint and it probably decreases a lot of the stresses those joints see. It takes away a lot of the inflammation at those and potentially decreases the risk of a shark or another joint, um, it's okay to operate early with an external fixator. So I think the old training was that any of the shark hose, especially when they're hot and swollen, total contact cast, uh, an external fixator can be put on right away, even if you can't do deformity correction, as Carol talked about, sometimes you just take the cuneiform out, uh, putting a thin wire external fixer on early is essentially a metal cast. You can watch them, you can see their skin. You don't have to worry about what's happening out of the cast and it's okay to operate early, even in hot, swollen joints with the idea of an external fixator being that source that calms it down. Um, it's just a tool, just like a cast or an internal fixation. Um, pin site infections are okay. They're sort of the norm. Um, a lot of patients get them. It doesn't mean a deep infection. These go away with simple treatment of oral antibiotics. And so, uh, we tell our patients that, you know, these happen all the time. Send us a picture, we send in an oral antibiotic. We often give them a refill and just ask for a picture before they get a refill. And so these are not things that patients need to come into the office or for every pin site infection, especially with telehealth. These days, we're able to do a lot of these visits virtual or just with pictures. And then the external fixation for a lot of patients is the definitive treatment. Uh, deformity correction with external fixator is great, but it's, can also be part of a staged approach. It can be done with internal fixation, particularly for the ankle shark hose. Uh, it's a great indication to do a TTC fusion nail with an external fixator. Um, or, uh, for infections to be done at a staged approach, right? So external fixation goes on. Infection is cleared. They now have it. Plant a great foot. And if they haven't healed completely, or you're at risk for recurrence, uh, going back to do internal fixation later, whether it's a midfoot nail or a hindfoot fusion nail, um, their deformity is already corrected and held. And so it's a much simpler second operation with, you know, much less, much smaller incisions, uh, and lower risk of infection. So, uh, the external fixation is often a staged approach for some of these most difficult cases. Um, okay. Is that, is that it, Adam? Yeah, that's perfect. All right. Thank you, man. Uh, you know, I first heard about, um, acute correction with external fixator from Mickey pins are, uh, years and years ago and, um, and he has created a school of thought around that. I think more and more, um, it's, it's kind of standard. Um, but there are a lot of people who are intimidated by external fixator. Give two reasons why two, two ways that people can get over that intimidation. Yeah. You know, I, I think the idea of these external fixers is nor can be really intimidating. I think, you know, the easiest thing is first pre-building them, right? I mean, these don't need to be complex. They're they're static. You're not doing corrections with the external fixer. The external fixation is just a way to hold your correction. And so I think once they're you pre-build them, all that work is done. Um, you know, at the beginning of the case or while the wound's being closed and it takes away a lot of that scary stuff, the other thing is, I think it makes the follow-up really easy with the external fixator, um, patient to weight bear on it, uh, they come back into the office, you don't have to worry about wounds or ulcers or what's happening on the cast. And so I think the post-operative course is a lot easier when they're external fixer and you can see what's happening to their foot, um, much more readily. Thank you. Um, you know, it's, it's amazing how many fellows come into our practice who have never really used that technique. And, um, and I think in our practice, it's pretty standard. Uh, I'm God, uh, you're gonna, you're gonna give us a talk about, uh, fractures in neuropathic patients. Uh, the reason we have this on here is that you may choose not to treat Charco, but you cannot get away from neuropathy. Uh, take us home with that. Sure. Thanks a lot for the invite. I'm honored to be amongst this eminent panel and, uh, let's see if I can get my slides to roll. There they are. Here are my disclosures. Uh, so just like you alluded up today, those, uh, fractures in neuropathics are very common. Uh, they can present acutely subacutely or chronically, uh, acutely being within two weeks. I think subacutely can be easily defined as anywhere from two to six and chronically more than six to eight weeks. Uh, they can include any anatomical region or a combination of everything, increasing the complexity, as we can see here, this is a list from associated with mid-tarsal fractures. Um, it can be further complicated by soft tissue compromise and ulcers as Adam, uh, and Carol Jones have alluded to, uh, just like Dr. Hodges, uh, mentioned, he's reading my mind. Even if you do not electively treat Charco in your day-to-day practice, it will see you, uh, neuropathic fractures will fall in your lap, uh, whether you want it or not. So you have to breathe, uh, just be comfortable formulating algorithms and implementing surgical treatments, whether you want to fix them or salvage them, uh, um, and, and, or fuse them. Uh, these are the tips and pearls, uh, that I would like to start with, but they took over the years. Uh, basics do not wait to optimize your patients. Uh, these are trauma patients. They have to be treated urgently. Uh, don't wait to get the extensive workout. Otherwise they're going to ulcerate and end up infected as CJ alluded to. Uh, you, but at the same time, you should get started, uh, to optimize them, uh, from day one, uh, from the PR visit, admit them, uh, always establish an interdisciplinary team, get all hands on deck. That's my motto. Uh, if you do not have a multidisciplinary limb salvage team, establish one, you will need a good hospitalist, uh, uh, a nutritionist, a cardiovascular medicine, uh, specialist and infectious diseases. Of course, if they're infected and, or look for plastics, if you have extensive soft tissue compromise. So, uh, we, we are lucky to have a team of these five. And I do advocate that you try and establish one in your practice. Um, always check the vascular status by definition. We all know that the Charcot foot or the neuropathic foot is a hyper perfused foot. Uh, so the incidence of macrovascular disease is minimal. Um, you can always check and find that these patients have pulses. Uh, if not, then get a cardiovascular medicine consult, get your ABIs, do the non-invasive studies, um, order a CT angio. Um, uh, but the, my key take-home message is I've seen a lot of neuropathic patients who have microvascular disease. Uh, believe it or not, you feel the pulses. They're good. You operate on them. You have the tourniquet up for two hours or so, and then you bring the tourniquet down and their foot is blanched and it doesn't come back and it dies. Uh, so you have to detect microvascular disease, uh, prevented by keeping your tourniquet to a minimum. Um, and always, always, if you have a history of diabetes, I'm sure this is basic science and we all get tested on the OITs, uh, have a, a since Weinstein monofilament on you. You can buy them cheap by the dozen off Amazon. I have, I have them in my pocket all the time. Even, even if it's a well-controlled diabetic and he tells you my A1C has been perfect 5.6 for, for, you know, years, uh, you will be, you will be astonished how many of these are near or have neuropathy that is missed. Or, uh, it's again, the patient is in a state of denial, uh, just completely saying that he has normal sensations when he has not. So I always do check them for neuropathy, uh, when they're, when they present with fractures. Uh, this is a very interesting study. Uh, that showed that the prevalence of vitamin D deficiency in patients with Charcot is very, very high more than you can imagine. So I always get a vitamin D as part of my workup, 47.4% are going to be deficient and 36.8% are going to have insufficiency. Uh, and, and of course my predecessor talkers talked about that and putting them on calcium and vitamin D, but get your vitamin D levels checked. Uh, always ask for a history of infection. Uh, sometimes again, they will not mention it to you. Uh, sometimes the skin is going to be perfectly healed, but the, with the history of infection, you're going to find a chronic osteo hiding somewhere. If that's the work, if that's the case, we all know the labs, uh, MRI with contrast in a set of fracture is not optimum of course, because of the fracture edema is going to be confounding. And there's no role for Indian labeled bone scan, uh, as opposed to the chronic Charcot de Font foot. But I always get a CT and fractured patient just like, uh, again, uh, they alluded to, uh, to assess the bone quality, look for occult or adjacent fractures, look for early chiropractic changes and collapse, um, look for the comminution extent and concomitant or adjacent arthritis that would require you to fuse, uh, golden rule again, double the fixation, uh, double the non-weight bearing time. Uh, this is a very nice review article published in the yellow journal, uh, about unstable fractures and neuropathics and the way to tackle them. Uh, this is a very nice paper, uh, about the salvage of the neuropathic ankle with a use of large fragment fibula plating and multiple somatic screws. And I, I think that has become the standard of care now with somatic disruption. Uh, again, uh, ankle and foot fractures and diabetics can provoke, uh, neuropathic joint changes. So they don't have to be neuropathic on presentation, but believe it or not, you fix them and then they become neuropathic and they fail. And I've got a couple of examples that I would like to show you. Uh, so they don't necessarily have to present with neuropathy, but they can subsequently develop neuropathy, uh, precipitated by the fracture as, as shown in this study. Uh, so operate ASAP to avoid the soft tissue compromise. And as Adam Schiff mentioned, it's based on the damage control. Um, I always think, uh, external fixation, uh, if infection is present or suspected, uh, I've moved away from hybrid construct. Again, uh, as, as Adam mentioned, you can mount a frame in 35 or 40 minutes, uh, with a super simple construct like this, uh, do not hesitate or shy away from complications of external fixator. This is a study that showed that. Again, external fixator is going to have seven times the complication rates and diabetics compared to the normal population. But however, all of these, we don't call them population complications. We tend to call them adverse events, uh, and they're all manageable and can bridge you to safety. Uh, fusions. So again, a JBJS paper in 2008, uh, talked about fusions in chiropractic, uh, the indications for fusion in the ankle is again, a foot drop or a dense sensory loss. Ask for it, look for it, but it may be supple, non-recognized. Comminution definitely is an indication for fusion and my practice, a contralateral below knee amputation, believe it or not, is an indication for a fusion because these patients are not going to be able to stay off of it with a contralateral below knee. They do not gauge how much pressure they're putting. They would wake up in the middle of the night without their prosthesis and walk on walk on their, on their fixed ankles. So, uh, it is for me, a no, a no brainer to do a, a fusion in a patient with a contralateral below knee and the mid foot and hind foot extensive comminution and subluxation in this location, uh, fusing, um, just think of putting the kitchen, sitting in the kitchen thing, uh, throw everything at them, uh, use autologous bone graft or viable allogenous bone graft biologics, CJ alluded to the, uh, platelet drug growth factor and a bone marrow aspect concentrate, which I use and postoperatively calcium and vitamin D and external bone stimulator. And then after you've done all of this brace for impact, uh, because you will get complications and you have to be comfortable treating them. I know I Nardi is going to be talking about complications, but I got a, you know, a couple of cases that, that will throw some take home messages very quickly. Uh, so again, this is a 61 year old male who was a controlled diabetic with minimal neuropathy struck by a bus presented with this. And this was actually presented to us when I was a fellow in HSS and I kept it because it was treated by a community doctor, uh, with this construct. So double plating on the fibula repair of the deltoid, but he did not attend to the syndesmosis. Uh, he kept the patient on weight bearing for three months, but as time went by and we saw the patient and follow up the patient presented with this X-ray and you can see, uh, the deltoid failure is eminent with the syndesmotic, uh, failure. Uh, so this is how the patients progress. The, the, the neuropathy in this patient become became denser and denser, and he ended up almost on the verge of a dislocation. So, uh, again, this is again, the ankle foot fracture provoking neuropathic changes, and this is where he was fixed with multiple syndesmotic screws. Um, I mean, another, another patient, uh, this is my patient. She is 78 year old, uh, type two diabetic, again, controlled yet with a neuropathic right foot drop. So she presented with this ankle fracture and the foot drop. Uh, she had been delayed six weeks to present, uh, diffuse dance by a lot of stocking peripheral neuropathy. So in her, I thought an ankle fusion would be the home run. Uh, she healed and consolidated the fusion and got that kept her foot plantigrade without the need for an AFO. Uh, this is another one, uh, uh, a, uh, diabetic renal transplantation with bilateral, uh, foot drop from dense neuropathy, uh, presented to me again with this fracture and unstable foot, I noticed this collapse. As you can see in his arches. Uh, so for me, this was an indication to do a TTC fusion. And as you can see before and after we were able to restore his alignment, again, give him a stable ankle to walk and he's walking without a brace, no way of those, uh, and that takes him to, um, uh, safety. Um, this is the last case on the ankle fracture series. A patient presented with this fracture. He was fixed by my trauma partner with this construct. Uh, again, he had mild neuropathy, uh, relatively controlled, but after the surgery, he started developing an infection. He was, he was washed twice. The hardware was removed. You can see now the multi-eating appearance of the fibula with developing chronic osteo and the metal and hardware failing. Um, and he became, it was the, the infection really fled up to a point where the patient became septic. Uh, this is when I took everything out and just like Adam mentioned, there was a, you know, huge infection. So I took out all infected bone, flat cuts, put a ring external fixator on, uh, give him IV antibiotics, got rid of the infection. So for me, a presence of infection is an indication for a frame. And then once he had consolidated completely, uh, healed the infection, uh, with inflammatory markers resolving, we took out the frame and put an antibiotic coated nail. Uh, I intend not to do external and internal fixation, uh, combined frames and nails, I tend to stage them. Uh, and this seems to be a very good option. Uh, and when I put the nail in, I definitely always coated with an antibiotic cement mantle. Um, a couple of quick midfoot cases. Uh, this was a patient who came with a completely fractured and crushed navicular sarcopathic. Uh, so, uh, for me, the, the, the navicular was completely comminuted. Uh, I didn't want to put a beaming, uh, construct, uh, in that because I was afraid of crushing and shortening the foot substantially. So I prefer to try and reconstruct this, went ahead and fix the navicular and then try to do a, uh, bridging plate to avoid the comminution with this construct. Uh, look to post-op X-rays look good. Proximal tibial bone graft filled the voids, nothing ruins your follow-up except a non-compliant patient. So she ended up walking on the construct, screws ended backing up. Uh, and she ended up with a fibrous non-union and we're taking her back again for revision. Uh, and at this time beaming, because I think she's going to have enough bone stock to be able to beam that. Uh, when it comes to Lisstronc, um, this is a very nice review article out of the JVJS in 2012 about fractures and dislocations of the midfoot and, uh, Lisstronc and Chopard injuries that I would, uh, uh, recommend that you read, uh, but this is, uh, this is the patient I talked about, he had a normal foot, he had a fifth-grade amputation with one of my partners for an ulcer on his lateral border, had a normal looking foot and two weeks later. And this is another thing where we can see an acute disruption, no major injury, just tripped and fell presented with this horrendous Lisstronc, uh, dislocation, uh, this is one where it went in acutely and beamed him. Uh, and had to slide his heel because he, he, he had the residual deformity. Uh, there's an argument whether I should have used his, uh, his subtalar joint as CJ alluded to the super construct. I did not, I thought he had very good hind foot range of motion. Uh, so I just midfoot, uh, beamed him. This is the guy who had a blanching foot after I took the trinikit down. Uh, and I, we had to, you know, hiperonize him. Uh, he had microvascular disease. The foot came back to life after two hours. Uh, and it was really, you know, uh, something that was breath breath holding, uh, for, for a while. He did relatively well. Uh, we alluded to the, uh, uh, the calcaneum cuboid, uh, collapse. So this guy ended up having some, uh, a lateral ulcer went in with the minimally invasive version, did a minimal exostectomy on the lateral side, as you can see here, and this was his ulcer, and this is after excision of his ulcer, uh, by MIS technique and exostectomy, which can help a lot in these patients, especially on the lateral side. Um, finally, uh, this is the last case, uh, a lady with chemotherapy induced neuropathy with bilateral foot drop presented to me with this problem. So besides the metarsal fracture that had not healed, she had a, again, a lisfunct dislocation, uh, and had an equinus deformity, as you can see. This was, again, another challenging one. She had comminution, so I ended up doing bridging plate fixation, but to treat her foot drop, I did a TTC fusion. I did not go all the way with a super construct because that meant a very stiff foot that would break later on, so I had to keep a mobile segment right there at the talonevicular joint. She ended up healing very well, but I saw her two weeks ago, and she had a healthy scab that fell off, and I had an exposed plate. I took out her plate, and she had solid fusion all throughout the first, second, and third beams in her TTC, so that was an easy run. Thank God we took out the plate and just ended up closing this ulcer after wound backing and a series of antibiotics, so all of these are patients that came up with complications. These are annuities. They're going to keep coming back, have the courage to be aggressive, as we alluded to. I think that's the theme of the whole talk. Just be as aggressive as you can. Don't shy away from your complications. They are manageable, and these patients can be taken to safety. In conclusion, again, I think the neuropathic fractures are integral parts of any foot and ankle practice. Early intervention, check the vascular status, always keep an eye out for microvascular disease, always keep an eye out for neuropathy, even if not recognized. Denial is not a river in my home country, Egypt. It is a status of the mind of the neuropathic patient, so make sure that they do recognize and acknowledge that they have neuropathy. Post-op optimization, throw the kitchen thing, put them on calcium and vitamin D, and use an external bone simulator. Remember, double the fixation and double the non-weight-bearing time. Ankles, do not use tightropes. Of course, use multiple syndesmotic fixation. We talked about the indications for fusion, whether we're going to do internal fixation, surface versus intramedullary, and external ring fixation. I think the take-home message, again, from all that's been said is not shy away from it. There are a lot of workshops that can teach you how to put on a ring external fixator in 35 or 40 minutes, and be aggressive treating your complications. After all, this is a very nice movie, so it's not always quite on the Western front, and you have to be ready to brace your complications and treat them aggressively. Thank you. All right, Omgad, thank you, Michael, as you get your stuff up. You're obviously showing cases where if you can't stabilize them enough, you're going to have to fuse them. In some obvious, like Blitzfrank's and other things, doing a primary fusion in this patient population sounds like the better part of valor. That is true. I totally agree, especially in the mid-foot, and I think the mid-foot neuropathic patient is the hardest to treat. Adam alluded to that. I think the hind foot and the ankle are home runs, but the mid-foot with the pressures and all the biomechanic stresses laid on it becomes a very challenging problem to treat, and I think the earlier we get to fuse them, the better. All right, so Mike, bring us home. We're going to talk about complications in the same patient population. I suspect there'll be a little crossover, but I appreciate you taking this one on. Thanks, August. I think I'll kind of jump through some of the literature stuff, because Omgod covered it pretty nicely, but I think the take-home points here are when you treat neuropathic patients and Charcot patients, you've got to be ready to manage big problems, and you've got to recognize them early, and you can quickly end up in limb salvage situations, so I think it's critical that if you're going to tackle these patients, you've got to be ready to use frames, nails, staging procedures, everything that's been highlighted, and don't miss neuropathy. We make all the residents here at Penn State run around with the Simms-Weinstein monofilament, and I think it's saved me a bunch. These are high complication rates. In some series, mortality rate can be 20% ankle fractures in those with Charcot, 25.7% amputation rate in this series, infection rates as high as 40%, casting is not benign, ulcers, non-unions, you name it, these patients will show up with it, and I'm just going to get right into a case. So, what bad can happen in a cast, right? And, you know, this is a 67-year-old, actually well-controlled diabetic, had a trimalar ankle fracture, was pretty well aligned, was casted, and she shows back up into outside hospital's partner's office in the cast with a pressure sore from the nursing home, looking like this, and here's her skin, and we got a call at Penn State from the outside surgeon, he tried to plate this, you can see the proximal drill holes he made, and he just could not get this back reduced, and so in just four weeks' time, this turned into a potential amputation case. You know everything's going to be infected, and so you need to stage this if you're going to try to salvage this limb, and the best way to do that is go in and debride everything you think is infected. So, I did flat cuts here on the tibia talus, fibula came out, I called in plastic surgery partner, because she was such a poor host, we decided to do a dermal allograft. She grew staph, enrobacter, she got a PIC, urtapenem and vanco for six weeks, here she is immediately post-op, five days, she's got her wounds dressed here at 10 days, dermal allograft appears to be holding, and we have her in her frame. At four weeks, her skin's looking pretty good, we start running a program, we did shorten her a bit, and I posteriorly translated the talus to try to take some tension off this skin, as Carol showed earlier, shortening can be your best friend in limb salvage, and in these cases, you got to think outside the box, anything you can do to get rid of the infection, and close the skin, and keep their legs stable, and save their leg is paramount, and you can see here, we're starting to bring her talus back, she's actually making some bone, eight weeks, we were able to normalize all her infection labs, and here she is in the frame, she's making a little bit of bone, you can see, on x-ray, and I had a long discussion with her about keeping her in the frame for full fusion, she was a very thin lady, and it's having difficult to get her around, so I talked to her about taking the frame off, taking cultures, and potentially doing a hindfoot nail, as she was pretty well aligned, and so she opted for that, so we took her frame off, cultures were all negative, and this is six weeks after hindfoot fusion, six months, you can see she's well fused, she's stable, she's using a double metal upright, and here's her skin at final follow-up, six months out, and so you can see how just in a short period of time, you know, I think the outside surgeon was being conservative, but I don't think he appreciated the extent of neuropathy and the instability present, like Omgad and the others have shown here in these neuropathic and Charcot cases, and how quickly you can get in a situation where this patient was facing amputation very, very fast. Another great case, loss of reduction aqua fixation and infection and pull out of a fixer, 50-year-old farmer fell off a tracker, closed ankle fracture, A1c was only 6.2, the outside hospital said he had normal sensation, this was not the case, I can promise you. Here's his fracture repair, as Omgad just showed, flexible fixation, not appropriate in this patient population, but that nonetheless had a nice reduction, and they did cast him, they protected him, still looking okay, at six weeks, at 12 weeks, a little pull out, and for some unknown reason, he was allowed to return to work driving his tractor, had to earn means. At two weeks out, he noticed significant increase in swelling and deformity, but had no pain, came back in for a follow-up x-ray, and this is what happened, you can see broke his plate, syndesmosis, this guy's in big trouble, and he's got tenting in the skin, the medial side, so the outside surgeon put him in external fixer, very appropriate management here, and reasonable improvement in alignment, took the pressure off his skin, but just one week later, you can see here, his cuneiform midfoot pin pulled out, and his ankles posteriorly dislocating, so my trauma partner got the phone call, he transferred in, he IND'd his pin sites, he actually took some cultures from his ankle, and just put him in a cast, I mean, I'm not weight-bearing, he sat in-house for 72 hours, his cultures were negative, and so I took him back, and did hind foot nail, and thought, hey, we got a win here, 12 weeks, had him in a total contact cast, was protecting him very carefully, his swelling looked pretty good, he goes away for 3 months, let him work in his cast, just operating the tractor, and he shows back up with this, and you can see his nails subsided, and worse, he's got elevated markers, and a blister on the bottom, and you can see his skin swollen, so I pulled everything, antibiotic rod, debrided, he was growing staph, he went on antibiotics, I debrided him further, as his inflammatory markers weren't fully down, his cultures were negative at the time of this debridement, and so I talked to him about going back, and placing an X-Fix, using some Iliac Crest to fill this area, he did not want any hardware internally, because of all of his previous surgeries and issues, and so here he is in a frame, just diamond pins holding him, you can see his crest graft mixed with some antibiotics, did a little osteotomy of the fibula, 4 weeks, his cultures were still negative, his labs look totally normal, you can see his wounds are healing nicely here, it's 3 months, he looks pretty stable, and at 4 months, he's making good consolidation, we decided to take the frame off and get him into a cast, and you can see here he is, at 9 months, he's working, he's in a double metal upright, I would call this a stable non-union, looking at his AP here, lateral looks pretty good, and here's his skin, and he's got his leg, and this is a win in my book, even if it doesn't look so pretty. And the last case, I'll kind of leave everyone with, just in the sake of time here, this is a great example of missing neuropathy again, and inadequate fixation, here's that kind of medial cuneiform, as Carol highlighted earlier, squirting out, and anarchy in the midfoot joints, and the outside surgeon, and I apologize, I don't have the immediate post-production films, but regardless, this is inadequate fixation for the nature of this injury, they did not appreciate the extent of neuropathy in this patient, nor the amount of deformity, and so for this, whether you do beams, bolts, plates, you need to stabilize this entire midfoot, and specifically the medial column, and so this patient had a planar plate with a cantilated screw up the medial column, and then screws across her midfoot, and here she is at nine months, fused, and you can see her Mary's angle looks good. I did avoid crossing her tarsal joints in this case, and I think I got away with it, but if there is any evidence of instability, I wouldn't hesitate to cross tail navicular and subtalar joints, and I think that, if we have a few minutes, might be a good topic for discussion. So in summary, I think, you know, neuropathic complications are serious and incredibly common, and everything from infection, amputation, loss of reduction, you got to counsel these patients appropriately, don't miss neuropathy and trauma patients, always check your SEMS-Weinstein, and when I pick up on a complication, I'm aggressive at managing it, just as Amgad highlighted, I think you delay and hesitate in these patients, and you very quickly will be in a situation where it'll end up in amputation, so be aggressive, be ready to manage your complications, and make sure you protect them and keep a real close eye and close follow-up on them. Thank you. All right, guys, thank you so much. So a couple of conversations that have been going on in the chat. One is, if you do an extended midfoot fusion with a triple, which in Charlotte is a fairly common operation, does that make the foot too stiff and then set you up for recurrent ulceration or even Charcot of the ankle? I'll lead by saying that's not been our experience. We have trended to go to more stable rather than less stable in the foot because we were seeing breakdown in other places and ulcers in those unstable segments, but are y'all seeing that, or is this just a North Carolina thing? No, Hodges, I would second that, and I think it was a course we were at together a while ago. I've made the mistake several times now where I didn't get good fixation in the hind foot and I was focused on the deformity, which was in the midfoot, and the talus can just rotate right around and the subtalar joint will collapse, and neuropathy and Charcot always finds a way to sneak into the next free segment, and I think if you can get that tripod back, it's much better to have a stiff, stable foot that's in a good tripod and the ankle's well aligned than it is to try to spare joints in these patients. Although I'm a big advocate of a stable foot and going to the super construct, I will rebuttal this, and I will tell you my only caveat of not including the hind foot. I will include the talus, but I will not include the subtalar joint. If I look at the CT, number one, I do not see an extensive talar equinus, so the talus is relatively preserved, because once the talus dips like that, then you've got a 45 degree equinus deformity in the talus. There's going to be peritalis subluxation, and the calcaneus is going to sublux from underneath the talus laterally. So, if I have a relatively preserved talus without significant qualis, I will include the talus in my construct and leave the subtalar joint, trying to leave the patient with some motion, but once I see that extensive sag, I will include it in my super construct. So, if you fuse the talus joint and the calcaneus cuboid joint, you think you get subtalar motion? I would not. I tend not to fuse the calcaneus cuboid joint unless there's a significant subluxation as well. So, my midfoot, it's going to be mostly a medial midfoot reconstruction leaving the lateral side, but if I see a calcaneus cuboid sag, definitely, I will include the lateral side. So, again, my two indications, just like you alluded to, are going to be the talar equinus, significant talar equinus and sag, and a significant calcaneus cuboid subluxation. All right. Not to push the external fixator idea down your throat even further, but I think that's exactly a reason to use the x-fix is that, you know, if you're doing your fusion through the midfoot, having the x-fix construct on, shuts down subtalar joint, ankle joint, all the other surrounding joints, but you're not fusing them, so they potentially will have motion later on. It'll be stiffer, no doubt. They'll potentially have motion later on, but maybe you decrease the risk of a charcot and an adjacent joint because you've treated them through their acute phase with the external fixator. All right. Jonte, final word? Yeah, no, I think everybody's right. I mean, if it's the frame's great because you can control the ankle and the hind foot without a fusion. If you're doing all infix, you really don't have that advantage. I think, I mean, our experience has been we weren't doing the subtalar joint or we were doing a limited midfoot, and then we were having collapse more in the hind foot, so we've sort of evolved to the, to adding the hind foot, but we still don't entirely know. I mean, I think where we've gotten burned is the quote midfoot charcot, but it's creeped into the TN joint and maybe the CC joint, and we've started just adding more joints and more fixation. If it's purely midfoot, which is not all that common, and the talus is neutral, as Amgad said, then maybe just a midfoot's okay, but it seems like the ones that we're treating surgically, there's often hind foot involvement, and that's been our trend, but we don't have all the answers, and we're looking retrospectively at kind of both constructs and where to come on that, we hope. All right. Thank you so much. I think we've run out of time. One of my, what's exciting for me is, as the oldest one on this panel, is to see you young, smart guys being interested in this, because I can promise you there are a lot of guys my age who don't have any interest in it, and I think that's to the detriment of this huge group of patients, so thank you for your passion, and hopefully this group can do some great things as we move forward in the next decade. Julie, do we have any other things we have to do from the foot study standpoint, or are we good to go? Nope, we're good, and we'll go ahead and we'll send out an email to all the attendees so they have the link to do the evaluation and claim their CME. Okay. Thank you very much, and guys, I'm sure I'll see you before before too soon. Take care. Thank you. Y'all have a good evening.

neuropathic ankle and foot conditions

Charcot foot deformities

internal fixation

early intervention

surgical techniques

external fixation

acute correction

pin-site infections

complications

fusion

management strategies