On behalf of AOFAS, I want to welcome you to tonight's webinar, Minimally Invasive Sports Techniques, Changing the Paradigm. Tonight's moderator is Dr. Christopher Gross. Joining him are Drs. Andrew Hsu, Vittorio Volcano, and Tyler Gonzalez. You can find their full biographies and disclosures, as well as disclosures for program planners, in the program document posted in the chat box and in the AOFAS OnDemand Education Center. 2024 webinars are provided free to AOFAS members and orthopedic residents, fellows, and medical students with funding from the Orthopedic Foot and Ankle Foundation, supported in part by a grant from Stryker. To support education programs like this, donate to the foundation on our website, or by texting GIVEOFAS to 41444. 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 attendees may earn one hour of AMA PRA Category 1 CME credit by completing the 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. The webinar is being recorded and will be available for on-demand viewing on the OnDemand Education Center content library in approximately 24 hours. We encourage you to ask questions during the presentations. To send your question to the faculty, click on the Q&A tab on your navigation bar. If we cannot get to your question during the live broadcast, the faculty will reach out to you following the broadcast to respond. Finally, please visit our website to register for upcoming events, including our next foot and ankle focus webinar on pediatric deformities and sports injuries, and the 2024 AOFAS Annual Meeting in Vancouver, Canada. I'll now turn the program over to Dr. Gross to begin. Thank you. Lucas, thank you so much for the introduction. I'm really excited to talk to you today and to talk with all of our panelists today. We have an excellent lineup. Let me share my screen. All right, so basically today we're going to be discussing how to make sporty foot and ankle sports here as Dr shoe would like to say. So, it's my pleasure to introduce Andrew shoe at UC Irvine, he's going to be talking about some of the advancements in foot reconstruction techniques that he has not only pioneered but kind of brought worldwide. We have Dr Volcano and where he's going to be discussing the Zadok osteotomy and his indications for surgery and he'll definitely share his expertise with with us regarding that. And then Tyler Gonzalez at Prisma Health in Columbia, South Carolina right up the road from myself is going to be talking about his indications and techniques for tendons. And I am more than excited to learn more about all of this. So I'm going to turn the show over to Dr shoe. Now, if you all have any questions please put them in the q amp a box. In doing so, I will feel the questions at the end, and then we'll have a lively discussion at the end of each of the talks. All right. Thank you. So, I'm Andy Hsu. I am Dr. Chris Gross's Asian sidekick. I am the short round to his Indiana Jones, if you will. So a few disclosures, I'm a consultant for Arthrex and I have kind of an unhealthy obsession with Achilles repairs. So we'll be talking about Achilles repairs from the tip to the end of the tendon. And so we'll be covering proximal and then mid-substance and then insertional ruptures and kind of where we've come from that. So everybody knows this guy. This guy has probably been obnoxiously in the news, obviously. And all of us have fielded questions about Achilles repairs and is this legit? And why did he get one repair and Kirk Cousins got another repair? But this has been all over the news. And so you can view it as kind of like tabloid sensationalism, or you can view it as kind of a good thing for our field because the minimally invasive technique that Rogers got has been around since 2015, 2016, there's really nothing new about it. But then you watch ESPN, you hear the news stories and it makes it seem like it's some new cutting edge type of surgery. And while it's not, the point is, is that public perception of what we do is very important. And if patients are excited about what we do and the ability to not only repair Achilles tendons, but do it in a fairly minimally invasive way and have rapid recovery, I think that's a good thing. Right? I don't think there's bad press in that regards. I think obviously you have to take it with a grain of salt, but I think the Aaron Rogers example versus the Kirk Cousins example is very profound because remember that Kirk Cousins got an open repair and Aaron Rogers got more of an MIS type of repair. And so where's Kirk Cousins? Where are all the news articles about Kirk Cousins, right? Where's him on the New York Post and things like that. And again, there are differences in surgery, there are difference in protocols, but it's really very much in your face in a very public way. And so on the left, right, that's a la Kirk Cousins, that's an open crackout type of repair. And then on the right is what I think personally is the new standard. I think the days of being able to say, well, it's all kind of a wash open versus MIS. I just don't think that's true anymore. I think if you approach it from an anatomy point of view, the devascularization that occurs at the peritoneum and the tendon itself, when you're just making that big of an open repair is completely different than when you're doing a MIS type of repair. It's not just about the skin incision, right? Anybody that does MIS know it's not just about skin incision. It's about soft tissue handling. It's about dissection. It's about devascularization. It's no different than plating a tibia shaft fracture versus doing an intramedullary nail. There's just far less scarring and soft tissue damage when you're doing more of an MIS type of technique. So one centimeter is the picture on the right. And I don't know that I can get that much better at this day and age without sacrificing construct stability. So the question is, how did we go from the picture on the left to the picture on the right? And so when you're talking about just kind of background, right, the classic story is non-contact type of injury. Kevin Durant was one of the more famous cases where he just took a step back. And there have been countless other examples as well of people just planting their foot or pitchers like Mike Sirocco and others really just kind of pushing off the mound and having a sudden pop. There was a very famous one of the San Francisco 49ers linebacker just jumping up and down for joy and then taking off and boom, there goes his Achilles. And so oftentimes it has to do with deconditioning of the tendon. And I think one really important lesson in all of this is preventing Achilles ruptures in the first place has to do with very consistent, very regular eccentric stretching and strengthening exercises for all of our patients in general to even prevent these Achilles injuries from happening in the first place. And yes, while the vast majority of these happen in the mid substance, you can't forget about the proximal repairs, which we almost never do, right? Those are all non-operative for the most part, because it's like sewing suture into ground beef. There's nothing to really grab onto. And then the insertional repairs, which by and far do not do well with nonoperative treatment. So what we tell patients about these athletes and conditioning and all those other things, I think is one arm of it. But then for the evidence-based medicine people, I think we live in a day and an age now where literature can be weaponized. And I really do mean that where evidence-based medicine is kind of this hot phrase where everybody wants to say, where's the evidence-based literature? What's the level of this as if that is by itself a gold standard, which I think is completely false. And I think a prime example of that is the New England Journal of Medicine paper, non-operative recircle treatment of acute Achilles tendon ruptures, which at first glance is a very good paper, right? How many of us in this room have ever published in the New England Journal of Medicine, right? We're probably never going to do that. So it's very easy to take that paper and say, oh, they decided that there was no significant difference between surgery versus non-surgical repair. And so if the New England Journal of Medicine said it, we shouldn't be doing any of these surgeries. We shouldn't even be talking about repairs and middling invasive repairs. We should always be putting everybody in functional rehab. But when you really kind of dig beneath the surface, there was a lot of data censoring that went on in this paper and the objective outcome measures were actually very subjective. It was just like these random questionnaires and a lot of people dropped off of treatment groups. So to the New England Journal, I say, do you like apples, right? Because Greg Guyton says, hey, I can prove your paper wrong. I can do a Monte Carlo analysis, which won the Leonard Goldner award during the 2023 AOFAS meeting, showing that if you were to redo all their data, the data censoring led to actually false outcomes. Meaning that if you redid the whole paper through a random number generator Monte Carlo kind of thing, which he understands better than me, the Achilles repairs actually did significantly better than the non-operative treatment. And I think that's really important because I think the tide is turning now where many of us are finding that having this very long conversation about non-operative versus operative and let the patient choose, the tide is kind of swinging now where you're almost sort of like, all right, operative. How do you want it? Right. MIS, very MIS, very sportsy. Like the conversation is changing quite a bit in terms of what the literature is even showing and what our conversations with patients need to be. Even five years ago, every single patient got the whole functional rehab talk and then got the repair talk. And now I'm finding that as I'm actually thinking more critically about the literature and just about anecdotally my patients and how they're doing, I'm almost kind of thinking, is the new standard Achilles repair and is the new standard MIS repair, am I actually more liable and open if I don't offer them an MIS Achilles repair? You know, like it's a very different way of thinking. And so functional rehab, there've been lots of great papers about that. But I think in America, I just don't think it's that practical. Why? Our internal medicine, our ER medicine, our urgent care practitioners are oftentimes not that well-versed in functional rehab. So half the time I'm getting these patients coming in at a week or two weeks after their quote ankle sprain, walking around in flip-flops. So the window of opportunity to do functional rehab has had largely passed at that point. If you're going to do functional rehab, you need them to be in a plantar flexion splint ASAP, and then immediately go into the protocol. And really, honestly, how many of your patients are going to be able to follow this protocol? Week zero to two, two to five, five to seven. I mean, most of my patients can't remember most of their follow-up appointments. So it's a great idea, but it's kind of an academic exercise unless you live in Europe, where I think they are much more regimented with a nationalized healthcare system about how they control patient care. So it's not without its merits, it's just that how practical is it in your environment? And so for the longest time, the idea was non-operative versus operative. Is it just surgery with wounds or is it re-ruptures? And that's kind of an oversimplification. And really part of the thing that got me to think maybe Achilles repairs is really just the standard, is when you look at kind of more of the functional outcomes, when you actually look at how people are doing in terms of strength, actual functional data, rather than these surveys and AOFAS scores and VAS, the Finnish group really did a very good job with these classic papers that I think everybody needs to know, basically looking at functional rehab versus surgery. And surgery had better return of calf muscle strength, improved physical function and pain scores. And I believe completely that once the promise guys come out with all their cat data, they're going to show the same thing with Achilles repairs. It's going to be non-operative treatment. But taking it one step further, when you look at the cross-sectional data on MRIs of Achilles repairs versus non-operative, the non-operative group had compensatory increases in FHL. They had decreased strength, decreased gastroc size. So no wonder why these patients come back in the non-operative protocol saying, yeah, it's pretty good, but I can't really run or sprint anymore. And so I think a good analogy is like how we treat lateral ligament instability, right? The whole MFULI, O-VICRAL, pants over vest, but then you really look at the data and 25% of them never got back to sports. That's a pretty poor outcome in 2024. I think if you do the same thing with Achilles, you'd probably say, yeah, a lot of the non-op people probably aren't sprinting anymore and they're not getting back to professional sports. So maybe we can do better. And so obviously our approach to lateral ligament reconstruction is completely different. And I think our approach to Achilles repair is completely different. So the crack house sutures, again, I don't do this ever. I think it's too much devascularization. It's too much liability, too many wound problems, but some people still do it. It is very, very shocking to me how many sports medicine attendings, senior level guys, when you get them in a room, when you say, how many of you do MIS Achilles repairs, none of them raise their hands. They still do this. And they're the first point of contact for most of these ruptures when they're treating like these college athletes and semi-pro athletes. So there's just this huge lag in terms of like what the literature is showing and what techniques are showing and then what people are doing. So that's why I'm kind of impassioned in a way about like lectures like this to be like, hey, like you need to pay attention to like what the new stuff is. And so these wound complications are horrific, right? These can lead to free flaps and BKAs and just really terrible things in general. And if you've seen one of these, which if you've been in practice for a while, you have, it's nightmarish. You just never want to see it again. So the PARS jig, right? One of my mentors, Bob Anderson, was part of the design team for this. That was basically an improvement off of the Integra Aclon, which was this disposable, very expensive thousand dollar jig that didn't have a curve. So as you put the jig in, you would just end up piercing too deep, you'd end up piercing neurovascular structures. So then they came up with the PARS system, which is just one iteration of minimally invasive repairs. There's the Ma Griffith. There's variations on that, right? There's what, you know, percutaneous repairs, doing cross sutures and things like that. The idea was, it's just like, can you do the same type of repair through a smaller incision? And yeah, you know, you can get a much smaller incision with much fewer dissections. And I think that really counts. And it's hard to kind of compare the ease of which you have peace of mind when you don't have to be worrying about wounds to hissing on you. And so my fellowship project, which is kind of what got me started back in 2014, was just looking at this in the general population. And sure enough, the percutaneous repairs did better and had fewer outcome problems and fewer complications than the open repair, right? And so obviously I went through every single chart, like myself going through it all. And it was very interesting to see how much of a difference there was in a larger cohort of non-professional athletes. Very easy to talk about professional athletes like they're normal people, but they're not, right? They're kind of freaks of nature. They're so much stronger and so much more resources than an average person. And so then there's not stack issues with repairs. And a lot of the times, even if you're doing like Ethabon not stacks, or if you're doing a Ma Griffith or any of those types of repairs, you kind of have to worry about that. So a lot of the more modern systems nowadays use a knotless type of system to basically create a bridging construct, right? And so yes, internal brace is a trade name, but think about what that is, right? Like it's a knotless type of construct to reinforce any ligament repair in the body. And so applying that to the Achilles tendon kind of makes a lot of sense too. So this is one of the options that's available right now. This is my preferred one. It's just a knotless system that you can use combining percutaneous repair with this. And this has been around for about six months now, this beta released last fall. And so regardless of your preferred system, you always want to kind of have good setup. And I cannot stress that enough. If the leg is too externally rotated, any type of repair you're going to do, you stand a chance of piercing the sural nerve, piercing the posterior tibial nerve. Just getting them neutral is very important, airing the incision on the side of the more proximal side to get access to the tendon. My challenge to everybody on this webinar is how small can you get it, right? If you start with a three centimeter and move to a two centimeter, can you drop it down to one? What is your physical limitation as to what you believe is possible? And so these are just pictures basically showing that we start with a small incision and we grab the proximal tendon. This has been around for quite some time. You really want to be very thoughtful about how deep you put this so you can grab as much of the proximal healthy tendon as you possibly can. But sometimes it's garbage, right? Like you see these sutures pulling out here and that's just garbage tendon. So that just shows you how bad the tendon is at the rupture site. So for all the open repair people, what good does it serve putting a bunch of sutures all through the rupture site? That's like the worst possible tendon. You want to bypass it. So in this particular case, we passed the jig way more proximal to grab healthier tendon. But think about how big of an incision I'd have to make on this guy if I was going to do it open. I'd have to extend this thing like 12 centimeters up to get to healthy tendon or you can use the percutaneous jig. And so this is just an example of why x-rays in an Achilles case would be useful. When you're doing knotless fixation of an MIS technique, I don't want to put anchors in that bone spur, right? Like he's going to feel that. And so I want to recess that right above those anchors, right above that bone spur. So these three nine anchors are going to drop in right above the spur to basically make sure that he doesn't feel that. I believe 100%, most of the people that use these systems that have heel pain, it's because you're either not completely at the right angle of your anchors, or you're not completely buried in, or you didn't shoot the C-arm shot because it doesn't occur to you that you need C-arm for a tendon case. But putting that five millimeters distal in that spur, I think is going to make him symptomatic or blow out the spur. Five millimeters proximal, wrong spot. You need to have it right in that exact sweet spot. That's what it looks like. It's kind of going down and in, and then passing sutures distally, creating a bridge construct, if you will. And then these smaller anchors, smaller footprints, it's a three nine anchor in the system in order to kind of create this knotless system. And that's what it looks like, right? So whether you're a percutaneous McGriffith, or you have your own derivation, or you're an open, or whatever it's going to be, you got to restore resting tension. You only have one shot at this. You can always stretch somebody out, but you can't re-tension them unless you go back to the OR. But how can you maximize construct stability and minimize dissection? That's the real goal here with any minimally invasive techniques. The reason why I'm partial to this particular one is because it's very reproducible. I have taught my residents on this again and again and again. And one of the things that gets me the most psyched up is when they go to the VA hospital and they do it on their own. And they send me pics and they go, Hey man, I did that too. And I go, Oh, that's awesome. The fact that I can get a PGY 3, 4 to do it independently without really any supervision lets me know that this is a safe reproducible technique. Nothing against McGriffith and percutaneous techniques, but that stuff is very nuanced, right? Like that stuff is very difficult, I think, to just teach one, do one, show one kind of thing. Like you got to really have kind of some experience there in terms of what you're doing. And that is sort of how it plays out, right? Like there are some very well-known surgeons that still do many open repairs and they pass the knots along the side. There was a recent FAI article about, you know, using little fishing hooks and all sorts of doodads to make this work. But how reproducible is that, right? Like, do you believe you could show a video of that to a PGY 2 and then have them do one without completely flailing? So I like kind of an algorithmic approach to this where you can really kind of walk somebody through the steps of it. I think that's so important of any MIS technique is that you can, you know, flex on people and show them all day long, your cool x-rays and your small incisions. But if you can't get them to do it safely, I mean, then that's just you showing off. It's not really teaching them how to do anything. And so we can restore resting tension overall. We can apply this exact same technique to insertional ruptures, right? So insertional ruptures, you cannot treat non-operatively. It's just, it's not going to work. So can we take a same type of percutaneous approach? And if you learn that approach, can you marry that to an insertional repair? So this is a patient that had an insertional rupture. And so what we did essentially is shaved off the Haglund. You can do this MIS with burrs, but I like to do it open, especially if it's a rupture. And you can use similar types of anchors to create a double row repair, basically again, knotless reconstruction, bringing that all the way back down to the calcaneus. You can have two rows of compression on this. This is a, what we call ripstop technique, basically where you're going to get tending compression against the bone to really suck the tendon back down to bone. Kind of like you're doing a cuff repair, very broad insertion coming down, multiple points of fixation to suck the tendon back down, especially for an insertional repair. That's what that kind of looks like at the end of the day, double row repair, all knotless, right? You're going to six proximal three, nine distal. And again, restoring Thompson's test. So at the end of the day, you're trying to get in there like a ninja and get out. You're trying to cut minimal dissection while getting a strong construct repair. And I think where a lot of the previous repair techniques fell short was, yeah, it's at the bond. Yeah. It's minimal dissection, but it's not strong. Or you had a very strong crack hour repair, but it's too much dissection. So we're trying to get best of both worlds here. And so the protocols are faster. You can move people that week two, you can get people weight bearing right away. You can definitely trust the construct more than worrying about the sutures tearing through the soft tissues. So six weeks PT, no dorsiflexion past neutral for the first 12 weeks. And you get them going as fast as you can after that with running and impact activities. And so this is Gordon McKay's paper back in 2016 when they were doing this stuff and really just showing very, very impressive early outcomes using minimally invasive techniques. So I didn't invent this, right? I'm just kind of one of the many people that's a big believer in it. There are people far smarter than me that kind of designed all this stuff, but seeing is believing. And when you kind of do a lot of these techniques after a while, it just makes you feel good to be able to offer to your regular patients things that the professional athletes do. And that's kind of my take-home, right? If Aaron Rogers gets it, everybody on this call is going to get it, right? And so we should expect absolutely no less than providing the absolute best care. So if that's what he's going to get, that's what I offer my patients. And obviously people eat that up. So the literature is changing. This is Kodakia's paper in AOS, Yellow Journal, basically showing that not only are we getting away from the conversation of non-operative versus operative, we're really just focusing on operative versus MIS operative. And I think this is going to be the new standard overall. So I want to thank Dr. Gross for having me and again, Achilles repairs from the beginning to the end, but thank you, Dr. Gross. Great. Thank you so much, Dr. Hsu. That was, even though I can listen to you talk all night, we must move on. Dr. Volcano, we'd love to hear about the Zeta. Thank you guys. Let me share the screen. All right. Can you see me? All right. So thank you so much for having me. And thanks everyone for participating. So I'll be talking about the percutaneous zetagosteotomy for insurgent Achilles tendinopathy. And these are my disclosures. So first and foremost, I really, really want to stress the difference between a Hagelin syndrome and insurgent Achilles tendinopathy, because I have a feeling that these terms are used interchangeably. And we're talking about two completely different animals here. There's one of the studies out there on zetagosteotomy. I actually have a feeling that most of the patients included were Hagelin's patients and not insurgent Achilles tendinopathy patients. So with a true Hagelin's patient, there is no degeneration of the Achilles tendon. It might be inflamed, you have bursitis, but it's really a pump bump. And clinically, typically these patients present with a dorsolateral bump, as you can see at the bottom image here. Whereas with an insurgent tendinopathy, there is degeneration of the Achilles tendon. Typically, the bump is on the posteromedial aspect of the ankle. And so that's already an easy way to differentiate one from the other. The other thing that is quite obvious is that in the overwhelming majority of patients, there is always some form of intratendinous calcification with insurgent tendinopathy, whereas you never see a calcification with a true Hagelin's deformity patient. And so just keep this in mind, make sure you differentiate the two types of conditions, and if needed, order an MRI. This day and age, I really only order it in patients where I don't see really a calcification, but my clinical examination is more suggestive of insurgent tendinopathy, such as pain right at the posterior tuberosity, as opposed to a Hagelin's where they tend to have mostly pain at the medial and lateral side of the bump. So what is the problem with the open debridement? I think Dr. Xu said that pretty clearly. It's really mostly the longer recovery and the wound complications. And then we get into the whole chapter of the FHL. When do you do it? Over 50% debridement. This is a completely arbitrary number. There's actually no true good study that says that 50% is a true cutoff. So why not 30%? Why not 70%? And why doing it at all? We were recently at a conference with some friends and colleagues, and some of them saying, I never do the FHL, even if I'm debriding 80% of the tendon, and they still do pretty well, or at least comparable to the other patients. Serral nerve issues, another reason why I wholeheartedly hate more open and aggressive debridements of the Achilles tendon. And so I think this, you know, images are worth a thousand words. This is exactly the reason why I essentially have stopped doing any form of open Achilles debridement for insertional tendinopathy. So why the zetacosteotomy? If you think about it, so first of all, what is a zetacosteotomy? It's a dorsal closing wedge osteotomy of the calcaneus. While we don't have an exact amount of bone that you want to resect, the sweet spot seems to be around 10 millimeters of dorsal closing wedge. And the reason I think it works is because it interiorizes the insertion of the Achilles tendon. Now when you think about it, when you're doing an open debridement, what are you doing? You're detaching the tendon, you're shaving down that posterior superior bump, and then you are reattaching that tendon onto that cancellous bone, de facto interiorizing the insertion of the Achilles tendon. So what the zetac is essentially doing is just that, it's interiorizing the insertion. When I first started doing this in 2016, I was doing it open with a saw. And then as soon as the burrs kind of came to the market in 2017, I rapidly converted this to a percutaneous osteotomy based on a conversation I'd had with Anthony Pereira in the UK. And ever since, I've never looked back and I couldn't be happier with this procedure. The indications are exactly the same as the ones for an open debridement. And so essentially any form of insertional Achilles tendinopathy. I don't care how big or small the intratendinous calcification is, to me it is absolutely never a contraindication to doing a zetac versus an open debridement. What we need to really understand is that the calcification is not a source of pain, it's simply the manifestation of the chronic degeneration of the tendon. But it's not the calcification that's causing the discomfort in these patients. The way I do it is I typically put patients in a lateral position so that the ankle is resting directly on the mini CR. And then I mark the osteotomy. So it has to be an oblique osteotomy. And I usually place it anterior to the insertion of the plantar fascia. You want to leave a plantar hinge. And this hinge is usually about five to ten millimeters. And the reason for this is that in my earlier series, I had one non-union which was in a patient where I had frankly violated the plantar aspect of that hinge and didn't even bother to stabilize it with an extra screw. So that patient went on to a non-union which thankfully was my first and only one. You want to adjust the orientation of the osteotomy based on the hindfoot alignment. So I got into an argument on LinkedIn with a surgeon who sustained that only patients with cavus feet were eligible for zetac osteotomies. And this could not be farther from truth. In a patient with a cavus foot, I typically keep the osteotomy a little bit more vertical so as to reduce the pitch. Whereas in a patient with a flat foot where I don't want to reduce the pitch, I keep the osteotomy much more oblique. And I'll show you a couple of examples later on. So this for instance is a patient with a flatter foot. What I did is after planning the osteotomy, and as you can see I made it a little bit more oblique, I used a 3x30 cutting burr or Shannon burr to gradually shave a bone until I removed about 10 millimeters of dorsal closing wedge. Now there's different techniques you can do the zetac. When I first started off, I made two limbs to the osteotomy and then I shaved down the bone between those two limbs using a wedge burr. Over time I felt more and more comfortable doing a more gradual shaving. So I make the first osteotomy line and then with the same burr I gradually start shaving bone on either side of the osteotomy. And one of the reasons for this is I just feel in my hands it's faster. And the other issue is when you make the two limbs of the osteotomy, there are certain times where you may over resect bone. Which it's typically not too much of a problem. They still heal absolutely fine, but they may have a little bit more push-off lag. I then stabilize the osteotomy after reducing the the ladder. And the way you reduce the osteotomy is by hyper dorsiflecting the ankle. I put two screws, the dorsal screw to close down the osteotomy and a plantar screw to stabilize the hinge. So that even if I violate the hinge, I don't have to worry about increased risk of non-union. This is a case of a patient with a cavus foot. So as you can see I made the osteotomy much more vertical so as to reduce the pitch once the osteotomy was closed down. Another thing to keep in mind is make sure you can send patients for a plantar spur exostectomy. Because as you rotate the posterior tuberosity more interior, that plantar spur, if patients have one that's particularly prominent, will just poke on the skin plantarly and the patient will not be happy postoperatively. So just make sure you can send them for that as well. And this is kind of to summarize what I said earlier. You can absolutely address either type of hind foot alignment, flat foot or cavus, by simply changing the orientation of the osteotomy. So more oblique for a flat foot and more cavus, I'm sorry, more vertical for the cavus. Vertical for the cavus. My postoperative protocol is fairly aggressive if you want to define it so. I allow patients to wait there immediately in a can boot. They don't need to sleep in the boot, it's really just for walking. And I encourage them to start moving the ankle immediately after surgery. I get them in physical therapy two weeks after the procedure, consisting mostly of strengthening, particularly eccentric strengthening, proprioception and stretching. And though you'll notice once you start doing these, that these patients have excellent dorsiflexion and no signs of Achilles or gastrocontractor. And then by six weeks, I put them back in a sneaker, a comfortable shoe, and they can start returning to most physical activities. They can start gentle jogging on a treadmill already at six weeks, more impact activities, tennis, basketball, football, whatever. I usually tell them to wait between 10 and 12 weeks. One thing to keep in mind is that every single patient will complain of medial and lateral hind foot discomfort for about four months. And then, I don't know why, but it's almost magical, but past the four months that discomfort goes away. The fascinating thing is that the pain they had at the insertion of the Achilles goes away almost immediately after surgery. So it's an incredibly fascinating procedure. In terms of the outcomes, you know, nowadays the literature has a lot of information. Granted, a lot of these studies are not the highest level studies, but unfortunately in orthopedics, a lot of the studies are not randomized case control ones. I first published on the zetacosteotomy back in 2020, and it was actually the first study on percutaneous and true percutaneous zetacosteotomy. But if you look back, there's other papers on open zetacosteotomies reporting on very good to excellent outcomes. Every few months, there's a new paper out there on the effectiveness of the zetacosteotomy, whether it's open or percutaneous. Together with Dr. Gonzalez and other co-authors, we recently had our combined experience on zetacosteotomies accepted for publication in FAI. My cohort of patients, which I contributed to the paper I present here in this talk, and basically it's 91 patients, that I observed between 2017 and 2021 with a minimum of two years of follow-up. And we had a mean follow-up of about 48 months, and the foot function index as well as the VAS significantly improved with a patient satisfaction almost abnormally high of almost 98 percent, which for open Achilles debridement is fairly unheard of. The complications I observed were that one non-union that I mentioned earlier, and I really believe that was my mistake. It was one of the first ones I was doing, and when I violated the plantar hinge, I just didn't think that stabilizing it with an extra screw would have made a difference. I had a couple of patients requiring hardware removal, but I did not have any sural nerve complications and no wound complications. Thank you for the attention, and I'm happy to answer any questions you may have. That was wonderful. Again, we have the Q&A chat box there. We can field questions at any point. I think I have a couple. What do you think the source of pain is if you're not really... Again, I'm just playing devil's advocate here. What is the source of their pain if you're not really fixing the things that we were taught to treat for this? Traditionally, open is you're removing the Haglunds, fine, but more importantly, you're getting rid of the degenerative Achilles and the calcifications, and eventually, they do get better. It does take a year. You're absolutely right, but what do you think that you're fixing sooner given your excellent data? That's a good question, and the truth is I don't know. What I do know is that I do not touch that calcification ever, yet the patients do better, and if you talk to any of our colleagues that have tried to do Zetacosteotomy, they will all have, for the most part, the same experience. I think it's that, again, the calcification I don't think has any role. It's simply the tip of the iceberg. It just tells you radiographically the tendon is degenerated, and I think it's the tendon that's being generated that hurts. Once you anteriorize that insertion of the Achilles tendon, and I don't know if you guys have ever done it, but you'll notice that the ankle dorsiflexion improves immediately, so you are lengthening essentially the Achilles tendon, removing the tension onto the tendon, onto that diseased tendon, but exactly why it works, I'll be honest, I don't know. Okay, I mean, that's fair and fair. Chris, I think and we're looking into why this is because I don't think we know the answer but I do also think there is, so I think the most interesting thing is which I really don't understand is what Ettore said, when they come back at two weeks their posterior heel pain is gone. Like it's immediately gone and it doesn't make a lot of sense because a lot of times I thought that by anteriorizing the calcaneus, decompressing the heel, almost doing like a decompression and then also by taking the tension off the Achilles while you gain that dorsiflexion, that would allow a healthy biological environment for the Achilles tendon to heal itself but they are such improved at two weeks that can't happen in two weeks but I think there is some impingement effect by decompressing it and by we know that doing just a strayer in some of these patient helps. So by doing this and you functionally lengthen the Achilles and gain dorsiflexion, that might be where that symptomatic relief comes. We are, Ettore and I, are doing a biomechanical study now looking at push-off strength in our Zetac patients compared to open Haglunds in the lab at one year. We're actually doing that study now because we haven't seen weakness in push-off. People think, oh, if you got a Rob Peter to pay Paul, if you gain dorsiflexion, you must be weaker or I actually think you restore a more appropriate length tension relationship because all these people have contractors but more to come on that but I think that's part of the reason why it helps. Awesome. Would it give you any pause if they were like an athlete? Like would that matter of doing like a calc osteotomy or do you still say, no, I'm going to go MIS, Zetac, even if it's like a, you know, semi-pro runner kind of person, like minor league soccer kind of person? No, to me it makes actually quite the opposite because they're athletes. I need them to get back to sports as soon as possible and reduce the risk of wound complications, which can be career-ending really in certain cases. So for me, actually, it's the opposite. I'm even more motivated to do it if they're high-level athletes or younger patients. Yeah, I agree, Andy. I as well and I've done it on several college athletes and we have a lot of military out here and they do very well functionally. That's why we're doing this study on push-off strength but there's one of the larger papers at FAI looked at professional soccer players in Europe and they all go back to sport within 14 weeks. So I think compared to an open Achilles debridement, which I was very reticent to do on any athlete, this I'm much less concerned because we haven't seen weakness in the Achilles and faster return to sport. The patients, I will tell you, the patients that, in my experience, did not do as well were usually two categories. A, those were, especially at the beginning when I first started doing this, I wasn't removing as much bone as I do now. So now I rarely remove under 10 millimeters. But a couple of patients where I removed maybe seven or eight millimeters, they did better, they did well, but they kind of said, I'm okay. They were happy but they were just okay. And then the other patients which almost essentially never heal are those with rheumatological conditions. So if they have RA, lupus, whatever, I really prepare them well. I tell them, listen, there's a good chance you're not going to heal. But I have actually, I have a feeling that you're not going to heal whether you do a Zadig or whether you do an open debridement. I think it's a matter of controlling the inflammatory response there. All right, Tyler, we're going to get to your talk and Dr. Falcano, if you could answer the questions posed in the Q&A chat. Sorry, I was trying to do that. Yeah, let me share. No, I appreciate that. But again, keep on answering questions. We'll try to answer them live if we can, for the sake of time. Let's go to Tyler's talk. Yeah. All right. Can everyone see this? Hey, everybody, Tyler Dallas University of South Carolina. As Dr. Xu said, anytime I can have an hour to look at Dr. Gross and be in his presence, I'll take it. So if I have to do a talk on tendinoscopy to be a sporty foot and ankle surgeon, I will. So here we go. Good. Let's see. All right. Here are my disclosures. So perineal tendon injuries, these are very common problems. Many get better, but not all of them do. Oftentimes we get MRIs, but they can be very confusing. They can show tears, tendinitis, but often inconclusive. So when we're thinking of surgery, we can think of tendinoscopy or an open procedure. What you're seeing here is a recurring theme. I could not agree more with Dr. Xu's opening statement about MIS. MIS is not percutaneous. MIS is not a small incision. It's soft tissue management. So as long as we are doing a less soft tissue stripping, less dissection, what we are showing is patients have less pain, less swelling, faster recovery. That is what minimally invasive foot and ankle surgery is. And it doesn't matter if you're doing Achilles, perineal tendons, a bunion, a Zadig, an MIS fusion. It is the same concept about soft tissue preservation, but also about periosteum, about biology, about maintaining that soft tissue envelope to get the healing. So I think everyone on this webinar is passionate about that and why we want to be here because we believe in it. And that's the way where foot and ankle is going because we've all seen our patients improve from that. So I think when we're thinking about MIS, it doesn't just have to be a percutaneous incision about soft tissue management. And so problems with open reconstruction of perineals are the same thing with Achilles, same thing with open Haglunds is there's wound healing issues. People have scar sensitivity. It can be a longer recovery. I'm sure we've all seen stenosine, tenosynovitis and impingement. However, MIS is not a panacea. It's not for every case, every patient. We have to choose our indications wisely and choose our patient wisely. And I think what Dr. Hsu, Dr. Volcano, Dr. Gross, myself, we have to study this and we are studying it. And as we study it and we believe anecdotally it works, but I think the data is following us and we have to see when who is and when is the best time to use these minimally invasive techniques. So preoperative management, for any perineal pathology, whether it's a chronic tear, degeneration, inflammation, you can do immobilization, anti-inflammatories, physical therapy, steroids. I know there's this this huge dichotomy of you can inject tendons, you can. I mean, we've, Ben and I out here, my partner, Dr. Jackson and I, we've studied, we've published several studies showing no increase of ruptures. I know some people still think it's heresy, but I'll inject the perineal tendons and I've never had a rupture. I do it quite frequently and they do well. But for me, that's also helpful because if they get better from an injection and it comes back, it helps me better identify if they'll be a candidate for a tendoscopy. And also I'm mainly talking about perineal tendoscopy today, not post-tendon, but that's also something we can talk about on another webinar. I hope Gross invites us to. All right. So indications, just like open perineal tendon repairs, it's almost the same. Anytime you fail nonoperative management, if these patients have tenosynovitis, I think they're great candidates for perineal tendinoscopy. Small tears are what you suspect is a small tear. But even if you're not sure it's okay, because part of the benefit of this is you don't burn any bridges. You can go in, you can identify a tear. And if you need to open, you can, it doesn't, it doesn't negate that you're in the lateral decubitus position. You can convert to an open, which I really like this technique. The other thing is, and this goes back to what Dr. Hsu was saying, there's soft tissue preservation. So I can go in and I can do a debridement and there's area where I need to make, instead of making a full seven, eight centimeter incision, I can make a one centimeter incision to repair a tear or two centimeter. I find that often my patients do better. Additionally, what I think is really important is oftentimes we don't have a tear behind right where the SPR is. And when you take down the SPR and have to repair it, we're at higher risk of scar tissue impingement and a slower recovery. So if we can debride or assess behind the SPR with the scope and then repair distal proximal open, we can get that faster recovery and more minimally invasive approach. So contraindications, this is kind of a trial by fire. I try to do this on a lot of revision cases. I still sometimes do, but it is very hard. You have a very small sheath, a lot of scarring. It is a lot more difficult to do in revision cases. So I just caution that it's not always, it's not as easy in these areas because we've all done revision perineal reconstructions and with all that scarring and minimal space, sometimes doing it with a scope is more difficult. So my technique, I do lateral with a beanbag. I use a 2-7 or a nanoscope. I have no conflict with the nanoscope. I just find it helpful sometimes. I use a 2-0 or 3-0 shaver and I do, I use a thigh tourniquet. So I do, I used to make my portals very, very small and sometimes that makes it a little more difficult to get into the tendon sheath. So sometimes I'll even make them about eight millimeters, sometimes a centimeter in certain cases. But again, like Dr. Xu said, you can go bigger or smaller and you can challenge yourself and it sometimes will depend on the case. But I use a little snap. I get into the sheath. I usually can see the tendons because they're so subcutaneous and then I get the scope in there and then I can do my diagnostic scope. I can assess the tendons and look at this and then if I need to open at that point, I can or I can proceed with my tendonoscopy. Often my portals, I usually start, again, and it'll depend on the pathology, but usually I make one portal proximal to the superior peroneal retinaculum, whether that's a centimeter or two centimeters there on the left. The central picture is about a centimeter and a half to two centimeters above the SPR and then usually one distal, kind of where it curves around the fibula. And then if you need another accessory portal by the peroneal tubercle or a little distal, you can make that depending on the pathology you're treating. And as you can see, they're very small here, small incisions and easy to visualize the tendon. So I'm going to go speed up here because we only have a few minutes left. But my post-op protocol, I protect the patients from themselves. So I usually split them for two weeks and then I get them walking in a boot and start physical therapy. They're usually in a normal shoe at four weeks and really advancing with physical therapy. So I'll just show a few quick cases. 40-year-old cashier, peroneal tendon pain after rolling her ankle, no instability, failed all non-operative management. I did an ultrasound, got an injection. She got 90% better, but then the pain improved. So, you know, here's her MRI. A little fast there. MRI here, you know, and you can see little inflammation. Don't see any, maybe a split tear in the brevis there, but nothing crazy on that MRI. And here you see there's a picture of the tendons with a small flap tear in there. And you can go in with your shaver, clean everything out, debride it, and then get that back to looking like that. So much healthier tendon after the debridement. This is an interesting case. This is a 19-year-old who got stung by a stingray in her peroneal tendons. One of my partners was treating her, never got better. She had an injection by one of the non-op sports guys and got significantly better, but then the pain returned. Her MRI showed right where her scar was and where the stingray went in. She had a ton of inflammation right there. I don't see much of a tear, maybe some stenosing tendinitis, maybe a little inflammation, but nothing crazy, but she got significantly better by the injection. So obviously I scoped it. Those you can see her scar where the stingray went in. So that's how I adjusted my portals. You get in there, you see a lot of inflammation, a lot of scar tissue there. Go in, debride this, and you get back to very healthy with no tendon tears, just a bunch of scar tissue, that to that. So really quick, minimally invasive procedure. And this is the last one because I know we'll want five minutes for questions, but again, 62-year-old female, two prior surgeries, but pain now is really above the SPR. Failed treatment, injection helped. MRI on the right here shows right there, there might be a tear, some degeneration in her tendon right there. That's what I was worried about. And so going with the scope, and you can see here that the tendons have kind of scarred together and she had a low-lying brevis. You can go in there, debride this kind of adhesion that has formed between the tendons. Otherwise, not a ton of inflammation. It's more of a tenellitis, so to speak, but debride the low-lying brevis, can debride this scar tissue, do it through a very minimally invasive approach and get her going. And here you could use a biter here. I'm just torturing myself with a shaver or torturing my resident, making them do it, to be honest, and just being able to debride that tissue and get this back, get her mobility, and then get her moving fast, which I think is really beneficial about this procedure. So for the sake of time, again, just last video showing that you can really see fraying of a tendon here, which is low-lying brevis, which I also debrided, and then you can go in and you can shave kind of this tendon debridement. And why I'm showing this video, this was all behind the SPR. And then I found this tear more distal in the brevis, distally, made a small mini open and repaired that with tubularization. So able to do a hybrid, but able to get her going faster because I didn't have to take down the SPR. And this is how you can just flip the tendon and kind of really assess for any tears. And you can see no tears right there behind the SPR. So you can kind of shave that, but I see that there's nothing going more proximal, which I think is helpful. And we'll go through that. So basically, there are some cases where you can't scope, but in summary, it's good for debriding tendons, debriding small tears. If you identify a big tear, you can debride it versus repair it and open just in that small location and just be careful with revision cases. So thank you very much for the AOFAS and thanks to a great panel. Always, always a pleasure to be with y'all. That's awesome, Tyler. There is a question in the chat for perineal tendoscopy. Do you typically use a shaver in the proximal port or use a scope in the distal portals or vice versa? I do both. So I will usually start with my scope proximally, but then I'll switch, just like an ankle scope. I'll start one way, shave and then switch the portals. Obviously with the low lying brevis, I like coming distal to proximal, but kind of the location of the tear and the anatomy. But I usually start with my scope proximal and then switch portals. Awesome. And are you using it in a posterior tibial tendon at all? I do. I do. So, you know, in people, I think we all seen this with lateral and medial pain, no hind foot valgus, but inflammation on the MRI. I inject the post-tib tendon too. I know it's heresy, but I do. If they get better, I'll do perineal tendinoscopy or post-tib tendinoscopy as well, kind of through a similar approach. I just didn't think we had time to show that as well. But yes, there's some great papers in FAI on that technique, which is a technique I use. And I just want to do this in the office, like, you know, Kennedy and them are doing all this, like, in-office nanoscopy, tendoscopy thing. What are your thoughts about, like, the procedure room setup? Is that too much for this or is that pretty on par or is Kennedy kind of like out on an island? I mean, I don't. For me being in the OR, in case I need to open, I want to be able to do that. And oftentimes, I don't personally have the setup for it. I think I do small procedures in the office, hammer toes, things like that. But I'm more of an OR guy, the way my practice is set up. I'm not that sporty yet to be using the nano in the office. Now, just to clear things up, when you're saying injecting the tendon, you're having someone do it under ultrasound or you're just kind of giving it your best? Always. It's always a she. I'm always under ultrasound. Awesome. All right. Unless anybody else has any other questions, we have gone through a tremendous amount of material tonight. You know, it's certainly going to change the way that I think about approaching all these different issues. I'd like to thank every single one of the attendees and most importantly, the panelists. Thank you so much for sharing your expertise. It's good to work with all of you. And have a good night, y'all. See y'all soon. Bye, guys. Thanks.

minimally invasive techniques

foot and ankle surgeries

percutaneous procedures

tendinoscopy

soft tissue management

periosteum preservation

Achilles repairs

Zadikosteotomy

insertional Achilles tendinopathy

perineal tendinoscopy