On behalf of the AOSAS, I want to welcome you tonight to tonight's webinar on cave ovarious foot deformity. Change slide. Tonight's moderator is Bofa Kriya. Joining her are Drs. Gregory Guitown, Jeffrey Johnson, and Edward Haupt. Change slides. You can find their full biographies and disclosures, as well as disclosures for your program planners in the program document posted in the chat box and at the AOSAS On Demand Education Center. Slide. Webinars are provided free to the AOSAS members and the orthopedic residents, fellows, and medical students, and funding from the Orthopedic Foot and Ankle Foundation, supported in part by a grant from Arthrax. Change slide. To support education programs like this, donate to the foundation on our website or by texting giveAOFAS to 41444. Change slide. I'd like to run through a few housekeeping items before we kick off the presentations. 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I will now turn the program over to Dr. Crea to begin. Thank you. hopefully those show. So welcome everyone, thank you for coming tonight. We're so excited to have everyone here and to spend the next little while talking about cable bear split deformity. As Shannon introduced, we have an awesome panel here tonight and a number of objectives to cover, specifically to go through some fundamentals and the approach to surgical management, including soft tissue balancing techniques, and let Greg take that over there. I will then take us through addressing the hind foot, followed by Jeff Johnson, who will take us through when and how to address the midfoot and tips and tricks, and then Eddie Hope will take us through the forefoot deformities that are associated. So I'll stop sharing my screen now and let Dr. Greg Bitten take over. All right, let me see if I can work on that. Let's see here, here we go. Okay, I'm hoping everybody can see that. All right, give me a thumbs up if you can see it. Hopefully you can. All right, great. So a great pleasure to be here tonight. I always love doing these webinars and thank you both for inviting me. This is one of my favorite topics and the reason is because you can go into this with all kinds of approaches and that's because there is no single unifying theme of the cavel varus foot. You can have some general clinical pearls and things that we need to talk about, but at the end of the day, when you start with a cavel varus foot, you have to have your bag of tricks and you have to apply those bag of tricks and you ultimately have to apply them to what you're facing because almost every cavel varus foot is different. That said, I'm going to start with a topic that we never talk about, which is how to deal with upper motor neuron pathology, or basically strokes and brain injury, because that's one of the things we have to face when we do cavel varus feet that we almost never talk about. Tradition is to start with CMT. So I'm going to get to CMT, but let's start with shoes first. And just because it's a topic that we tend to neglect in orthopedics. So cerebral vascular accidents, well, you probably haven't seen a homunculus in a while, maybe since the beginning of medical school, but occasionally it's worth remembering where our muscles that we deal with are coming from. And they come from the mid cortex and the sagittal sulcus, deep down in the middle of the brain that provides lower extremity sensory and motor function. And that is actually an anterior cerebral artery defined area. So if you think about the parts that we deal with, when we are dealing with a patient who's got an upper motor neuron issue that's coming from the cerebral cortex, it's coming from the ACA, which is very different than a traditional middle cerebral artery stroke, which you usually think of with upper extremity deformity and aphasia, but anterior cerebral artery issues. About 80% of the strokes that we will deal with are thrombotic, 12% are hemorrhagic, and the rest are anoxic. And they have very different prognoses. Obviously, anoxic is the worst. It's also important to remember that CVA is involving the brainstem will also cause very severe deformities. There's a dynamic to the acquired spasticity in dealing with a patient who's had a cerebral vascular accident. And this will take you also back to medical school. There's an initial flaccid paralysis and hypotonia, which will last hours to days. But then there's an increased tone and hyperreflexia, which peaks in about days to weeks. And then there's a very slow return to normal. And why does that matter to us? It matters because we need to know when we can operate on them. In other words, when you're not shooting at a moving target, just like if you're dealing with perineal nerve palsy, when you're not shooting at a moving target, when they are not going to recover. So a traditional CVA is about six months. After about six months, you can start doing rebalancing of the foot to improve their gait. Traumatic vein injury, and then spinal cord injury, these are 18 months or longer. You really have a long term before you say, now I'm ready to do the tendon transfers. And of course, the Noxic has a poor indication for surgery. The indication for surgery, ambulation, but don't discount positioning and transfers. That can actually be a life-changing event for patients with acquired capovarious foot deformity in the setting of spasticity. And after the wheelchair bound patient, after a CVA, ultimately 25% of those patients will get back to normal ambulation. So these are not life ending events for these patients. 75% of them will get back to some form of ambulation, even if they're wheelchair bound. And those statistics remain. The next statement is very, very important when you're dealing with a patient who's had a stroke and is wheelchair bound, because often we will see these patients, they'll come in, they'll be there for their foot deformity. Their foot will be turned. But in order to get back to gait, to get back to walking, they have to voluntarily have hip flexion. And that's an important part of your exam. They have to be able to flex their hip. And of course, they can't have a flexion contracture of the hip. They have to have balance and they have to have limb stability. The last thing you want to do is straighten out the foot when it's not going to make a difference or get them able to walk. So you have to be plantar grade. They have to have hip and knee extension in order to be able to ambulate. So they have to have the glutes firing as well. And of course, adequate balance. Now, I've told you all of that to get to the fun part of my talk, which is the lesson of the decerebrate sloth. So some of you may have heard this from me before, but this is an actual paper done by a couple of researchers from Hopkins in 1926. And they had a brilliant idea. They said, let's take an animal that does something different. A mammal does something different than we do all our lives. So if you decerebrate a sloth, they actually posture inflection. Why? Well, the animal spends their entire life upside down. These are the anti-gravity muscles that have to have some tonic tone in a sloth because they hang upside down from trees. And this may not be so PC anymore, but you can hang. This is from that paper from Brain 1926. They will even be able to hang upside down, even in a decerebrate condition. And so the point is, if you're going to engage in phenomenology or teleology, if you will, and say, why when we posture, when we're why do we go into extension in our upper and lower extremities? Well, it's because upright quadrupeds posture and extension, but a sloth postures inflection because it's the anti-gravity muscles. So if you are bereft of what you have for upper motor neuron input, well, brainstem will have a tonic, a tonic output for your anti-gravity muscles to maintain you in an upright position. And that is the phenomenological reason why you posture into extension. Why do we do that? Let's talk about equinovarus deformity. So if you've had somebody who's had a stroke, what do we see? If you actually look at the EMG output, you might also remember these sorts of graphs from usually from OID tests years ago. But what you see is spasticity of the anterior tibialis tendon all the way across the gait cycle. So down at that fourth line there, you'll see the anterior tibialis getting EMG input all the way across the gait cycle. But the gastroc is much more powerful than the anterior tibialis. So even though the gastroc is not tonically spastic, it still overwhelms it. So they posture into plantar flexion, but they also posture into inversion. In a stroke, it is driven by the anterior tibialis. And that's the key point in most CVAs, driven by the anterior tibialis. So what do we do? And now we're going to get to some clinical referrals. If you're doing an anterior tibialis transfer for managing spasticity, it's mostly an upper motor neuron disease. Now, the one caveat to that is that doesn't count for cerebral palsy. So if you have a static encephalopathy, commonly that patient may have a posterior tib spasticity, which is very different. Well, this is obviously a historical photo. It comes from a textbook. And this is the classic answer. It's the splat, the split anterior tibialis tendon transfer. So here's the outcome of the splat. And you see that tendon that's been transferred here to the cuboid with a little bit left intact to the medial cuneiform. So here's what Mr. Dunk has advertised. Allegated to the world of pediatric orthopedic surgeons and historical waistband. And they still do it. I'm just messing with them. But it's not a great option. There have been several papers. I'll show you two of them. This is a cadaver model from JBJS. The lateral arm of the splat is always active regardless of tensioning. In other words, when you do a splat, it is essentially a single tendon transfer. It's only the lateral arm that works. You are basically discarding the entire medial arm. We did a paper that was also aimed at this. This was in probably the early 2000s, mid-2000s, looking at medial and lateral. After a split transfer, a classic splat, versus a whole tendon transfer through the third cuneiform. And basically what you see is that even when we simulated spasticity, it is essentially impossible to force the foot too far back. In other words, you are not going to overcorrect the foot if you take the whole anterior tibialis and just plug it into the third cuneiform. I would argue that it's a simpler procedure. It is a more reliable procedure in terms of getting fixation, and it is the preferred procedure. Now, Mickey Penzler has also written on this. So, several people will tell you the splat should be relegated. And the original relegator was Ignacio Ponsetti from Iowa, who knew that whole tendon transfers of the third cuneiform in cases of plug foot recurrence were the answer. He did not do splats. He did the whole tendon transfer. So, the first clinical pearl of the night is do a whole tendon transfer. Well, what about the posterior tibialis transfer? Well, we usually think posterior tibialis transfer when we are talking about a foot drop. So, let's talk about that. It's typically not spastic except in cerebral palsy. So, this is the classic. It's an interosseous membranous transfer of the posterior tibialis. And you go between the fibula and the tibia, and you plug it into the middle or lateral cuneiform. I typically use the lateral cuneiform. The modern standard is done with interference screws. Of course, we're all familiar with this as the bridal transfer. The bridal transfer here is a tritendin-anastomosis in which one would take the non-functioning anterior tibialis and the non-functioning posterior tibialis and bring it up to hook into the anterior tibialis. Now, this was developed many years ago, but primarily before we had reliable ways of hooking the posterior tibialis directly into the middle or lateral cuneiform with interference screws. I have not done a bridal in a long time. If you do a bridal, most of the time you can take that posterior tibialis and plug it right into the middle or lateral cuneiform. And so, the bridal transfer has a lot of play in it. I would tell you that the modern way to do that transfer is to actually just take the posterior tibialis and plug it in with an expected good result. And that's Raul Rodriguez's classic paper on the bridal. Well, let's talk a little bit because occasionally, and the whole purpose of this talk is to give you some concepts of things that you might not appreciate otherwise. What happens if you've got a problem? Let's say that for some reason you can't get it into the third cuneiform. Let's say that there's a massive amount of hepatitis patients have and you can't bring it between the interosseous membrane. Well, it sometimes is worthwhile going back and looking at the historical literature, some of which deals with polio, some of which deals with CP, and see what did they do back in the 1930s. So, one of the things you can actually do, the first posterior tib transfer was circumtibial. And they brought it around the medial side, not through the interosseous membrane. And that was described in JBJS all the way back, first description in 1933. It works and you can get away with that. It's in the pediatric literature that the key point of that is that if you do that procedure, you need, you're not quite getting the same angle of pull, but doing a triple or at least a subtalar, talandovicular fusion will give you the better option. There's another modern correlate of that when you do some weird, some weird cavus foot or weird nerve issues. And that's what if you have lost all your other options, there's distal motor spaling with L4-5 failure, but you still have peroneals. In other words, you've lost the posterior tib that you otherwise might transfer. Well, another little historical oddity from the ancient versions of Campbell's orthopedics is to do a peroneus longest transfer, which you can bring around the lateral side. And that of course dates from the old polio days in which we used to see the anterior motor horn cells would knock out a segment of the spinal cord, give you a terrible cavus foot, but would leave you with distal motor sparing. And so you do see occasional situations like that. The most common reason we see it today has nothing to do with those issues. It has to do with failed spine surgery. And so we see that a lot and I'm seeing a lot of failed spine surgery that comes in with a modest cavus foot, but say has some distal sparing. Let's see if I can get this video to play. So this is a, I'm sorry about the sound, but that is actually a patient of mine that I did a peroneal transfer and you see it brought around the lateral side that has restored dorsiflexion of the foot. This one also, I tend to do with a subtalar fusion in order to park the hind foot in a neutral position, but you can restore dorsiflexion just with active peroneals in patients that have lost their anterior tib and their posterior tib. And that's the, that's the clinical pearl. All right, well, let's move on a little bit where I told you I'd get back to the peroneus longest transfer and talk about forefoot cavus. It is traditional to start these talks with a discussion of CMT. So in my little remaining time, let's talk about Charcot-Marie-Tooth disease. First described by Marie and Charcot. Charcot, the most famous neurologist of the 1800s in France and Tooth in England separately. It was called progressive muscular atrophy for years. Charcot thought it was a motor disease. He thought it was from the muscle. He actually got the etiology wrong just as he did the etiology of Charcot foot, but it got his name on it. And so there it is. It was called hereditary motor sensory neuropathy for years. And it was classified by a large number of EMG criteria here of Dyck and Lambert. If you go back in the literature and you'll see that, but it's now outmoded because we know there's a genetic basis. So about, about 60% of patients will have CMT1A, I'm sorry, 80% of patients. But in CMT1 is a duplication of the peripheral myelin protein 22 gene. Now that's all we'll talk about tonight because I'm just going to, we're going to be short on time, but there's a CMT2, there's a CMTX, and these are all, there's actually a whole host of different phenotypes and genotypes of CMT. They all have unique motor weakness patterns and the classic pattern for CMT. And what we're really talking about is CMT1A, is the intrinsics go out and the anterior compartment goes out with the paradoxical occasional sparing of the EHL. Now that's really bizarre because the EHL is the last thing in the anterior compartment, the last muscle that is innervated as the perineal nerve comes around, deep perineal nerve in the anterior compartment of the leg. And then of course the lateral compartment where the brevis goes out but typically spares the perineus longest. And that's what makes CMT so unique and gives us opportunity for tendon transfer is that it has these paradoxical patterns of motor sparing. And that's shown from MRI data. So I did a study probably about 20 years ago now in which we looked at the branching patterns of the nerve as it comes around the perineal, sorry, as it comes around the fibular head and looked at the perineal nerve branching pattern. And we also noted the fact that there's a disease called hereditary neuropathy with liability to pressure palsy, which is a deletion of one copy of the PMP22 gene. It's not a trisomy, which is CMT1A, it's a deletion. First described in Dutch potato diggers. I guess that's a Dutch potato digger in my old slide there. But it dates from, this was described and these patients get terrible perineal nerve palsies and episodic foot drops. So one of the things that we noted is that there was a lot of anatomic variability and it's likely that PMP22 somehow provides some protection against compression neuropathy. Whereas the nerve to the anterior tibialis is directly applied to the periosteum of the fibular head of the nerve to the EHL and the perineus longus takes off in some cases well before it gets to the fibular neck and follows a less compressive course. So that could potentially be a reason for seeing EHL sparing. Now, of course, where you might lead with that is why don't we go do nerve releases in all the young patients with CMT and would that make a difference? I don't know. That would take a heck of a randomized controlled trial over 20 years. So this is the CMT surgical algorithm, which is flexible dependent. The anterior tibialis is the weakened agonist. The perineus longus is the intact agonist. This chart is in a lot of textbooks, including our chapter in Mann's book. And you see the things that you can do. But what I wanna emphasize here for soft tissue balancing is the perineus longus to brevis transfer, which is an option early in the course of disease while things are still flexible after they've been described as having CMT, but before they've gotten a fixed deformity. Now, it is often described as doing this. In fact, that was the way I was trained to do it. But I will tell you the operative pearl I would throw out here is consider doing your perineus longus to brevis transfer approximately. In other words, above the superior perineal vernaculum. Why? Well, if you do it distally, anytime you do a transfer, whether you do it a pulvotaft or side to side, whatever your choice is, I usually do a small pulvotaft. You leave a small lump, and that lump is pretty asymptomatic if it's up above the level of the ankle. But if it's on the side of the foot, it's both next to the serral nerve, and it's in the shoe, and it's close to a calcaneal osteotomy that you might have also done in that patient. So it works just as effectively above the ankle, and that would be my recommendation. Let's also talk about the EHL. We talked about EHL sparing in CMT. Happens in CMT, happens in polio, and you'll see it in failed spine surgery, which is another place that I see it. This is also a useful procedure if you've had somebody who has had an anterior tibialis rupture that's not reconstructible. And of course, you see overpull of the toes with the absent anterior tib, but the EHL's still functional, and the toe extensors are used as a dorsiflexor. So the Jones procedure, classic polio procedure, IP fusion with transfer of the EHL to the metatarsal neck. You don't have to do the classic Jones. If you're already plugging something in to the midfoot, you can also take the EHL. You can even do it with the posterior tib transfer and plug the EHL directly in the midfoot if you like. And I will do that in some settings, particularly if they don't have a dropped first ray. It's a reasonable thing to do. Just go ahead and plug that into the third cuneiform or wherever you choose to go in the midfoot. It's important to remember the Jones procedure is an adjunct. It really doesn't have the cross-sectional area. If you look at the EHL, it's not quite up to the task of the anterior tibialis, and the penation angle is not the same, which implies that the throw or the excursion of the tendon is not gonna be the same as the anterior tibialis. It's important also if you have complete perineal failure to keep in mind your other options. Allograft reconstruction, if they still have a motor function, or FDL transfer all the way around to the fifth metatarsal, which is an out-of-phase transfer, but can at least, it doesn't really provide great strength, but it does provide foot balancing, keeping the foot from turning back to the inside. So the next question, and this will be very, how do I deal with all of the incisions? Because, man, we've got a capovarious foot, and we've got to deal with all of these plans. So imagine you're doing a brostrom, you're doing a perineal reconstruction, you're doing a Dwyer or a perineal transfer. How are you gonna deal with all of those incisions? So the general caveat, number one, remember you can do a brostrom and a Dwyer together through two incisions. And usually if you leave about four centimeters, you're going to be fine. You cheat the brostrom incision a little bit anterior and use a proximal tenodesis if needed, so you don't end up making the incision down on the side of the foot. So if you're doing a perineus longus to brevis transfer, remember that trick of doing it on the side. But the other one is to learn MIS techniques and get yourself a lateralizing calcaneal osteotomy done through a percutaneous incision. And you can also do allograft perineal reconstruction MIS, particularly in these patients that don't have a lot of perineal adhesions. And you can do that often through two small incisions. I've done that many times. So that's a quick tour. I know it doesn't have an overarching theme other than we visited some unique pathologies. And we also talked about a couple of little tricks and pearls that I've learned over the years for dealing with unique situations. And I hope that's useful to you in getting something out of that. Thank you very much. That's fantastic. Thanks, Greg. And I should say that I see your questions and I'm noting them and I hope that we either have time to go over a case at the end. And if not, certainly go through the questions. I'm gonna share my screen now. See if that's working. All right. Greg, will you give me a holler if the screen shows my slide? Yeah, you're good. I can see it. Okay, perfect. Okay. All right. I am gonna focus on hindfoot corrective procedures. So talking about the role of arthrodesis and corrective osteotomies. So when I graduated from fellowship, which doesn't feel very long ago, I took this photo of the whiteboard in one of our lab sessions where we discussed how to approach the cable varus foot. I have had fantastic mentors. A lot of people that I've pulled on to my mentor team to talk about cases. One of which is here, Jeff Johnson. I'm extremely grateful for everything he's taught me in the last year or two. I have evolved in how I treat cable varus foot and I hope to share that with you today. Greg did a fantastic job talking about Charcot-Marie-Tooth, which as you know, is an inheritable peripheral neuropathy. I'll go pretty quick through this, but wanna highlight the fact that CMT types are distinguished based on the type of nerve cell that's affected. So when you see type one, that refers to when the myelin's affected and that's demyelinating. Type two, when the axon's affected. You can inherit it via an excellent pattern and those patients either present with axonal type symptoms or somewhere in the middle. And then when you see type four, that primarily refers to an autosomal recessive inheritance. But there are actually over 130 different types of genetic identifiers, which have now allowed us to sub-classify CMT into 13 different types that you see here. The last category refers to the specific gene types. So for example, SWORD, or Cervital Dehydrogenase Deficiency, was only discovered five years ago. That is a form of CMT that you'll see. When you see a letter designation assigned, so 2A, 2C, 2F, 2J, that refers to the fact that a certain gene has been identified for it. 90% of what we would see in our practices are typically 1A, 1X, 2A, 1B, 2J. I think that this is really helpful pictorially to conceptualize what needs to happen when you approach the cable varus type. So our group has been studying both static and dynamic plantar pressure distributions in CMT. We divide the dynamic pressures via two masking techniques. And just to keep it really simple, if you look at the video that's playing on the right, that's a neutral hind foot position, well-positioned tripod foot. And if you compare that to this 2A patient, the purple and the red are hotspots, so high load areas. And the biggest differences that we see in peak pressures are in the lateral forefoot and the midfoot regions. And these changes persist over the gait cycle. So this is 50 of our CMT patients compared to 36 healthy controls. And what we're seeing is that the most dominant lateral overloading occurs during mid stance, internal stance of gait. So how do I approach the cable varus foot? Well, first of all, the goal. The goal is a plantar grade foot that's balanced, that has active dorsiflexion. Understanding the pathophysiology, I think is critical, especially in the setting of progressive neuromuscular disease, where you know that the symptoms are only gonna get worse and progress over time. The cable varus foot, it's multi-planar, but it's also multi-system. So some CMT types have a predilection, for example, hip dysplasia. 4C presents commonly with scoliosis. So I think understanding the specific genotype can be really helpful in reconstruction, as is understanding the bony morphology on a case-by-case basis. And I'll talk about this a little bit in some cases. And if you suspect that your patient who presents with cable varus foot pathology might have CMT, and you plan to refer it to neurology, one extremely helpful thing to do as you order your EMGs is to order both an upper and lower for classifying the disease, because even in the setting of a demyelinating CMT type, those patients often have distal axonal degeneration. So their speeds in the lowers look axonal. And so we compare them to the uppers where speed is a lot more, I would say, valuable, and the lower EMGs are typically better for axonal disease. So that's just a tip that's really helpful if you're gonna order an EMG. When I do a motor assessment, I pay very careful attention to each and every motor unit. I don't just grade them. In my mind, I have an idea of, so is this muscle paralyzed and dysfunctional? Is it weak and I can't use it for transfer? Or is it strong? And then I try to get a sense of reducibility. So is it reducible? Is it partially reducible? Is it irreducible? But to be truthful, I don't feel like you can truly get an idea of reducibility until you get into the OR, until you release all the soft tissue structures, release the medial structures. And only then do I really know if it's reducible or partially irreducible. And then I draw out all my planned incisions. So these are big cases. The last thing you wanna do is get boxed out by incisions. My approach to the cable varus foot. So even though my focus is on hindfoot corrective procedures, I think it's important to talk about how hindfoot bony work fits into the overall framework of how you approach the cable varus foot. For me, I always start with soft tissue. And that's the beginning of the case. I assess whether or not there's an Achilles or a gas drop contracture. If the Aquinas is due to that, or if it's actually due to bony morphology in the talus position, because an inverted hindfoot can cause an Achilles contracture. The first thing I wanna decide is if I'm gonna do a TAL. And if I do, I have a tendency to wanna leave the lateral attachment. I always release the plantar fascia. I think I heard Jim Simarco talk about, it doesn't have a really dramatic effect initially, but over time as the patient ambulates, it continues to settle the arch. I have a preference for doing this in the midfoot. I think you can sneak around there and get to the abductor hallus fascia as well when you need it. So that's typically where I go. As far as a posterior tibial tender transfer, I always start my prep work at the beginning of the case. So I do everything I need to, I dock it at the end into the lateral cuneiform. I've heard people talk, and I found this extremely valuable on tips and tricks on what to do here. I always go as difficult as possible, pass the navicula and take some bone with it. I feel like that extra centimeter is so critical, especially since it's often contracted. And then I move to my medial releases. And depending on how bad the cable varus foot is, I'm pretty aggressive here with a TM capsule release, a spring ligament release. And I credit Jeff Johnson and my conversations with him over the last year on really being aggressive with a long plantar ligament. I get all the way under, try to get to the cuboid even. And then I look if FDL or FHL need to be addressed. Okay, so I think that's important to establish first, and then I'll start going to the hind foot corrective procedures. Then I do my bony work, then I move to the first ray positioning, either my transfers or my osteotomies. Then I move to checking for ankle loxity, and then if in the same setting, I'll do the forefoot. All right, so let's start to the hind foot now. Okay, so I feel like when I was a resident, I remember learning a lot about triple arthrodesis and indication and rigid and painful deformities. I think over time, I've heard a lot of people talk about poor long-term outcomes. If you look at the historic studies, especially one of the ones I noted up there, there is a high percentage of poor or fair outcomes. And a really recent study by Glenn Pfeffer and his group, including Eddie, looked at the arthrodesis. I think they showed that physical function promise scores were actually lower in the arthrodesis groups. But I think that it's important to discuss the limitations with historic papers. There's often, if you look, no real objective assessment of alignment in all three planes. I often ask myself, was there sufficient soft tissue balancing? Was the positioning of the triple inadequate? Because if you put a triple in anything other than a favorable position, you're unlikely to get satisfactory results. And then our outcome measures, especially in CMT, I wonder sometimes if they're capturing what we want them to. So for example, can promise physical function discriminate between foot and ankle versus patient disease-driven outcomes? So those are just some limitations to note. I want to go through some technique adaptations. Separate published a technique described, I think, in the early 60s that involves a wedger section in the portion of the talus, and you can see that represented by the arrows in that figure in A. And with more severe cavus, they described a proximal extension into the talar neck. So Bopa, we're not seeing your slides. Oh, you're not seeing my slides anymore. Well, I think your audio went out, and then when you came back on, it was just you and not your slides. OK, let me see. Thanks for telling me that. Can you see them now? Can you see them now? No, no. You want to just reshare maybe or something? Yeah, let me try one more time here. I'm going to stop. Yeah, I'm going to reshare. There you go. Awesome. Thanks for telling me, and then I'll do this. And will you give me just a shout out that it's working? Yeah, you're looking good. You got it. OK, perfect. OK, so going back to Sifert's description for his triple beak arthrodesis, leaving that intact ledge that you see here in B, the shaded areas also represent the resections. So you can take a wedge of the talocalcaneal bone. And then Lambernoudi published this original paper in 1927, and it was actually written on drawfoot triple arthrodesis technique. So his technique utilizes intra-articular osteotomies of all three facets of the subtalar joint, typically from the talar side, to allow the talus to reduce in a more plantar flex position for preparation for fusion. There was a later paper in 1977 that looked at long term outcomes over 50 patients in 18 years, and they showed pretty good and fair results. I think these principles are really important to go back over because they can help. So this is actually one of my patients. She's 19. She's got 1A. She's had four prior attempts at a reconstruction of her hiravirus flow alignment. She had an apparent in situ fusion of both her subtalar and her CC joints. You can see her clinical radiographs as well as this 3D image here where you can see that she's starting to fracture her fourth and fifth metatarsals. She has really, really bad lateral column overload pain and she's developed ankle impingement. So I have this made into a 3D model. This is a really tough case for me. I felt that this really helped me understand the bony morphology element of her case. And if you look on her weight-bearing CT, you can see how the navicula is actually perched on top of the cuboid. You can see it here in these images, but you can really see it in the 3D modeling for her. Luckily, her joints hadn't fused. The subtalar and CC hadn't fused, and that was a blessing in disguise for us. So using some of the Lambernudi techniques and principles, as well as Siffert's descriptions, I focused not only on the subtalar joint where I did do a wedgery section like Siffert described, and I've heard Bruce and Jorzen talk about that. So I drew that in the arrow there in red, but also the entire inter-column area to free up the middle, the medial and lateral column so they can move independently in the coronal plane. And then did a revision of her CC joint where I did almost an inverted cuneiform osteotomy of the cuboid at the joint where you take more off the bottom, you take more off the top than the bottom, and more laterally than medial so that you can shift the midfoot laterally and you can push it up. You can see that here, we were able to get her a neutral position. These are her clinical radiographs, her follow-up. So when do I do a subtalar fusion then? So for me, I do it when I don't have viable transfer options to achieve hindfoot stability. So my first choice is a longus debrevis, if not an FHL debrevis. If I can't do it, I don't feel like I can get a stable hindfoot, that's when I'll do a subtalar fusion. In a non-CMT case, painful arthritic joints were truly irreducible. And again, always in mind the soft tissue respect, not just the bony procedures in isolation. So this is another one of my patients. She's 1B. She has a genetic protein abnormality of the peripheral myelin protein that causes 1B. Most of them are infantile, so about half of them, 40 percent. And a third of them actually have scoliosis, and the remainder present in adulthood. She's got a pretty significant cabal varus foot alignment. She wears custom shoes and braces, but has really significant pain. So for her, I did not feel that I could give her the stability that she needed without a subtalar fusion, in addition to all the other steps. And I ended up doing a subtalar fusion with her cabal varus correction. She did well overall. I think she's about a year out now. So then what about osteotomy techniques? So the Malerba is a technique that I was taught in fellowship. It's a lateral closing wedge Z osteotomy that was described extremely powerful. I started out my practice utilizing this as what I was taught in fellowship. I think it's safe, effective. It's extremely powerful for multi-plane correction. I have moved away from this. I think I can get the correction I need outside of this. I find it to be a pretty aggressive requirement of stripping of the soft tissues, but it is effective. Liz Cody and her group, Scott Ellis, HSS, they published a great study looking at modeling of four different hindfoot osteotomy corrective procedures. And actually, the technique I employed was number one as far as correction. Malerba was number two. So this is what I do. I tend to do a Dwyer osteotomy with a lateral displacement. I try to keep my osteotomy more anterior. You get more power that way, but there is more risk associated with neurovascular injury. I aim for a more vertical wedge when I do the Dwyer. There is the opportunity to rotate the tuber so you can correct not just the coronal plane imbalance or the coronal plane deformity with the Dwyer and the lateral displacement, but also axial curvature with it. And then to keep going on this topic, but just to hammer home the point that not all cable varus is CMT or idiopathic or cerebrovascular. This is one of my patients who is post-traumatic, actually. He had a tail fracture that was fixed, a calc fracture that was not properly treated. Subsequent Dwyer and then a subtalar arthrodesis with a fixed hind foot position and a lot of pain over the lateral column. You can see here CC subluxation that I've highlighted. This is him in his standing position and you can see his entire medial column is actually off the ground. And so how did I approach this? Well, I don't want to steal Jeff's thunder and I know he's going to go through this, but I ended up doing derotational work through both the tail navicular and CC joints with an exostectomy and addressing that with joysticks and osteotomizing through that to get his foot rebalanced. This is him post-op now and you can see his foot is plantar grade. And yeah, just to hammer home the point that there's a lot of ways to address this. It's not one catch all. So in summary, cable varus foot is a complex multi-planar deformity. I think if nothing else, one of the most important parts to understand is there's a postural component, yes, but there's also a body morphologic component. So it's a case by case basis. Every case is just a little bit different and you have to really study it. And you lastly have got to respect the soft tissue and you have to balance it to want to achieve your goals in the OR for a neutral plantar grade balance foot position, but also to avoid failure. OK, I'll stop there and I'll pass it on to Jeff. Thanks, Popa. That was great. And I just want to start by saying I'm talking mainly about the midfoot deformity correction. And as I think you've already understood, this is a multi-planar, multi-part, the foot involved. And so but I'm going to kind of concentrate on the midfoot. I have no financial relationships with anything regarding this topic. So I think we can all say cavus deformity is challenging and midfoot deformities, I think, are particularly challenging. And so I and they come in a lot of various forms. So what I want to do is present some principles, show some various types of midfoot cavus and then demonstrate multiple techniques with case examples. So the typical midfoot deformity in cavus is associated with equinus and adductus. And often it has soft tissue contracture. And as a surgeon, you want to know what structures are tight. And it's hard for you to know what static bone and joint deformities there are and where they're located until that until you've figured out and released this tight structure. So we really have two questions, soft tissue contractures and bone and joint deformities. So one of the basic principles, then, is that we're going to typically perform a soft tissue release first and then reassess the foot to determine your hind foot, midfoot and forefoot and how much adductus there is. So typically you start with an open planar fascia release. And many of my colleagues that do it right here in the middle of the arch of the foot, I tend to prefer a more proximal incision to release the central band of the planar fascia back just anterior to the heel pad. But there's a lot of ways to do it. So once you've done that, then you want to know where are my fixed deformities that now have not been released by a planar fascia release? And if you have continued equinus or adductus at the tail and navicular joint, and you can see in this in this young woman, you can see the adductus to the foot. You can see the equinus through the tail and navicular joint. And on this right hand x-ray, you can really see the medial rotation of the navicular around the talus. So this is at the tail and navicular joint and often a midfoot extensive soft tissue release is very helpful in this type of case. Now, if it's just a pure mid-tarsal deformity, as you can see here distal to the navicular, then often a mid-tarsal osteotomy or a single metatarsal osteotomy alone is helpful. So I think we're so now I'm going to kind of proceed to what we would do if we if we decided that we need to do an extensive midfoot release. And so and these this next set of slides really are slides that I borrowed from my partner and colleague for over 25 years at Washington University, Perry Schoenecker, and he because it's really his technique. And I think just as an aside that and I think Bopa alluded to it a little bit in that in the adult patient, you know, in the peds patient, we thought, OK, fine, you do your medial release. These are young, flexible people. But in the adult patient, at least when I started my foot and ankle career some years ago, the thought leaders in our society at courses and meetings taught that in an adult patient, a medial release was not effective. Number one, if you were capable of getting a release, you would put joints in a in an incongruent position. It would just it would just make stiffness or pain. And the other thought was that really they're an adult. They've had this for a long time and therefore a medial release is not effective. I think that we've learned at least I have learned from my peds colleagues over the 20 years that I worked at the shrine, that that is maybe not the case. And so this release we're talking about is of the abductor, the posterior to the tail and vicular joint capsule. And then you go across the bottom of the foot to to release the long plantar ligaments. And so this is Perry and myself. And really, I just years of working with him and and, you know, they beats folks come at it from the clubfoot perspective. And so they're in this bottom of the foot doing this a lot more than we have in years past. So here we are. We've finished our plantar fascia release through a separate incision. And now we've made a medial skin incision. And we're we're looking for the posterior tip tendon. And so you can also do the abductor hallucis fascia release from this incision. Or you can you can actually do it through your plantar fascia incision as well. So you need to identify the posterior tip tendon. And this is just a picture from Grant's just showing that we're going to go around the bottom of the foot, releasing all the bands of the plantar of the of the posterior tip. And here we are. We're identifying the navicular and we're going to release all the the portions of the posterior tip on the navicular that goes around the even around the bottom. And here we are now. The posterior tip has been retracted. And you can see just a small opening now in the tail and navicular joint capsule, because we're going to make an incision in that and we're going to release the dorsal, the medial and the plantar part of the of the tail and navicular joint capsule. And we're going to come right around underneath the tailored head and neck and release the spring ligament. And so here we are. You can see the tail and navicular joint capsule is opened. We're putting retractors in and we're going to come across and ultimately release the long plantar ligament. So you continue the capsulotomy laterally and we're going to come right across here to release the long plantar ligaments. Now, this is Perry's drawing. And in a normal situation, the long plantar ligaments are very strong structures. They go from the anterior calc and they go up under the navicular and under the cuneiforms and the metatarsals. In the cavus foot, they are much more thick and contracted. and so they need to be released in order to be able to get the foot up. Once they're exposed, you start to transect them. It's actually a fairly safe exposure. It's a little dicey. There's other exposures that have been described that are all around the neuravascular bundle. This is actually right up under the arch of the foot, and really as long as you stay there and keep everything else retracted planarward, it's pretty safe. Here's the last view of it as you continue to go across. As you can see, we've released the talon-invicular joint capsule, everything underneath the invicular all the way over, and that little strip of vertical cartilage you're seeing is actually the calcaneicuboid joint. You go all the way over, and you even can release the capsule of the calcaneicuboid joint. Of course, at any point along the way, we're testing the foot. If you don't need to do all of this, you don't have to do all of this, but this is the complete release if you want to release everything in a person that has a significant deformity. Once all that's released, there's a lot less seductus, a lot less equinus, and you push up on the foot. Basically, you're trying to determine at this point what's going on. Here is a radiographic representation. You can see the before x-ray, and here it is intra-op. We put a sponge in the wound and pushed up, and you can really see the beautiful realignment of the joints really anatomically. You don't even see any planar flexion of the mid-tarsal joints or even the first metatarsal distally. If we push up and we don't have any pathology in the mid-foot, then no additional osteotomy is needed. On the other hand, if we don't think the forefoot is in neutral, especially if the first ray is down or the rest of the rays are down, then you need to proceed on and do some type of first-ray osteotomy or mid-foot dorsiflexion osteotomy. You can often feel this pressure with your hand. There are numerous variations, if you will, of equinus that's really part of the forefoot, not equinus at the ankle where you might do a heel core lengthening. We're going to talk first about first-ray equinus, typical of CMT. The treatment options really are a dorsal closing wedge osteotomy of the first metatarsal. It's farther away from the cora of the deformity, but it's an easier exposure and it's a very accessible osteotomy. Or you can do a plantar opening wedge osteotomy through the first cuneiform, or some people do actually a dorsal closing through there. I find that even though it's closer to the cora, it's technically a little more difficult and I don't feel there's quite as much correction obtainable through that. Or you can do a combination of both and do a little on the first metatarsal, a little closing on the metatarsal, a little opening on the cuneiform. Here's such a case, I like to make the skin incision very dorsal so that you're taking the EHL medial. The reason you do that is so that you can bring your saw in directly anterior to posterior. If you're struggling and the EHL is in your way, sometimes it just makes you, because you're afraid of cutting the EHL with your saw, it makes you cut that osteotomy a little bit where the wedge comes out dorsal medial. Of course, all that does is create more adductus. Here we are going straight dorsal, taking the wedge out, pushing the foot up. I like K-wires for this, there's a lot of other implants. I would say that if you want to use any type of permanent implant, just make sure it's very low profile because this is an area that patients often complain of hardware. I like the K-wires, they come out, there's nothing there. They're very accessible and they actually give great fixation. Here's the same patient throughout. You can see the right foot's been done, the left foot's still to be done, but you can see how much longer the foot is once the osteotomies are done and the soft tissue release are done to make the foot straighten out and become plantar grade. Here's the plantar opening wedge of the first cuneiform. I think if you're underneath the bottom of the foot, you've already done your plantar release, you are right there. It's closer to the cora, but it does require this plantar approach and a bone wedge. The anterior tibia tendon insertion is right there, which you need to retract. You are going to make the foot maybe a little bit longer. You can see here just out of a schematic of how that bone wedge goes in there and makes it a lot straighter. The soft tissues are already a little bit tight sometimes on the side, so lengthening it can make that a little bit worse. Just another thing to consider if you're going to do the plantar opening wedge. What about this variation? The first and the second raise are in equinus. You can really do pretty much the same dorsal approach and do a combined closing wedge of the first metatarsal base and the second metatarsal base through the same skin incision. You can also pin that percutaneously with a K-wire. As you can see, it was done in this case looking at the lower right-hand slide. What about if there's more midfoot global equinus, in other words, where the entire midfoot is in equinus? Really what the surgeon needs to know at this point is where is the equinus? Basic principle number two here is that you want to try to make the correction at the location of the deformity. If the midfoot equinus is localized at the transverse tarsal joint, you may want to do something there. If the midfoot equinus is in the midtarsal joints, then you would try to localize something there. It sometimes is difficult because you may want to maintain motion at the talonevicular joint if there's some residual deformity there. Let's look at midtarsal equinus first. This is a CMT patient. I think when we've done the releases, there's midtarsal deformity. I like medial and lateral skin incision and take a pin and put it across the midtarsal joints starting at the mid part of the cuboid and go across into the cuneiforms. I usually make my pin go fairly proximal and it's at the edge just distal to the naviculocuneiform joint. Then you make a saw cut across and then I like to continue with an osteotome and have the osteotome just barely make it out the opposite side. Then you can see the plane of that osteotomy clearly and then you take your saw and come back along exactly along the plane of that osteotome. That way you get a straight planar cut across the foot, across the midtarsal joints. As you can see, the laminar spreader is inserted. I love these malleable retractors that keep the dorsal tissues safe. Once you've done the osteotomy, you can put pins above and below if you need to rotate the foot or if there's angular correction and you need to pull the forefoot into adduction or abduction to correct deformity. Then you start removing from that cut, you start to removing dorsally based wedges of bone and then you force the gap closed once the foot is plantigrade. Multiple pin fixation I think also is great for this because you can cross a lot of joints that ultimately you want to have mobile and you can get good fixation and it heals very, very readily. This is another patient with CMT. Here's a little bit of variation of global midfoot equinosis. This is a 19-year-old male who has no known neuromuscular deformity. We don't know a lot about his family, but as you can see, he's got a lot of heel varus and he's got a lot of first ray plantar flexion. It's difficult to exactly tell where the deformity is. He's got a little bit of a spin to the foot, but as we started off here, we realized that he has midfoot equinus, but it only involves the first, second, and third rays. How would you deal with this? Either you could do three metatarsal osteotomies or do an osteotomy through the cuneiforms. We did a lot of soft tissue stuff with him and that's really not the point of this talk, but you can see we did an open plantar fascia release, anterior tip tendon transfer, relengthen the posterior tip, and we also did stuff in the hind foot. What we did with him was a dorsiflexion closing osteotomy, the first, second, and third cuneiforms and started that again with a pin that crossed where we want to make our cut at the most proximal level where I wanted to go. If you start distal, what ends up happening is you take more and more wedges proximally and pretty soon you're into the navicular cuneiform joint, which isn't the worst thing in the world, but if you want to try to maintain some of those joints and not have to do a fusion essentially, that's nice to stay just in the cuneiforms. Here he is after completion and you can see by just releasing or just taking a dorsal wedge out of the first, second, and third cuneiforms, we were able to make a plantar grade foot from this. I think what the hardest thing about this young man was as we were in the operating room and as I remember this case, is we were trying to figure out where the deformity was and how to fix that deformity, and really it was a pathway that really we took after doing each successive part of the operation. We did the soft tissue releases first, then we did the hind foot, and as we moved to the forefoot, it was starting to become more evident exactly where the deformities are. This is where we also then realized once we did the midfoot that his first ray was still in slight plantar flexion, so we took another dorsal wedge out of the first ray specifically just to bring that one element up. Here he is at the completion of that. We also pinned his lesser toes and moved his anterior tip over. Here he is with a more plantar grade foot with those two osteotomies. Here's another variation where there's midfoot. This is a patient that had clubfoot release as a child, he's 17 now. He has midtarsal cavus, but also adductus, and probably the adductus is a bigger part of the problem than the cavus. In this case, we did a midfoot biplanar transverse osteotomy, and we used an allograft medial wedge to correct some of the adductus. Then because the first ray was still down, we did a biplanar dorsiflexion and lateral first metatarsal osteotomy. Here we are. You can see the preoperated grafts there, a lot of adductus. You can see how his foot's bean-shaped. Despite the plantar fascia release, it really didn't get a lot of correction with him because he's such a stiff deformity. You can see we've done our traditional midfoot osteotomy. You can see the laminar spreader. You can kind of see daylight looking through. Here's the osteotomy. We took a wedge out of the cuboid so that we could tip the foot into more abduction, and then we put the laminar spreader on the medial side to create a space for placing a medial wedge, not a dorsal medial wedge, but just a straight medial wedge. Here we are creating the wedge and placing it in the osteotomy. Here it is. We've done the midfoot osteotomy, but now the first ray needs to be brought up. This cut is actually trying to basically bring the first ray up and into some abduction at the same time by taking a little wedge, dorsal and dorsal lateral. We've done a longus dubrevis transfer here, anterior tip tendon transfer. Here he is at the end of the case with a planted grade foot. These club feet don't move very easily, but we got him planted grade, and here he is at a year with a much improved foot, as you can see, compared to what he had preoperatively. You can see how the medial cuneiform wedge really took the foot out of induction and into more abduction. What if you do a big medial release, and there's still equinus adductus at the tail endovicular joint? This is a young woman with some unknown neuromuscular disorder, and she has cognitive difficulty, but she had a big time equinus contracture at the ankle, but also through the midfoot. In this case, because she's so stiff and you've done all the releases, fusion is the best way to manage that. You can see the fusion is really just a wedge resection through the transverse tarsal joint. Here's the result of that, where you can see there's not much left of the navicular, as we took much of the wedge from that. Just like the other case, her first ray was still preferentially lower than her others, and so we brought the first ray up through the dorsiflexion osteotomy, and we're able to get the foot to a much more plantigrade position. Of course, there's soft tissue stuff that goes with that as well, as you can see, but here she is much more plantigrade and braceable. Option number two, if you're still in equinus and the adductus is at the tail endovicular joint, the other option would be just to ignore the tail endovicular joint, especially if it's mild, and then do the correction at the midfoot. Now, we're violating some of the general principles of deformity correction because we're moving away from where the core is, but if you can create a plantigrade foot with that, that is probably acceptable if you want to leave some range of motion. I think that as I've gotten better at my plantigrade release, this is less common, and I think that it's really more in the adolescent where you want to retain some range of motion and not do a fusion where this might be something to do. You can see the core is way up there, but we're making our osteotomy much more distal, and this is why the principle is try to do the correction at the location of the deformity. I think in terms of take-home points, I think the physical exam has been pointed out earlier that it's really critical to determine the reducibility of the deformity, what structures are tight, and what motor strengths the patients have, because the global deformity has to be balanced appropriately despite what you're doing to the bony work. You also need to perform plantar and medial soft tissue releases first, and then reassess again the residual deformity in the hindfoot, midfoot, and forefoot, just as we've shown with this extensive plantar medial release if you need that. And try to correct the deformity at the location of the deformities. You can see on the right here, there's a mid-tarsal deformity at the top, and then a tail end navicular deformity below. And then trying to save range of motion at the critical joints is really important, but I think getting a plantar grade foot is more important, and especially if they're ankylosed or they have fixed deformity, lack of motor control, then I think that's where arthrodesis really comes in and is preferable. But I think even if you're doing a fusion, the midfoot release that I showed really helps getting the joints apart and getting them denuded, and I think you can do much less wedge resection if you do the midfoot release first, even if you're going to do a fusion. So thank you very much. All right. Can everybody hear me? And hopefully you can see my slides. Okay. I got a thumbs up. Do you guys can hear me? Great. I don't know. I'm having some kind of error here. Maybe I need to un-share and restart. Okay. Let's get going. For some reason, it's supposed to jump through my slides. If you don't know me before, my name is Eddie. I'm going to maybe have to switch out of this. Briefly, I'm from Florida originally. Not much more Florida than it can possibly be right here. But I was a fellow at Cedars-Sinai. The CMT experience there is unparalleled. I had four fantastic mentors, but a credit especially to Dr. Pfeffer. Not only did he train me, and I loved CMT. I think just like in the children's book, if you give a mouse a cookie, he's going to ask you for a glass of milk. If you train a fellow to treat CMT patients, he's going to want to build a CMT practice in his own practice. So credit to him. There's a lot of pictures in here and videos that are both he and mine. I'll point that out as we go. I'm just going to have to do this on the actual PowerPoint slide because it's not working for whatever reason. First off, hopefully everybody can see the video, but this is a video of somebody with a CMT foot. As they're walking, the left foot is obviously worse than the right. What is the goal of all these talks? It's really to provide treatment for this patient as they go through life. Hopefully it's something successful, so gaining information to do so. We'll return to them at the end. I think the important thing here is all these characteristics of the – I don't know why none of the animations are working. This is bizarre. All right, so we'll just go through the other animations. The midfoot cavus, I think as we all know, is the first ray is depressed, but it's also adduction and metatarsals are rotating. I don't know why this – I'm getting a lot of errors. Hopefully this isn't happening to you all as well. The cause being intrinsic muscle contraction and paralysis. The claw toes are obviously part of the deformity as well. That occurs both – I think it's characterized as MP joint dorsiflexion, but also IP joint flexion. The cause is intrinsic contraction paralysis and long muscle overpull. As describing those, we'll kind of figure out exactly how to treat them based upon the deformities. I'm not going to spend time too long on the presentations. I think everybody here knows these. They're going to have foot pain. They may have callusing. They may have difficulty shoeing. They'll have poor balance. There will be functional impairments from CMT as a whole. But focusing on the forefoot, I think these are probably the big ones. Not on management. Again, we don't have to belabor this very much. Accommodate, accommodate, accommodate. Try and get bigger shoes, different shoes. Try and employ braces for gait instability as needed. And assist with walking. Activity modifications will be really helpful. Then orthotics can obviously be used as well. For the classical CMT deformity, that's a lateral wedge and first met pressure relief. But obviously this needs to be customized as needed. How common is this? I think from this paper down here, this is some math that's extrapolated. But it's about 1 in 1,000 people in the U.S. have CMT. About 70% of those are going to seek treatment. And 30% of those seeking treatment will receive surgery. Many patients are treated nonoperatively. It may not require surgical treatment. But nonetheless, extrapolating on these numbers, it's about 60,000 people in the United States may seek surgical treatment at some point. How common is forefoot treatment? Again, from the same paper, this is a survey administered to surgeons looking at both pediatric, on the left, and adult orthopedic surgeons on the right. And I've highlighted here with the red boxes that out of 12 possible treatment options, things involving the forefoot, so first metatarsal osteotomy, soft tissue procedures involving elevating the first ray, and soft tissue or bony procedures elevating the toes are employed more than half of the time. I would say almost every time there's a first metatarsal osteotomy and or something to deal with plantar flexion of the first ray. So before we really talk about surgery, hopefully I can get, I'm going to try one more time just because unfortunately none of this is working. Before we really talk about surgery, I think the real key, as Jeff really pointed out, as well as all the speakers before me, everything is connected. Correction of the heel may make first metatarsal depression worse. Maybe not always, but as the deformity is corrected, if you don't release the soft tissues adequately, some of the other components of this will evolve as the case progresses. Correction of an ankle equinox contraction may make the toes worse. I think as we all know, as the foot is dorsiflexed more, the shortening of the tendons will become more of a problem. As far as what you're going to do for surgical management, I think the real key is to decide what you're treating. Are you going to do the toes at the same time? I'm focusing specifically on the forefoot here, but that is a lot of surgery. Some surgeons are going to do the toes stage, and I think safety first should always be remembered. There's nothing wrong with that at all for the patient and for the surgeon doing their best work. Being deliberate with the sequence and the OR is very important. I think here's a surgical algorithm that was published that's easy to follow. The CMT consensus statement that came out a few years ago also has a sequence to follow. Every speaker before me has mentioned that sequencing is important. Oftentimes, beginning with soft tissue release, then the order in which tendons are released or transferred really matters because it may change ultimately what you do by the end of the case. I was just going to point out a table real quick about how some of these things, the classical teaching at least delivered to me, how the treatment as you go may affect other areas. Like an Evans or a lateralizing osteotomy may exacerbate first-rate depression. A TAL, like we talked about, may exacerbate plateau deformities. There's some other things that you're going to do that may alleviate first-rate depression. Fascia release, all the releases that Dr. Johnston talked about. A longus to brevis transfer I think is a big one. Apparently, this longus is attached to the first metatarsal base, and so there is some elevation of the first ray if you're going to do that transfer regardless of the location that you do it. Some of these other things too, if you were going to do an FHL transfer to brevis, the restorative version, that may alleviate some tension for a hallux callotus. Transferring the extensive tendons to the midfoot, same thing, may also be used as a treatment adjunct for claw toes and foot drop at the same time. A fantastic study that was published about a year ago from Malhotra et al. It has this excellent one-slide review. They looked at exactly this, how sequencing might be examined using weight-bearing CTs. They took weight-bearing CTs of folks at CMT. These aren't pre- versus post-op. This is a pre-op CT, and then with a simulated correction of the talon-avicular joint. In all 20 patients, they looked at that, and they looked at what happens to the rest of the foot after the talon-avicular joint is corrected, and they tried to define morphotypes. The vast majority of the patients here, type 1 and 2, have a plantarflex first metatarsal. There is some residual element of forefoot correction that oftentimes requires an osteotomy or other management, but there was some variation here, which I think is really important. Some of these will have more adduction. Some may be balanced at the end, but the key is that sequencing, like we talked about, is very important, and you begin with soft tissue release and progress as needed. As far as how important is the first metatarsal, this is a paper from within the last year where there was an analysis also using 3D CTs looking at Miri's angle. The group of patients here, CMT patients, all of them with a very significant Miri's angle, greater than 20 degrees. On average, in comparison to the controls, though, the real plantarflexion of the first metatarsal is only 8 degrees more. Where does all that extra angular change come from? Well, it comes from multiple sources. It comes from the TMT joint. From the appearance of these scans, the core is actually within the medial cuneiform, which I think obviously was pointed out by Dr. Johnson as well. But there's more than just the first metatarsal, and I think though it's one of the easier treatments to include, it's not necessarily at the core of the most powerful of the treatments. And so I think Dr. Johnson, I do not need to go over what he said for the myphidosteotomies because those are obviously fantastic corrective tools, but oftentimes we use this because it's straightforward and simple. Again, the consensus agreement that we talked about from a few years ago, they held consensus that a dorsal closing wedge of the first metatarsal is needed in almost all cases. And then again, one member of the group pointed out that once perineus longus and the plantar fascia are divided, it may not be necessary. So it's one thing to evolve as you go. You know, I think the key here, and maybe this is nice that... Oh, boy. I don't know why this is doing this. The key that you're trying to achieve, even though I can't edit any of this font right now, is that you're trying to get the first metatarsal head out of Aquinas. Oftentimes that's going to be equal to the second metatarsal head. And that's the goal that you're trying to achieve with a dorsal closing wedge osteotomy of the first metatarsal or with a plantar opening wedge osteotomy of the cuneiform. I think oftentimes, I was always trained that that was used in pediatrics primarily because you wouldn't be violating the growth plate from the first metatarsal base, and oftentimes these patients are teenagers or otherwise young. A first TMT orthodesis is also a fine option, especially if you include that dorsal closing wedge element. I think, you know, I wanted to bring this up that we're frequently trying to achieve a zero degree or what we consider to be normal for the Mary's angle. But like I pointed out before, there's more to that Mary's angle than just how far the first metatarsal is plantar flexed. So ultimately, we want there to be a well-balanced plantar grade foot. So, you know, there's many ways to do these osteotomies. Dr. Johnson showed some using K-Wires. When I was a fellow, we did an open dorsal closing wedge osteotomy of the first metatarsal using a screw and a tension band wire, which is effective. It's not expensive. It's something easy to do. You know, that's not what I do anymore. I think my own practice has evolved, as I'm sure everybody does in their graduate fellowships. So I oftentimes do these minimally invasive now with a buried headless screw. You know, again, trying to get to the goal of the first metatarsal head being equal to the second. And so I think what I was trying to show on this slide is that if we take a pre-op image on the left, the first metatarsal head is depressed. The foot is rotated. We're ultimately going to get to this post-op image on the right, which is fantastic. The foot is well balanced. You can see the whole foot being derotated in that post-op scan. But the point was, how far did you have to elevate that first metatarsal? And so in relation to the second, the axis of the second, that first metatarsal head comes up quite a bit with that first metatarsal osteotomy. And this is Dr. Pfeffer's. You can see there's the tension band and the screw right there. But, you know, it's equal to or perhaps above the second metatarsal, and I think that's a big component of what becomes a lasting and good correction. So, you know, a main thing about goals. If you're also involving the second or third metatarsal, obviously it gets a little bit more complicated. So what about the toes? You know, I think the key answer is, what problem are you really trying to solve? Is it just toe callusing the way that somebody would complain, a typical hammer-toe patient would complain, or is there more going on there? And so for somebody that was as simple as a toe callus, you could do a simple procedure like an FDL tenotomy or maybe a minimally invasive digital osteotomy, if you have the skills. If the PIP is rigidly involved, I think a PIP-affecting treatment is going to be the most important. For me personally, that's a PIP fusion, but there are reports of other things. If the MP joint is involved, I think this is probably the hardest portion to correct because there isn't like a specific bone I can correct or fuse. I think that's the main source of recurrence is also the MP joints. So, you know, you probably need to address the extensor tendon and the contractured structures there. You may need to shorten the metatarsals in some way to put slack into the tenonous system, other than your lengthening. And so your options are tendon-based, metatarsal osteotomies, and obviously contracture releases. I think most of us agree that pinning across the MP joint is a mainstay of treatment for the toes, especially with severe contractures, just to try to maintain your correction over time. There are a few other patterns to keep in mind with the toes. Does the patient also have a foot drop? Do they have rigid claw toes that you're going to sacrifice the function of EHL or EDL anyway with arthrodesis? Are you going to fuse joints, like I said, or is the EHL or EDL is going to be nullified? In these cases, there's a good cause or reason to transfer the extensor tendons to the midfoot. Even though this was a biomechanical evaluation of that from a couple of years ago, this is not a new idea. That's what the Jones and the Hibsch transfer is represented anyways. And so they're trying to take a deforming force and turn it into a restoring force. I think it's like one of the most intellectually satisfying things that we all like to do, and it's obviously good for the patients too sometimes. So I'm going to just show you some treatment options, you know, that we would otherwise look at for the forefoot. So, you know, PERC, flexor digitorum, longest tenotomy in the toe. It's safe, it's easy, it's fast. Those are all great things. It corrects the DIP joint contracture and to a lesser extent the PIP and MP joint. It will lead to less of a gripping function. And for people that are pretty impaired, you know, that can be meaningful for plantar flexion as well as balance. And so personally, I try to avoid that if I can. There's a girdle stone transfer. Like I said, it's not a big mainstay in my own practice. It's more powerful, obviously, than a tenotomy. It's an advantage and a disadvantage that you have to pin the joints there. Digital osteotomies can be done. MIS that doesn't sacrifice FDL, which is good, but I don't think they're very powerful, and I think they're prone to recurrence. You could theoretically pin them, but, you know, that's my own personal level five or level six opinion there. PIP fusions have excellent PIP joint corrective power. You can pin them, you can put other implants in, just like Dr. Johnson said before. Probably the problem here is that there's a possibility of a mallet deformity if you don't sacrifice FDL. And it may require implants. Transfers of the extensor tendons to metatarsals with a midfoot. Those are also excellent corrective power at the MP joints. It takes a deforming force and makes it into a restoring force. It has a unique complication of the possibility of a drop toe, even though extensor brevis tendons are still intact and you can sew them or otherwise tend to use them in some way, which is what I do. And in these cases, you know, I have seen it. I'm going to present a patient with a drop toe here momentarily and not really sure why he got it and other people didn't. Perhaps pinning could also be an advantage there. And then metatarsal shortening, if it was somebody with just toe issues, I think that's something to think about. So here's the mainstay of my own practice. You're considering tenotomies of the extensor or flexor tendons, PIP fusions, and then transfers of the deforming forces. As far as like algorithms are concerned, I'm not going to give up here, so I'm still going to try and use my slides here. Here we go. Nice. So anyways, my own algorithms, I exhaust, not on management. Braces are, they are difficult, so I don't belabor them too much. I want the patients to wear them, but I don't, I think it's very hard to brace a severely deformed foot and I let the patients give it their best shot and then we move on. In surgery, I think I very carefully sequence these things to try to minimize overtreatment. I typically write it on the whiteboard in the room so everybody knows what's up. I almost always do the toes last and I can usually do the toes and foot in a single stage, but not always. And again, I think safety first is always important, again, for the patient and for the surgeon. If the deformities are mild, I'll consider FDL or EDL tenotomies or perhaps digital osteotomies. Like I said, it works well for a less is more patient. Perhaps you could do digital osteotomies. I really don't like the loss of tendon function that is irreversible in a dysfunctional foot. Severe deformities in my hands require a powerful procedure of some kind. So that's going to be arthrodesis of a very low threshold to pin across the MP joint because of this fear of contracture release or toe drop, then I would say of a very low threshold to do a Jones or Hibbs style transfer or variant to the midfoot, especially in people with foot drop. And so I think that's a powerful tool that I've seen work well many times. So here's a couple of cases. This is a 53-year-old male, CMT, we don't know much about his family, traveled down for management of that. His primary concern is foot drop and claw toes. You can see on his imaging here, obviously has interphalangeal joint flexion contractures. He has a cavus foot. It's definitely not the most severe deformity. Ultimately, with sequencing of soft tissue release along with some brevis tendon transfer, I was able to actually avoid osteotomies, which is an interesting scenario. And I'll show the kind of ultimate post-op results at the end. I did a MIS-PIP fusions of the toes. You can see on the AP there, there's multiple tunnels under the midfoot from all the tendon transfers. So I typically put the postive tendon in the lateral cuneiform, and then once that tension is set, then I'll put the extensor tendons in the middle and medial, if needed, cuneiforms. Ultimately, we did both feet. Here's that image. I think something very interesting to show here is that just that pre-op for the right foot on the top right and on the bottom right, the post-op, and there was a substantial improvement in the mires here with no osteotomies, right? And so a good soft tissue release. Some of these patients have some real flaccid paralysis components to these, and as you release the tendons, you may get a plantar grade foot and not have to do as much osteotomy. So ultimately, this patient did develop a toe drop on the right, but not on the left. So far, we don't have, you know, no surgical interventions are planned for that, but I think at some point soon, I'll have to deal with that. I typically transfer the stump of EHL, I sew that down to EHB for the first metatarsal. This is the only patient I've had an issue with that with, and I think most likely I'll either do an NP fusion or some kind of static tenodesis for that for him afterwards. Here's a 14-year-old female, a vastly different patient, same thing, painful lateral border of the foot and toes. He's exhausted all the options and wants surgical treatment. So here's the bilateral APs. I think we can all tell it's a pretty severe typical CMT deformity involving the toes as well as the foot. Pretty significant imaging on the lateral pictures as well. For her, she ended up having a weak posterior tibial tendon and foot drop. I did a longus abrevis as well, and, you know, I did a first metatarsal, I did a calc. On one side, I did the IP fusion of the hallux, and she hated it before I did the second side, and I deferred that on round two, but nonetheless, the extensor tendons are transferred to the midfoot, and we got a good correction for her. And so here's some examples of the pre versus the post-op, and again, you can see a dramatic correction there, both in the appearance of the cavus as well as the toes. Now, lastly, to wrap this up, here's another older female. She had CMT1A, she had surgeries as a child, and I think this one's interesting because she was overcorrected into a plaintive algus position. She collapses into pronation. She does have some posterior tib function left, but otherwise, it's essentially a flaccidly paralytic foot. So, no everter function, she has foot drop and claw toes, although an intact post-tip tendon and, you know, plaintive algus deformity in many ways. And so, you know, there's her old dorsiflexion closing wedge osteotomy, you know, as well as the appearance of her foot now. And so for her, you know, considering there was really minimal tendinous function to utilize, I performed a tail navicular fusion to stabilize the hind foot, just like Dr. Johnson there had mentioned. When I employ orthodesis many times, it's for people with minimal muscle function. And then I transferred everything that was useful to the top of the foot to give her as much dorsiflexion power as we could because, again, it was a weak post-tip tendon, not an ideal tendon transfer candidate. For the toes, you know, similar algorithm there of the IP joint orthodesis to the HALX MIS-PIP fusions. And then for the second and third toe, those were more severe, so I pinned across the MP joint, and I did it for the fourth. Most of my practice now is involved in getting cone beam CT scans at three months when they're standing as opposed to getting x-rays, and so I'm fortunate I don't have a standing x-ray ever, but I do have a cone beam. And so here's the 3D recons, and I think something important for these patients, you know, the fusion healed. I like the alignment of everything, but she got mallet deformities, right? So I did not sacrifice the FDL tendons. She did develop symptomatic mallet deformities, which I ultimately took care of. For me, a lot of times I can do those in the office, especially with a neuropathic patient. She did need subsequent treatment for that, but otherwise I'm very happy with the correction, and so is she. So again, this is the video that we started with. These are from Dr. Pfeffer's library. These are feet with severe deformities. This is the result that I think the tools that everyone just talked about in this lecture, and I think why a lot of us are drawn to these cases. This is an amazing result. I don't think this is something that I could necessarily pull off on myself either. It's certainly credit to Dr. Pfeffer. But I think another key step for these patients is that they're incredibly resilient. The patient I'm mentioning, one guy had a drop toe. Another one had mallet deformities after her foot reconstruction. The patients are just happy as a clam, continuing to fight the good fight to get through life. And so I think it's in honor of them that we're all doing this work. And so I really appreciate everyone's time. It's a great pleasure to be here. Thanks for including me on the panel, both of them. Sorry for my technical difficulties. I don't really know what was happening. That's fantastic, Eddie. Thank you for sharing that. So we're at about 925 now. I do have a case. I just think it's getting a little bit late. So I wonder if we should wrap up. We've answered all the questions. I'll see what the panel thinks. I think five minutes might not quite be enough time for a case discussion. But I'm open to all. I'll just make a comment about Eddie's last toes. I've seen a lot of mallet toe deformities after PIP arthroplasty in the spastic cases. And of course, it's an important point to make for everybody that CMT is not a spastic condition. But in the patients who have cerebral palsy or have upper motor neuron disease, I've stopped doing PIP fusions alone. I transitioned to putting screws in the toes because I don't know how many times I've taken those pins out, had those stupid toes fuse at the PIP, and they come back pissed off because they have mallet toe deformities about a year later. And I've had to come back and do mallet toes. Other people had that experience? Because I'm just putting a screw down the toe. I do claw toes for all four when it's a stroke foot or CP. I think that was our first dialogue, Greg. When I reached out to you, I had followed your work. And I had listened to you talk about that exact point. And I didn't want to get a recurrence or a mallet toe. Ever since then, I've followed what you taught me. And I usually drop a screw in there. You know, I think I've done some of those procedures that Eddie talked about. And those are beautiful reconstructions, Eddie, when you take the longest, cut it distal, take the brevis, cut it proximal, then try to get the two to come together so you have some control over the toes. But I have been pinning, or what I did was I pinned the toes. Typically, a percutaneous epithelial tenotomy, if they were claw toes, manipulate the toe into extension. And if the toe wasn't just vascular at that point, just pin it for six weeks. And granted, I don't think I looked up these patients carefully for the presence of a claw toe. But to me, that was fairly effective, just to leave a pin in for six weeks and let all the IP joints kind of just learn to be stiff in that position. And they seem to get along OK with that. I don't know what other people have had experience with that or not. But it's just maybe a shortcut. You know, the hardest patients I've dealt with have been focal dystonia patients, if you ever run across those. And it's amazing how you can do a tenotomy on them, and they will come back with the same deformity through the skin. Right, right. It's unbelievable. I do think this, right, the tone, the patients with increased tone, that's a whole level of difficulty, and they will defy you many times. I was talking more about probably the non spastic patient. Yeah, yeah. I'm happy to hear it's not just me. I was attributing it to that. Yeah, I just unbalanced that joint by leaving FDL intact and having the extensor tendon compromised. And so I'll have to give a lot further thought to just putting a screw down the toe. I really like that idea. But yeah, to the point of, like you guys said, the patients are incredibly resilient. Like, I think they were almost certainly happy with an improvement in the toe. And it's just not the same as a non neuropathic, non CMT patient. So, Greg, I have done the screw down the toe, but I did not find it technically easy. What screw do you use? How do you make sure you bury the tip so that it's not a problem? And it's just not that technically easy. I mean, it's hard to get a K wire sometimes down the DIP, the PIP, and you know. Yeah, so I put a dot on the end of the toe, and I tell my fellow he owes me a beer for or she owes me a beer for every millimeter they're off. And of course, we cheat when we measure. But no, I actually just put an 062 K wire down because it's so much easier to manipulate. So I put a K wire, and then the last minute I pull the K wire out and drop a guide pin for a 2.0 millimeter cannulated headless screw. And the reason I do that is it's so much easier to manipulate and get the K wire to go right down the path you want than to try to take a guide pin for a cannulated screw, which is all wiggly. So use your 0.062 K wire, and it's effectively a 1.6 millimeter drill bit. And now you've created the path for a 2.0 millimeter screw. And then I just drop that right down the path. So I just change it out. And of course, no attempt to fuse or address the joints. You're not doing resections of the DIP, PIP. No, I'll fuse the PIP. So I'll just do a standard hammer toe through a dorsal incision, elliptical or straight. And then I don't fuse the IP. But this is for when I'm doing four claw toes in a stroke patient or CP patient. And it's not for your routine hammer toe, although I will sometimes do that in an older patient. But the one caveat of that is that if you have a really older patient with compromised bone, occasionally they will remarkably overpower your screw. And they will just cut the bone right out of it, and you'll come back and you'll see a screw under the nail. So there can be some currency to doing a flexure tonotomy with it. But you can get burned on both sides. But I have certainly been burned by mallet toes many times. Yeah. And Naomi Shields made a note here that in Europe, they're doing planar PIP releases, minimally invasive, leaving the cartilage intact, soft tissue releases, and then pinning without shorting. Is anyone doing that? I know Eddie, you like to do MIS. I personally took the courses, and I started doing those releases. And I found there to be recurrence. And so I started doing fusions. But I probably was not doing it right or something. I don't know. But I found the fusion to be much more reliable. Well, using our old techniques, that's what Mike Hoffman found, too, is that PIP fusion was the most effective. I think it's 930 now. I thank you all, everyone, for joining in. I hope that it's been a fun hour and a half and maybe educational for everyone. And thank you for the panel who joined on, who are proud here. And I really appreciate everyone's time and knowledge. Thank you, everyone. I'll probably shut this down now, and everyone can go to bed. All right. OK. Well, thank you. Thank you. It was great to be with you.

cavovarus foot deformity

surgical management

orthopedic professionals

neurological aspects

soft tissue balancing

tendon transfers

bony morphology

Charcot-Marie-Tooth

hindfoot corrections

midfoot correction

osteotomies

arthrodeses

minimally invasive techniques