On behalf of AOFAS, I want to welcome you to tonight's webinar, The Role of Primary Fusion for Complex Foot and Ankle Trauma. Tonight's moderator is Dr. David Thordeson. Joining him are Drs. Bruce Njorzin, Thomas Harris, and Max Mikulski. 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 On Demand Education Center. 2023 webinars are provided free to AOFAS members and orthopedic residents, fellows, and medical students with funding from the Orthopedic Foot and Ankle Foundation, supported by a major grant from Stryker, and additional funding from Arthritis. To support education programs like this, make a donation to the foundation on our website or by texting GIVEAOFAS to 41444. I'd like to run through a few housekeeping items before we kick off the presentations. 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The AOFAS Winter Meeting, taking place this January at the Saddlebrook Resort in Tampa, Florida, and our new in-person course this April, Sports Injuries of the Foot and Ankle, registration opens tomorrow. I will now turn the program over to Dr. Thornton to begin. Thank you. Great. Thanks, Lucas. Thank you all for joining us this evening. This is going to be a really interesting webinar. We have three experts in trauma who will be speaking on, not the bread and butter, but the really complicated fractures. We are going to go from proximal to distal. We will start with primary PLN infusions, Dr. Max Mahalsky, one of my colleagues at Cedars-Sinai in Los Angeles, an assistant professor who does all the complicated foot and ankle trauma at our Busy Trauma Center, will present on primary ankle fusions after complex PLN fractures. So, Max, if you can take it away, thanks. Thanks. All right. Thanks. Yeah. Good evening, everyone. Tonight, we'll be talking about acute fusions for PLNs. These are my disclosures. If I need to start out by thanking some people, I'm really lucky to be at a trauma center with six awesome orthotraumatologists and this dedicated team of microplastic surgeons. These teams meet weekly to manage these complex patients, and every PLN I've fused has been done alongside trauma, as well as the majority of required some form of plastic surgery for soft tissue coverage. So, we'll begin by discussing why, who, and how to perform fusions for PLNs. We're going to go through the literature about the why and who, and end with some cases about the how. And I really have to commend anyone who's done any published, any literature on this, so the treatment of PLNs in trauma population, because they are inherently impossible to get follow-up. I've had an interest in these since the first primary fusion I did, have kept a list of them all, and despite my best efforts, the majority of them have been lost to follow-up. So, this landmark study from 2003 in JBGS was pretty eye-opening when orthopedics started to look at the patient-reported outcomes. Looking at the SF-36 scores, they reported high-energy PLNs not only are lower than the general population, but also worse general health than patients with AIDS, acute MIs, and diabetes in the SF-36 physical scores. Initially, they showed that about, of the patients who were working before the injury, 43% were unemployed at latest follow-up, with the majority attributing it to the injury. Shortly after, this was published in FAI, also looking at high-energy PLNs that were treated either with OIF or XFIX. At two years, over half the C-type PLNs had radiographic signs of arthritis, and two had undergone fusions. The challenging part about interpreting any of these studies is that radiographic arthritis and the rate of conversion to fusion aren't very good indicators of success or failure. Not everyone with radiographic signs of arthritis are symptomatic. Conversely, many patients are unhappy and symptomatic than those undergoing conversion to a fusion. They may not want to undergo another surgery and recovery period, especially if they had complication with the initial OIF. I think the real answer will be in the patient-reported outcomes. In this cohort, they were able to get functional scores at eight years post-out from C3 fractures, which showed pretty poor musculoskeletal function assessment scores. Similar to the previous study, 39% were unemployed and over half acquired modified duty. But half of these results from the early 2000s stood the test of time. Ten years later, this study looking at type C PLN fractures was published looking at differences to compare early or staged fixation. But the end results look a lot like the previous studies, 80% with daily pain, 70% stiffness and swelling, only 72% satisfied and many were unemployed. Finally, this year, a study came out looking at the recovery curve following PLON surgery using promised physical function scores. They found that patients plateaued around six months post-op and remained at a level one standard deviation below the population need. So if not fixing, what else? Given the results of PLONs had been so poor, people began primary fusions, and I'm really glad to have Dave here as the moderator for this talk. He was one of the early pioneers of primary PLON fusions with his preliminary report in 1999 and followed up by this article in 2008. He did 15 primary PLON fusions in 14 patients with a posterior approach using a blade plate and posterior iliac crest. Although one plate broke, all achieved union, there's one deep infection that required implant removal. In 2014, there were two publications describing primary fusion for PLONs. Beeman and Gellman described a technique for open reduction with fusion using an anterior plate and supplemental ring fixation added depending on soft tissue envelope, bone integrity, stability and patient compliance. In this series of 12 PLONs, all ankle fusions healed and 11 of the 12 tibial fractures healed with the primary procedure. There's one superficial infection that required a split-thickness skin graft, no deep infections. Then Zell et al. published their study on primary arthrodesis in JBGS using a blade plate similar to Thoracin series. 19 of the 20 patients healed, there were no infections or malunions, and the one nonunion went on to heal with revision and grafting in a frame. They included this graph comparing their SF36 scores to the prior Pollock study in JBGS. The only differences were the physical function and role physical components with the lower scores in the fusion, but this is really a difficult comparison. The ORAF group was published at three years post-op, and these were published at seven years post-op. The more concerning aspect is when I bring the other graph from the Pollock paper and see where the patients land in terms of physical function. They're somewhere between CHF and a nursing home. So my aim here isn't to discourage primary PLON fusions, but more so emphasize the importance of this preoperative counseling and setting realistic expectations for these patients that this is not a typical fusion recovery. So there's only one real comparison in the literature looking at PLON ORAF versus fusion, but again, it's hard to have a real comparison when there's inherent bias that all the worst fractures get fusions and all the less bad C-types get fixed, but regardless, I found relatively similar outcomes except for pain and physical role limits. So why perform primary fusion? This really limits the patient to a single recovery period, and I think this will likely improve the missed work time, which is extensive in these patients, especially if they require a secondary procedure for hardware removal and or fusion. Infection rates in the literature, although small numbers, are extremely low compared to ORAF, which even with staged fixation reports hover in the 10 to 20% range. You can take advantage of the fracture hematoma biology to heal both the fracture and the fusion, and finally, it avoids this complex hardware removal and difficult ankle fusion that can oftentimes be complicated by the history or possible history unknown of a infection with the ORAF. This is the kind of situation I'm hoping to avoid with primary PLON fusions. 25-year-old girl jumped off a cliff into shallow water. She gets an X-tips on day one, comes to my office with this CT at one year. She eventually agrees to fusion and is healed now, post-injury day 580. But what if, on day 19, she had this? Then day 580 might become day 121. She might have saved 460 days of recovery period. There aren't really any standard accepted indications as to who gets fused, but in general, all the papers discussed 43C3 and some C2 fractures with more than 50% articular cartilage loss, and of course, surgeon discretion. In Foot and Ankle Clinic's review and a really great talk on this topic from 2022, John Katz gave further insight on the indications. He also included B3 fractures, open injuries where the soft tissue damage is going to hinder the recovery, and those who present late when anatomic reduction becomes significantly harder. Some patient characteristics leading to fusion include elderly and neuropathics. The top three is really the focus of this talk, and these are, I think, of the ankle fusion candidates, whereas the bottom are the TTC candidates. So why now include B3 fractures? These studies show a pretty high rate of converting to arthrodesis following an anterior impaction pylon, and at 12 months, this group out of Australia published that B-types were actually doing worse than the C-types in terms of physical component summary and pain. This is a B-type. I think we can all guess how the story ends. In our office, one to two years later after ORF, now I'm needing a fusion, but I don't think just because they have that intact posterior column doesn't preclude this patient from bad outcome. When you look at that front of the joint, basically completely vaporized. So I'm going to conclude with how to do that in a series of cases. The goal is, like any fracture, restore length, alignment, rotation. In this case, you're always trying to get a fusion. I'm not going to really call these principles because that would imply some sort of fundamental truth, more so components that are important, in my opinion. First, timing. I like the span, scan, and plan approach for several reasons. First and foremost, the discussion about long-term impact of this injury and the nuances of why you think a fusion is their best bet, I don't think is one made in the emergency room or preoperative holding on day one. Next, there are complicated procedures that require planning. Oftentimes equipment might not live on the shelf. When possible, I template most of the case beforehand. Second, soft tissues. You've got to take what the soft tissues give you. There's not one single technique or approach, and if you're flexible, the fusion can oftentimes be done earlier as you only typically need one approach to the ankle and don't need the kind of access needed for the perfect reduction and the implants. Third is joint prep. It's not a typical joint prep. You're not getting that good compression like a normal fusion. My goal is to extend this as a metaphyseal fracture that includes the tailored dome and then bridging it. I aggressively prep that dome and try to drill it to create a soft cancellous surface. Fourth is the stability. I often like two forms of bridging fixation. The blade plate is the exception, as it is very strong with a proven track record for withstanding these forces to bridge the tibial shaft to the talus. But often, right now, the implant I use is dictated by the soft tissues and what's available. Fifth is grafting. Just know that you're going to need probably a large volume. I don't have one specific recommendation. There's no literature for that. There's oftentimes a lot of bone loss or just simply volume loss from the impaction. And finally, I love using drains and incisional vacs at the end of these cases. So this is the first one I did, and I'm including it more for historical perspective. This is a 37-year-old male presented at ED after inability to follow up. It's outside insurance due to insurance or outside surgeon due to insurance. He was a porous dorian, but says it was about four weeks ago. Here are three sequential cuts of the CT and the ED. Now, if there were wounds or an open injury, I would have a pretty high suspicion for infection with the appearance of the bone. With a closed injury and porous dorian, I'm just thinking there's probably more than four weeks out. But even in the more acute setting, I don't believe this is reconstructible, and this is a candidate for acute fusion. Our chief, a trauma trained with Thordeson, asked me to join him for this case. He said, we're going to fuse this guy with a blade plate. Without experience in really harvesting posterior iliac crest, I opted for femoral rea, which in hindsight was a huge pain, getting the imaging and start point for femoral rea in a prone position. Eventually got plenty of graft to fill that. Then we followed Thordeson's technique, went along the posterior level of the Achilles and used the candylated system. So I had initially gone much longer when I failed to realize that the fibular malreduction was really putting me in varus. I took the fibular screw out, and in the case of the blade plate, you're pretty much married to that blade position, so I had to go to a shorter plate, so when I correct it, I wasn't overhanging immediately. So as the saying goes, nothing beats good results like follow-ups, so this has to be my best. He was worried about insurance, and he left AMA from the PACU without any medications or anything and hasn't been seen again. Sadly, this is listed as historical because in 2016, the candylated blade plate was discontinued, and I don't even know where we got this for this case. So case two. This is a 41-year-old male who's well-known to our trauma service. History of contralateral open tibia, clavicle, pelvis fractures. He now lives with his parents and was trying to sneak out and jump off the balcony. Comes in with this. Five sequential cuts. It's really telling a story. I don't really measure the percent of joint impaction, but more looks at these kind of cuts of dust. You had a bunch of slices in a row and just tons of pieces that you know you're not reconstructing. So his initial clinical presentation on the left, but after two weeks, the lateral side, thankfully, it was never open, but not healthy enough to make an incision in that region, so this is taking advantage of what the soft tissues give you. This case, I, again, like femoraria, but it was much easier supine, then I took what they gave me. I wanted to be as far away from those lateral wounds as possible, so I actually went medial to the tibia in this anterior approach. If performing an ORF, I probably would have had to wait significantly longer to get access to that lateral side. And some advocate reducing the fracture before prepping, but I actually find it much easier when everything's mobile and you're staring at it. Just grab the tibial cartilage pieces with a ronger and leave the rest behind as graft. So started off thoroughly prepping the joint, held it in some K-wires, and eventually swapped those out for a clamp and used the plate to hold it in place with an olive wire. And many of the available fusion plates aren't designed to bridge the joint, they're meant to compress, so I decided to add another plate medially, especially get some more fixation above that, because not many of the fusion plates extend very high. So in hindsight, I'm pretty glad to have that 90-90 fixation. He didn't listen to any precautions, walked into a six-week post-op, 12-week visit, came in in I think sandals or tennis shoes, but denied any pain. And at 12 weeks, here were his final x-rays, and as trauma patients do, he has not been seen. Case three, this is a 35-year-old woman, so I'll try to wrap this up quickly. Contralateral head, say this open injury with an ipsilateral segmental femur, contralateral subtroke, pilon, lisfranc, underwent bilateral femoral RAF, spanned the X-FIX on an outside hospital two weeks prior to transfer. We had planned to go back for repeat I&D with plastics, but she was having issues with the X-FIX. She had a subarachnoid hemorrhage and TBI. She was agitated, using the X-FIX as a weapon against nursing and hurting herself. So with this amount of bone loss, joint continuation, we discussed with the family that she was going to get a staged fusion. But I wanted to remove the X-FIX and get stability for a flap, so I made the choice for a repeat debridement, reared the canal, and placed an antigrade tibiotailor nail with antibiotic cement to fill the void. Just to make sure I wasn't crazy, I found something in the literature describing this. So through that traumatic wound, I extended distally. I had direct access to the tailor dome, so I prepped that, removed the remaining cartilage. I placed this guide wire in overdrill with a biotinodesis reamer with a plan for a line-to-line fit. I really wish I had taken the time to ask the tech to straighten up this image because it's subtle, but I was working to get the tibia out of the way, get my start point. I went too far. Now I'm drilling this in a little bit of planar infection, which will come back to haunt me. With the nail docked in the tailless, now time for some perfect circles. These aren't straightforward. I always use a K-wire and a cantilated drill. Sometimes you have to be off-axis, like in the front in this tailless. And I'm doing a nail like this for the first time, and thinking about a hundred other things, I failed to recognize that my previously well-reduced posterior medial piece is now kicked out proximal and posterior because I hadn't stabilized it. Most techniques discuss this reduction first, but without bone loss, I couldn't. But I really wish I'd just placed some K-wires across that fragment to keep it in place. The reamer is not going to keep it in that path. It's just going to push it out of the way when it comes down. So prepping the tailless is a good position. Nails in, it's up there. And then I struggle and fight and try to get it pushed back down, but there's really no room for it anymore. But I had to accept that position for where it was. In the end, place of antibiotics, and the anterior, you can see that outlining where the antibiotic spacer was. And Trent looks a little distracted almost because of that elevated piece. She ended up on a flap, and six weeks later came back with some Iliac crest grafting. Like I mentioned earlier, that nail placement came back to haunt me. One year follow-up, she was actually doing pretty well, but complaint was instability. She couldn't get her heel down. She was walking on her toes. CT scan showed, I wouldn't say robust fusion, but partial fusion that I'd like to see more of. So that nail placement came back to haunt me. Here we go. So like I'm sure you never want to take those interlocks out again, but after getting them out, everything was still rigidly fixed, so I had to really break it up. I took a burr in front of the nail, flexed up the talus, and had backed it up a little bit so I make sure my nail didn't go into the sub-tailor joint, and then I used the anti-primer peel-on fusion plate with graft. So this is the most recent follow-up at six weeks. Now this construct, I'm pretty happy with her walking in a boot at six weeks. She was in this x-ray without me knowing anyways. So I'm gonna wrap it up here. I'm just gonna couple other cases, just same points. Let's go through it. Also, if you're going lateral transfibular, I do love the bone mill. This is I usually template, and you get a lot of awesome grafts if you use a fine blade and a bone mill. All right, thank you. Sorry, I ran over. No, no, don't worry. It was a great talk. It's an extremely complicated topic, and it's controversial. It'd be fun to discuss this later to see if all the panelists are in agreement that there's ever a rule for primary fusion and accommodative peel-on fractures. That'll be fun. Next up, we got Bruce talking about primary fusion for accommodative calcaneus fractures. Bruce. So even though this is quite different than a peel-on, the principles are very similar to what Max just talked about. I don't have any disclosures. I want to take a moment to say that we wouldn't be having this conversation without Sigmar T. Hansen Jr., who passed away this weekend. He was about three weeks short of his 88th birthday, and the time was coming, but he has had a major impact. The picture at the bottom here is just a small number of the fellows that he trained over the years, both trauma and foot and ankle. And if you take a quick picture of that YouTube link, you'll see a really nice tribute to him. He was probably one of the most impactful people in the history of orthopedics. So what are those principles that we carried over from the trauma world to the foot and ankle world? Here are the basic principles for trauma care. Restore the length and rotation of the bone, just like Max talked about. Anatomic restoration of the articular surface, if you can, just like Max talked about. Fixation sufficiently rigid to support early motion and the prevention of fracture disease, which includes stiffness, muscle loss, and bone loss. Those principles are quite well established in the long bones, not quite as well established in the tarsal bones. So why primary fusion for the calcaneus fracture for the subtalar joint? Theoretically, it saves a second surgery. That's one theory. You don't need to be perfectly anatomically realigned if you can't do it. So those are the pluses. The primary subtalar fusion is not supported by data and the minority of calcaneus fractures go on to fusion. So it may be not such a great plan. And the definition of too comminuted to ORIF is very, very subjective. So the idea has been around R.I. Harris, no relationship to Thomas Harris, as far as I know, talked about doing primary subtalar fusions many, many years ago, back in the 1940s. Toronto was a hotbed of treatment of calcaneus fractures at the time. And he looked at 47 fractures in 35 subjects and they used a modified galley approach. This was the method of reduction, this big old frame that they would pull traction on the tuber, pull up on the foot. Looks like quite a diabolical event, but once that was done, you could then place the patient prone on the table, take a piece of tibia in the back, fold it in half, put a block underneath the talus to get the height back. And you can imagine trying to sell this to a patient nowadays, it's not exactly a minimal incision approach. The results they reported were quote, very favorable, most returned to work in less than six months, no outcome measures, no pain scales. This was typical orthopedics in the mid 20th century. Hall and Pinal, who wrote a lot about this subject, reported on 35 cases. Again, old fashioned, five excellent, 18 very good, et cetera, et cetera. But they had a very telling portion in their results section. Results are not easily assessed on the basis comparable to other series, because you don't have a baseline, basically. You know, they use the quote, I'm terribly grateful to the doctor who put the bones in my feet together, but I can only walk one block. So this is the kind of outcomes that we did accept in those days. Doesn't really tell you if it's a good idea or a bad idea. Lindsay and Dewar did a great study in 1958. They were also in Toronto. They looked at 400 patients. This was a graduate thesis for one of them, and they drove all over Eastern Canada, found 390 subjects treated with a, for a calcaneus fracture, and basically said, don't do a primary fusion. It doesn't help the patient at all. They do no better and somewhat worse than the patients who are left alone with just an ACE wrap and an early motion. So recent systematic review on primary subtalar fusion showed a union rate between 90 and 100, which is fantastic, almost unbelievable. The weighted average of the outcome was measured by the AOFAS score, which is full of challenges, but it was 77 points out of 94. It's really out of a hundred. I don't know exactly what that means. They reported adverse event rate of about 20%, and they looked at all the studies reporting this and reported there was a very low evidence level, all the publications to actually support the idea. There was one primary study done for calcaneus fractures, primary fusion, 169 acute interarticular calcaneus fractures treated by primary fusion. AOFAS score was done afterwards. So retrospectively, even though it was a prospective study, they had no non-unions, only five complication. They had no comparison group. And one of the authors had financial interest in the device that they were studying. And here is that device. And at the top of the screen, you see how it's theoretically supposed to work. It kind of has a nice mechanical concept. On the bottom, you see the x-ray of a patient with a minimally combinated fracture that could have been fixed in about 15 minutes with a mini-incision technique. And that's what they're doing a primary fusion in. So I don't think any of these data are terribly helpful. You put on top of that, the fact that we have no level one evidence for ORF of calcaneus fractures yet, don't shoot the messenger. I fix them all the time, but we still don't have level one evidence of who needs to be fixed and who can be treated non-operatively. But we do know that we want to avoid the things that drive salvage procedures, which is a lot of lateral displacement, loss of height, and varus. But if you haven't before, please read this paper on prospective randomized treatment of operative treatment of calcaneus fractures. It's a great study. It's ethical and pragmatic. It certainly has some limitations. And one of the limitations is that they didn't put anyone in the study who had extreme deformity, which he defined as subfibular impingement varus or valgus. Leaving those out, comparing people who had open treatment to early active range of motion, did not show any difference in four different outcome measures. They were the same. So if you take those patients who you know are going to do poorly, take them out, randomize the rest, you conclude that you don't really need surgery. So that kind of tells us if we can get the heel aligned without doing a big operation, maybe we don't need to do a big operation. It's a great study and you should read it, but it's not the focus tonight. But they compared 69 and 70 patients operative and non-operative. Kerr-Atkins was their primary outcome measure, but they used four other very reliable outcome measures and didn't find a difference. Plus the world now is driven by small incision techniques that are pretty easy to do and can get people, once you're trained, you can get a fracture that looks like this with lots of comminution, before and after with a largely completely anatomically reduced fracture, no real incisions, just a bunch of poke holes. So wouldn't you rather do that if you were a patient? Wouldn't you rather have that outcome? So considerations for doing a primary fusion are poorly prior dysfunction. So you have some with an arthritic joint, some lux joint, now you have a fracture, go ahead, that makes sense to do a fusion there. Injury patterns can drive it, a really severe injury pattern with a high amount of comminution. Concomitant injury, like a sheer fracture of the posterior set of the, on the Taylor side, that's a good indication. Poor bone density, that's a plus or a minus. Age of the patient, very relative. But the biggest thing is unreconstructable can't be defined. At our institution, we see 200 calcaneus fractures a year. We do maybe one primary fusion during the course of a year, and it's usually because of something other than the fracture pattern. So if you're going to do it, highly comminuted fracture, you try to put the pieces together. I'm not advancing here, let me try again. So you take this, our normal plan is to build from anteromedial to posterolateral. If you don't have a piece anteromedially, I don't know if you can see my cursor, but here's anteromedially. There's nothing there to build to. So you could argue that this is one where it's reasonable to do a fusion, primary fusion. This is three weeks later when the blisters finally put up. We took all these pieces of posterior facet, put them on the back table, reassembled them, put some screws in to do it, to put it into the shape of joint. And then we went in and removed cartilage from the underside of the talus, put all those pieces back in, not as anatomically as if we were doing an ORF, but anatomically enough. Here's the reconstructed calcaneus with a big hole in it where there's no more bone. We put some bone graft substitute in there and just treated it like an ORF, with the one exception is that we prepped the subtalar joint, put a couple of screws across it. In this case, we just used two screws, I believe, but you can do others. Just a three-point fixation because we bridged it to the cuboid as well, because there was no anterior process to hold screws. This is what it looks like at the end of the operation. This is what it looked like at six weeks, healing pretty quickly and surprisingly. And I just looked that patient up. He's 16 years out. He hasn't been back, which doesn't mean he's doing well, but he hasn't been back. So use the same sequence of reduction as you do for a primary open reduction. And this is a picture stolen from shippers at all in foot and ankle, where they did pretty much the same thing. They used the Sinostarsy approach, put it back together, and then bridged it with a couple of screws, being very careful to get their alignment back. The push screw technique is an alternative. This is something we published, I think, 18 or 19 years ago when the fracture is too common to fix. You drill a hole through the tuber with a 4-5 drill. You let that very long 6-5 fully threaded screw push on the bottom of the talus. And as you turn it, it pulls the tuber down and away. And at the same time, you correct the alignment. Once you have Bowler's angle restored, then you can put another screw into the talus. So here's the screw on the left that's pushing against the talus to pull the tuber down to restore the alignment. It's there. We have the restoration. We put a pin in and then we put a fully threaded 6-5 screw next to the original, take the original screw out, and then put it, place it all the way into the talus. It's basically a strut that is holding the height, holding the alignment in place. You let that heal. And six months later, if they need a fusion, you can do it. But more than half the time it heals and it doesn't need a fusion. It's just auto-ankylosis. And that can be used in these complex fractures as well, where there are multiple fractures. You can't make an incision on this calcaneus because there are too many other incisions that you're competing with. You do the push screw technique. It corrects the anatomy, lets it heal. And in this case, we didn't have to do a salvage either. So things to think about are irreversible damage to the cartilage, pre-existing arthritis, unhealthy subjects with a reason to avoid multiple surgery attempts. But you have to balance that against the uncertainty about whether it will need to be fused, the unclear definition of too comminuted, and alternatives like minimal incision techniques that can work for those reasons. So there are fewer and fewer reasons to do this than there were in the past because the skill level and technology level of fixation implants is aligned. But if you do it, just get the coronal alignment, prep the joint, and treat it like you were just doing a primary fusion. Thank you for your time. Bruce, great talk. And I, you know, you need no introduction. I don't know if I mentioned that Bruce is a professor of orthopedics at the University of Washington. And also, I'd just like to comment that that was an extremely appropriate comment on Ted's passing and that he was truly a giant and just an amazing person also. And last, going from proximal distal, we have Tom Harris, who's chief of foot and ankle surgery at Harborview State Medical Center and also in private practice in Pasadena, will be speaking on primary fusion for Lisfranc injuries. Tom, okay, let's hear your screen. Okay, I'm trying, buddy. Let's see here. While he's doing that, Bruce, one of the comments you made was irreversible damage to both sides of the joint. But what if you, you know, you've got an injury where you've taken all the cartilage off, let's say the posterior facet. So, that's not an indication in your opinion for primary fusion? I would say that I don't know. Certainly, if you think that the damage to the joint is not recoverable, that's an option to do. The, when the talus also has lost its cartilage, that pushes me more in that direction because you have two beaten up surfaces they're probably going to scar together. But I've put together a lot of really smashed posterior facet pieces that ended up not having to do a fusion that, and I think, you know, experience is going to determine what you can do with what you have to work with. I don't think anyone's going to, can judge you either way, whether you try to fix it or they try to do primary fusion. I just think there are fewer and fewer indications because people are getting better at fractures and there's more limited, there's more technology that doesn't disrupt the soft tissue. Great. Perfect, Tom. It's all yours. Tom, you're muted. I can't hear you. I think if you go in the lower left-hand corners where it is on my screen, the mute button. The host should be able to unmute too. I don't know how I do that. Is that a little better? Sure. You got it. Perfect. Thanks. Good. Yeah. Well, sorry about that. We got some disclosures here. I have designed some of the plates that you'll see here. Otherwise no relevant disclosures. Who was Liz Frank? Gynecologist, French, hated and unpopular, worked with Napoleon, thought you could diagnose a fracture with the stesicope or all of the above. So as usual, all of the above. This is why we pay attention to these things. These guys are out there. This is a Minnesota Liz Frank fracture lawyer. I don't know if you saw Chris's study or not, but these sharks are circling. So can't miss these. Overview of this talk, when to fuse, we'll talk a little bit of prognosis, which is pretty dismal. Diagnosis, how to make sure we're not missing them. Injury patterns, kind of my overview in terms of fixing and fusing, and then incisions as well. And then literature, mostly from the last three to five years, one with a few cases. The three columns of the foot, very important, medial, middle, lateral. It's just like your hand. So the hand's going to, the lateral side moves a lot more. And this is important for fusions. When you're doing fusions of the midfoot, you do not want to fuse TMTs four and five. The overview here, I think that's an underestimation, 0.2% of all fractures. I sure see it a lot more than that. The direct is more of a crush in MBA. Indirect is more of the sports, hyper plantar flexion of the midfoot. But I think we'll all still disagree with what's high energy, what's low energy. And I'll talk to you that specifically about that later in the talk. That one there, I think we'd recommend fixing that. The one on the right, we definitely recommend fusing it, but it's never that simple. This is a slide about the prognosis out of Spain from a couple of years ago. And you can see these were all low energy. They were followed for 4.3 years. They're fixed with screws, wires, and plates, not fused, but you can see flattening of the arch 43%, CRPS in 30% that resolved and chronic pain in 74%. So not great. This was a study out of Switzerland, 2016, 11-year follow-up. 82% had ORFs, 18% fusion. 72% had radiographic OA, but only about half of those were symptomatic. High rate of loss of follow-up, but most had moved away and only two declined participation. The risk factors for a worse outcome were malreduction, myers-sensee, and the divergent type, as well as smoking. So this was interesting in terms of diagnosis. We always kind of say we need to get weight-bearing views. Well, this was a non-weight-bearing view out of Korea and 90% of the cases had at least some minor abnormality at with non-weight-bearing views here. So you need a high index of suspicion and still need to be vigilant. Here's the non-weight-bearing views there. Those are pretty obvious, but a lot of times we'll not look as much on the oblique view. We'll just look at that lateral column on the oblique view, and what they're noticing there is a loss of parallelism of TMT2. So keep that in mind when you're looking at your non-weight-bearing views. In terms of stress views, it can be painful for the patient. It's really hard to do this practically in the office. Two millimeters of widening seems to be the magic number, but I've seen the literature all the way up to about five millimeters. And when you're doing this, don't forget the first TMT joint, because that is often unstable as well. You can see that fracture. You think, is that a stable injury? Should I just let that fracture heal? You stress it in the OR, and you can see how that first TMT opens up. So keep that in mind when you're doing your stress views. I think of this as a complex. This is more of a subtle case, but you can see how that first medial column has just shifted down, and the first and second TMT joints are almost at the same height there. There's been a rotation of that navicular and medial cuneiform there, and you can see how it's just shuffled proximally. This was described by Dr. Porter a couple years ago, where he looked at this medial column dislocation, and it's more common than we think. It was most common in football. Something to keep in mind. It's not just as simple as Frank injury sometimes. And this is the natural extension of that. This was a case from Harbor where the energy's high enough, it'll just break right through the navicular and you can see that happening there. So in this particular case, even though we had already X-fixed him, we put a plate on and then fixed the navicular through that area as well to span it. I think we have a better understanding of these high energy Lisfrancs from Chris's study, Landmark 2006, recommended a primary fusion of the first three rays, medial and middle columns, not the lateral column. Although it's more of a dramatic initial X-ray and perhaps a little bit more operative work, patients seem to have a better outcome, but the early reduction is important here. So this is a case, 20 foot fall. Why do we care? Well, I think that's gonna put us in the higher energy column. Why all columns are involved? Why do we care? I think that just gives you an idea of how much energy is imparted to this foot. So how are we gonna treat this? Or if it's screws or if it's plates, fuse all five rays, first three rays fused for an amputation. And this guy, we did an arthrodesis of the medial three rays and some pins more laterally and went on to do okay. The benefit of the arthrodesis, as Max kind of alluded to, it's one surgery. It's not three. You don't have to do an ORF and then a hardware removal and then a fusion, less visits, faster return to work. And I think there's something about that initial injury milieu where these heal just a little bit faster. It's not recommended for athletes. And I remember this ICO from Mark years ago, and it's kind of dogma, but it does make a little bit of sense. And he's always said that maintenance of that medial column is necessary to return full function, especially in an athlete. Again, that's level five evidence, but keep that in mind. When do we need to provisionally fix this on the day of injury? Well, obvious skin endangerment, prominence from the dislocation, vascular compromise. When you see this bag of bones, it makes life easier later. And I think it quickens the resolution of the swelling. KYRs are okay, but the external fixator is an option as well. Remember where your incisions are gonna be later when you're doing this. Once the foot is reduced surgery, usually a fusion in cases like this can be performed later two to four weeks even. This was a forklift injury from Harbor. You can see just a massive bag of bones. And I'll show this case later. We tried to do a provisional midfoot X fix like this and some pins in there. It's not perfect, but it's better. And I'll show you how this case ended up later today. How to decide fix or fuse? Preoperatively, we can look at the mechanism of injury, low versus high, degree of displacement, low energy. I really try to avoid a fusion personally. Acute versus subacute, six to seven weeks is my kind of cutoff. Revision cases are fusion and the age and the activity level of the patient as well. Interoperatively, if there's a lot of articular damage, even at one joint, then I think we should probably be fusing these. And periarticular convolution goes along with that as well. So fuse the high energy. You'll know, I think you'll know based on the energy. Delayed multi-column, not necessarily this talk. Revision, obese, very large patients I think do better with the primary fusion as well. And articular convolution do well as well. So fix those stress positive, low energy ones. And those ones that are truly stress negative, I think we can leave alone. Incisions for a fusion, I've been doing more and more medial incisions for the first TMT and putting a plantar plate. That allows you to get a bigger skin bridge and put a dorsal plate over the second and third TMT joint. Or you can also do a long extensile. And then sometimes you'll need that lateral incision for the fourth and fifth as well. For an ORF, it's usually a dorsally between the EHL and the EHB. For fusion in terms of fixation, if there's no combination, you can use two 3.5 screws or four O screws for that first TMT joint. And for the first, second and third TMTs. If there is combination bone loss or a larger patient, I think you need to go with some bridge plates across that area. Staples are a viable quicker option, but you have to have good dorsal bone stock to do that. Bridge plates are almost exclusively used in my practice for ORF. And I don't typically use a home run screw. Flexible fixation is worth discussing, but not in a fusion talk. So these are some of the studies that are out there, fix versus fuse. This is level three from the Naval Medical Center in San Diego. These are low energy, Liz Franks, 32 patients, 14 fused, 18 fixed. And you can see the fusion group returned to full duty 4.5 months, two months earlier than the ORF groups. But keep in mind the hardware removal does delay the return. So that's something to keep in mind when you're doing this. So it's got a better early outcome with arthrodesis, but the long-term effect isn't known. Equal fam long-term as well. This is a nice study out of Norway that I thought would help solve this. And this was fixed versus fused. This is a level one study, 24 primary arthrodesis, 24 bridge plating, but only of the first TMT joint. They did not fuse two and three in the one study group. So the same scores, but there's some study drawbacks to that as well. So they really only looked at first TMT joints, not the whole midfoot that we wanna see with that as well. This is a nice study by Heather and her group out of Case Western. They looked at functional outcomes after high energy, Liz Franks. No fusions were done here. The FFI scores are important in that they were worse than plafonds and distal tibia, as well as talus fracture. And an independent risk factor for this was smoking, female and chronic renal failure. So keep that in mind. I mentioned this slide here because this paper generated a nice letter to the editor and FAI because they had a hard time differentiating high versus low energy. And this was a patient I saw about a month ago. And you look at that, you think that's some sort of car accident. She fell from the ground moving into her new house. So this is a ground level fall that led to that sort of thing. And I mentioned this next slide here because is her lateral column okay? Should we be fusing this or fixing this? So I just mentioned that. It's not always easy to tell the high versus low energy. This is a nice study out of Kentucky. They looked at 272 patients, but only about 81 of them responded to the survey. And they kind of concluded that neither was superior when appropriately triaged by the treating surgeon, which makes it a little bit difficult. I think we all would love to know how to appropriately triage these things, but nearly identical rates of reoperation between the two. This was a nice study from my friend Anish in Northwestern. And you can see here, this is a division one quarterback. It's got some comminution at the base of the second. And what he did, he used flexible fixation for the first TMT joint and then fused two and three. So it's kind of like an anti-glide fixation for the midfoot. Didn't fuse the first, but left it to heal with flexible fixation. So something to keep that in mind. And I liked that idea. This person was ready to go back in about nine months. And then lastly, before we go into some cases, this was the rate of displacement of inpatient reported outcome following minimally displaced Liz Franks. And this was out of the UK a few years ago. 26 patients followed for five years and the rate of displacement was 54%. And the flex sign was not associated with the risk of displacement. So the outcome of fixation was similar to those that remain non-displaced. So keep in mind, a lot of these, even the low energy ones displace. So this was some cases we'll go through. And this was a 44 year old MVA. You can see they're pretty dramatic injury, but really just at the first TMT joint. So we got our length back immediately. We put a medial plate and a screw and then fix the midfoot with just K wires there and went on to do well. This was a more interesting case. A 63 year old male foot was crushed by a water heater. And you can see there that lateral columns completely dislocated and the navicular cuneiform joints involved as well. So note that double density at the third, fourth and fifth TMT joint. So this one I look at, we definitely need to go toward a fusion here. And in this case, we used a long medial plate, a dorsal compression plate there. We definitely needed two incisions for this as well. I needed to unlock that lateral column to get it out from underneath the foot before we could do anything. And we can see we extended the fixation all the way back into the navicular to kind of bridge this area there. They're about seven centimeters between the two incisions and both incisions were definitely needed in through this area. This was that forklift crush I showed you a little earlier. And we did do our best here, but you can see this went on to a midfoot amputation. So you don't always win with these. They sometimes you do the best you can. And unfortunately sometimes with this just level of energy, you just can't do anything other than that. So this 18 year old female, high-speed motor vehicle accident, BMI 45, 370 pounds. Not too impressive of an X-ray, but with a BMI that high, and you may find this controversial, we went ahead and you can see some comminution there in the second. There's our stress fluoro, size matters, age matters. And we did a fusion. We did a plantar plate medially, and then we're able to do a dorsal plate. So you've got a nice skin bridge and she went on to do really well. And I think the main deciding factor in this particular case was her weight more than anything. 23 year old female, 30 foot fall into shallow water, almost like Max's case earlier. You can see the amount of comminution there. When you get those axial CT scans, you can just see all that comminution and pieces of bone. I think these are be better served with a fusion. So we went ahead and did a plantar plate over the first, TMT joint, a spanning plate over the second, given the comminution and went on to do okay there. This was that one we talked about from that Porter study. This was a skateboarder, youngest guy, and kind of a shortened medial column there. We're able to get that back out to length, used a distractor here to do that, and then put a single screw across the cuneiforms as well, just to help address that. And then near the end here, 37 year old, high-speed NVA. You can see the first MTP joint dislocation. So significant amount of energy there. You can see the lateral there, which is pretty striking. Able to do some temporary fixation with just some K wires the day of injury, and then go back and note the instability. And then this one's going to be one that we're going to fuse, again, with the same sort of construct we've mentioned there and gone on to have some nice alignment and already some early OA, as you'd expect at the first TMT joint, sorry, the first MTP joint. So in summary, acute fusion, the literature is still lacking a little bit. I still think the classic is Dr. Kotsuya's article. Most recent articles haven't really shown a difference between fusing and fixing. The techniques and the fixation for fusion are different than ORIF. So who do you fix acutely at this point? High energy, obese, and severe comminution. So things we've hopefully learned. Keep in mind that Perez study out of FAI where a significant amount of these collapsed even with low energy and easily fixed. Keep in mind that proximal migration to that medial ray from the Porter study. Consider a plantar medial approach to the first TMT joint, which allows a larger skin bridge to get to the second and third. That hybrid technique that Dr. Kodakia mentioned is worth looking at as well. And from the Heather study just this year at 8.7 years, the FFI was worse with Liz Frank's than with Plafond's and Taylor's fractures. Smoking, renal failure, and female were all independent risk factors. So thank you very much. All right, well, three outstanding talks on three very, very complex topics. I appreciate all the input. A couple of questions from the audience. Naren Gurbani asked, Bruce, this is gonna be directed towards you. In patients with these high energy injuries with a ton of swelling, is there a role to perhaps lean towards doing your primary fusion to just allow the soft tissue to calm down? Or does your minimally invasive techniques allow you to not have to wait that long? So the case I showed was exactly that. I was a patient with a tremendous amount of soft tissue swelling, blistering everywhere, and we waited quite a while to get in there. So I do think soft tissue swelling can be part of the decision-making. It's just not a very clear cut impact. If you have enough tuberosity intact that you can use a push screw technique, I think that is a nice way to get the soft tissue swelling to improve faster. So yes, but hard to define is the answer. Right. And Tom, Seth O'Donohue had a question for you. On those high energy Liz Frank injuries, do you find a lot more intercuneiform instability in those types of injuries? I think in general, you just find more instability throughout the whole midfoot. And that's why that one case we showed, we extended the fixation all the way back to the vicar. But yeah, I think as you see higher energy, you get more and more intercuneiform instability. So I'd agree with that. And a follow-up question from a Dr. Gray to you, Tom. Anytime you're bridge plating for fusions beyond the affected joints, did you then subsequently remove the implants? No, this particular case is if we are not fusing those extended places, then yes, I'll remove the hardware down the road. But sometimes given the comminution that's present in the affected areas, you need to kind of get more of a more robust fusion. So I'll extend the fusion parts to those other joints that weren't necessarily injured. It looks like the Liz Frank's on a roll. Andy Lefty had a question for you also, Tom. What about that pure ligamentous Liz Frank injury? Are you gonna fix it or fuse it? Does that influence your management? Not as much as the energy, the size of the patient and the degree of displacement as well. So I'm really using that. And I know it's hard to define the energy. I think that's still a part of hard time we come across. But like that one slide I showed where the first and second TMT joints were completely dislocated, but the lateral column was intact. That's ligamentous, but I won't necessarily fuse that because I still consider that low energy in a younger patient. I'll still try to save those joints. I know that in the high energy ones or there's some really dramatic and all three columns are displaced and dislocated. I think those need fusions. But if it's just a one or two of the columns, I sometimes will try in a younger patient to save them. So Dave, our original recommendation to consider primary fusion was just that. It was the pure ligament disruptions. And Rod Kuo talked about it in the early 2000 paper. And the index patient was a patient of mine who was six foot eight and had a size 13 shoe and had a pure ligamentous disruption. I put two screws in the first, one in the second and one in the third. And everything's going great, going great. He wants the screws out because he got a little aching there at six months. I take the screws out and three months later, he comes in with a complete collapse through those ligaments because he was just too tall, too long, too heavy to stabilize that without a fusion. So I do think that is one of the considerations. Yeah, that's the one case I showed too. She wasn't as thin, but it was just as heavy. And so that one, I think, went to the primary fusion as well. Yeah, the 13 size shoe means a long lever arm during heel rise. So Max, question for you. So you were obviously talking about these cognitive pilon fracture where the injury is confined to the ankle joint. Would you have like a higher threshold for fusion if you have somebody that's destroyed other joints? So for instance, let's say the head of their tail is navicular is powdered. So to do that pilon and your TN joint, or let's say you're going to fix the TN joint, but you're at a higher risk for a pan-tailor fusion. Is that going to change things or is it really going to be more dependent upon just the level of combination of the soft tissue envelope? I mean, my goal is in general to avoid a pan-tailor. So that would have me leaning more towards fixing, even if I don't think it's, even if it's what I would normally fuse in isolation, I would lean towards it, but you got to look at what the cartilage looks like. If it just, if every cut for the CT scan is just those flecks of bone, you're not going to do them a favor by just, you save the joint for a couple of years and now they have a pan-tailor a couple of years later and plus or minus infection and multiple surgeries. Right. Tom, another question for you. How long do you keep your primary mid-fit fusions non-weight-bearing? Oh, at least eight weeks. At least eight weeks. Yeah. All right. So another question, and I'm for anybody to answer on this one, not just Tom necessarily, but it's like with Achilles ruptures, you will never find a sports medicine doctor anywhere in the world that takes an elite athlete and treats an Achilles non-operatively. So why is it in athletes, we don't want to fuse their mid-fit joints because of functional considerations? And, you know, but the other average Joe like me, I'm going to get a fusion. So it's always an interesting question. See elite athletes, we treat them differently. I totally get the, you know, screwing a Jones fracture so you can get them back to play earlier. But what about this situation when we're talking about their eventual functional outcomes? So how do you rationalize that? Well, as I talked about a little bit, a lot of it is purely dogma. And it's all the idea that athletes need motion and they need that medial TMT joint to move a little bit. And it was from an ICO in 2008 where it was first written. And I think I saw Dr. Meyerson give a talk on that soon thereafter. And that's definitely colored my opinion of things. But I often wonder that, because even with these bridge platings and even keeping her off it for a while, and it wasn't really the purpose of the talk tonight, but you'll remove a plate or you'll, and then you'll see just a little gaping. It never quite healed completely with that. And it's a big bugaboo. So that's my short answer is dogma. So Dave, many years ago, I was treating an elite college football player with a list rank and I fixed it as a trauma person would fix it. And he wanted to know what his chances are for playing on Sundays the next year. So I called several of our colleagues who took care of NFL players. And one of them told me, oh yeah, I've treated plenty of those, they do fine. I said, could you give me a couple of names so he could talk to them? And we called the names and they never went back to playing afterwards. But this patient of mine actually did go back, just not as a quarterback. He went back in a different role when he played. So I think you can fuse them and they can play, but my bias is high energy with fractures I don't fuse, but the ligamentous laxity I do fuse on those patients. They have a lot of power. Their torque is very high. They accelerate a lot of rate and the midfoot gets a lot of bending stress. All right, I got one minute left. There's one additional question, Max. The question, do you use any other augments besides Rhea to get your primary pilon fusions to go? Yes. So one, I didn't get to the case, but if I'm going, depends on the soft tissues, but if I'm going laterally, I use the bone mill and take as much of the fibula in the case I was about to show there. I just kept, I didn't have enough. So I went a little higher and kept grinding it up. Another thing I've been doing is, I mean, it's called a biomimetic hematoma. I don't have data on it yet, but it's a mix of their whole blood, thrombin, calcium citrate, and a low dose BMP. And it makes this clot that looks just like when you get into a fracture a couple of weeks late. It's like that jelly. It's the same constitute as a fracture. And I put that in there and I've had pretty incredible healing rates, but don't have that published yet. So I don't want to say that that's the way to go, but I do like doing that or fibula. Well, this is a fantastic symposium. We're at the top of the hour, so I don't want to keep anybody late, especially for those East Coasters. We're all West Coasters on this symposium here, so it's time for dinner now for us, but everybody else got to get up for the OR tomorrow morning. But anyhow, I want to thank all three of you again for outstanding presentations on a super complex topic and looking forward to more level one data coming out of your institution, Bruce. Thanks again, everybody. Thank you. Thank you. Bye.

webinar

primary fusion

complex foot

ankle trauma

role

energy of injury

degree of displacement

other injuries

risk factors

prognosis