Good evening, everyone. My name is Ahmed Halim from the University of Oklahoma, Oklahoma City. As chairman and on behalf of the Young Physician Committee of the American Orthopedic Foot and Ankle Society, I would like to welcome you all to this resident OITE review webinar. This webinar continues to evolve every year based on your feedback. This year's format has changed from last year's, where we have decided to deliver three talks, each focusing on two of the six most high-yield OITE topics tested on the foot and ankle section. We will be covering OITE questions from the year 2012 to 2017 in an active polling format, so please do actively participate in answering through the polling system. In addition, based on resident feedback we got from the resident scholar program during the annual AOFAS virtual meeting held last month, we will have a live interactive session on foot and ankle fellowships, with emphasis on fellowship applications specifically with virtual online interviews this year, how a foot and ankle fellowship year is going from a current fellow, and foot and ankle as a career for those of you interested in pursuing a foot and ankle specialty. I would like to highlight again the resident lecture series we have available for you. There are foot and ankle podcasts available on Spotify and through Apple. They are very, very OITE-focused, so I do encourage you to listen to them. We have currently eight or nine topics, each of them 10 to 15 minutes that you can go through on a run or during your drive home. We also have online talks available through the Physician Resource Committee and the Center on the AOFAS website, and these are comprehensive resident lecture series covering most of the topics. Without further ado, we're going to start with our OITE review section, and our first speaker is Dr. Mustafa Abu-Sa'id from the Orthopedic Care Physicians Network out of Boston. Dr. Abu-Sa'id. Thank you. I'm good. Welcome, everybody, to the OITE resident webinar hosted by the AOFAS. Let me get my screen going. All right. So I got the assignment of talking about Halox valgus and Halox frigidus, and let me first start by saying I have nothing to disclose. I want to give a thank you to AOFAS and YPC committee for the opportunity and a big, big thank you for my mentors at MedStar Union Memorial. Before I start my presentation, I just want to let you know that these talks have been tailored to focus on the most tested topics or even parts of a topic, so I'll try to focus on what's being tested and skim through other parts that are not high-yield in the OITE. Again, first is Halox valgus, or commonly known as bunions. This has been defined by Huerter in the 1800s as static subluxation of the first MTP joint characterized by lateral deviation of the great toe and medial deviation of the first metatarsal, as you can see from the pictures. Several factors have been proposed in the etiology, some extrinsic, particularly tight shoe wear. That's why we see it in females more than males. However, some population studies have also shown that Halox valgus can occur in unshoed population. Several intrinsic factors have been proposed, including severe fasciitis or flat foot deformity, as well known, metatarsus primus verus, which is congenitally excessive medial deviation of the first metatarsal, and then ligamentous laxity, which leads to hypermobile first TMT. Other factors, hereditary, 70% positive family history in some studies, generalized neuromuscular disorders like CP, inflammatory conditions like rheumatoid, finally traumatic conditions or second-to-amputation. This slide, while not frequently tested on the OET, but it's important to understand what's going on with Halox valgus. You will know that the metatarsal head has no muscles attached on it, so it's subject to external forces. Once that capsular attachments and muscle support and ligaments fail, the metatarsal start deviating medially, and then the toe deviates laterally, and then you get the Halox valgus deformity. As the deformity gets more severe, the medial capsule is stretched and attenuated. The lateral structures are contracted. You have the abductor hallucis, which you can see from the axial cuts, starts migrating plantarly, so it becomes a deforming force and leads to pronation of the Halox. The EHL, which sits in a normal individual in the midline, becomes more lateral to the mid-axis of the metatarsal, so it becomes a more deforming force. The first metatarsal head moves medially. This leads to uncoverage of the sesamoids, which are anchored in their place by attachment with the deep metatarsal ligament. And finally, with severe cases, you can get a second toe pathology, like a hammer toe or a crossover toe. Now, this is the most high yield parts of the OET, which is the radiographs and analyzing radiographs and angles. All patients with bunions should get a standard foot series, which is AP, lateral and oblique weight-bearing radiographs. And the first angle to measure is the Halox valgus angle. This is the angle between the long axis of the first metatarsal and the axis of the proximal phalanx. Usually, this angle is less than 15 degrees. Second angle is the 1-2 inner metatarsal angle, and again, as you see, it's the angle between the long axis of the first and second metatarsals, and usually it's less than 9. The distal metatarsal articular angle, unfortunately, it's sometimes tested on the OET, and it's sometimes not clear on the radiographs, so be cautious when you're analyzing radiographs. It's the angle between the long axis of the metatarsal and the articular surface. And the numbers have varied in the literature. Usually, it's less than 10, but normal can be up to 16 degrees. And then finally, the Halox valgus inner phalanges, which is the long axis of the proximal and distal phalanges of the big toe, it's usually less than 10. One concept to consider when looking at radiographs is if this deformity is congruent versus non-congruent. And to do so, you look at the articular surface of the metatarsal head and the proximal phalanx. And if you see from the figure, you can draw those two lines, the X and Ys on the metatarsal heads and the proximal phalanx, and if they are parallel, then this is a congruent joint. If not, then this is an incongruent joint. And that has applications when you decide the treatment algorithm. So jumping to treatment, like most of foot and ankle pathology, initial treatment is usually non-operative. Shoes with white toolboxes, orthotics, you can do spacers and splints. Unfortunately, eventually, they don't work with bunions, and most of them require surgery. The main goals for surgery is to obtain anatomic alignment, improve pain, deformity, and maintain motion if possible, avoid excessive shortening, and devascularization of metatarsal head. I'm going to go through some of the surgical procedures that are commonly performed and commonly tested. We hear the term distal soft tissue release or the modified McBride. This procedure is never done in isolation, so you never pick this as the sole correct answer. And it's not done in a congruent joint, because it will transfer it to an incongruent joint. And if you can see from the figure that I put, if you can look at the bottom far left picture, you can see that part of the soft tissue release is taking the transverse metatarsal ligament. And then on the far right, you also take the joint capsule and the adductor hallucis. In addition, you do the medial capsule RFE, because as we mentioned from pathoanatomy, the medial capsule is attenuated. And it's called modified McBride, because the original McBride included excision of the fibular sesamoid. But studies have found that this led to helix varus, so we stopped doing it. Some of the common procedures that are tested are the most common distal osteotomy is Chevron. I put scarf osteotomy as a separate category, because it doesn't fully fit distal or proximal, but somewhere in between. And it can be done for moderate or severe deformities. Some of the common proximal osteotomies are crescentic osteotomy, the Ludloff, and the proximal opening wedge. And finally, Lapidus, or a first TMT arthrodesis, and Aitken osteotomy, which is the proximal phalanx closing wedge osteotomy. So now that we know these procedures, how do we answer the question on the test? You're going to ask yourself four questions in order. First, is the MTP arthritic or not? And they're going to give you a clue in the question if it is arthritic. So they're going to tell you if the patient has pain with range of motion or positive groin test. Second is, does this patient has instability at the first TMT? Is it hypermobile? Is the patient having pain? They can give you also radiographic clues, which I'm going to show in the next slide. Third question, is this joint congruent or not? And finally, we start measuring our angles. Here are some of the signs of hypermobility. I think it's a little maybe excessive if they show that on the test and rely that you would recognize them. The one on the right, which shows the plantar gapping is the most common one. Be mindful if you see that on the test. So here's the algorithm. So you ask yourself again, arthritic, then you do an MTP arthrodesis. If not, is it hypermobile or not? If it's a hypermobile TMT, then you do a lapidus or first TMT arthrodesis. If not, is this deformity congruent or not? If it is a congruent joint, then you have to do usually multiple osteotomies, double or triple. Or if it's a very, very mild osteotomy, you can just escape with a distant metatarsal closing wedge. Finally, if it's a non-congruent joint, which is going to be the majority of the questions, then now we measure the angles. And we classify it into mild, moderate, and severe based on the angles. Mild with helix valgus angle less than 25, IM angle less than 11, moderate IM 11 to 13, helix valgus angle 25 to 34, and then severe, which is above these numbers, equal or above. And if it's a mild deformity, you usually can do a distal osteotomy with soft tissue release. If it's a moderate, the answer can be a distal osteotomy or a SCARF with a soft tissue release. And then if it's a severe deformity, it could be a proximal osteotomy or you can do a lapidus. There are some special considerations that might hit you on the test if they show a case with wide open physis. The answer is first, cuneiform osteotomy. Another indication for MTP arthrodesis other than arthritis is if they give you a neurological condition or inflammatory condition like gout or rheumatoid. Some of the complications that are associated with surgery and are, again, are tested on the OIT include recurrence. The risk of recurrence is increased if you under correct the IM angle, failure to recognize an abnormal DMAA, and if you do an isolated soft tissue release. Other complications, dorsal malunion and shortening, that's more common with proximal osteotomies and it can lead to transfer metatarsalgia. AVN, the blood supply to the metatarsal head comes from a combination of a nutrient artery that goes through the middle of the shaft and send two branches, approximately one distal. The proximal branch anastomose with some metaphyseal vessels, they mainly enter the head by penetrating the capsule more dorsally and laterally. So overzealous dissection, that area can devascularize the head, so you have to be cautious. Pelvis varus, increased risk with resection of fibular sesamoid, over resection of medial eminence. I know that was tested before, excessive lateral release or overcorrection of the IM angle. And nonunion, which is common with fusion procedures like lapidus or proximal osteotomies as well. Just wanted to give a hint on juvenile or adolescent bunions in case they ask that. It's often bilateral. You have a strong family history. The problem is mainly cosmetic, more than pain, commonly associated with flexible flat foot. Commonly, they have an increased DMAA, distal metatarsal articular angle. So treatment would be double or triple osteotomies. And they have high risk of recurrence with early treatment. So some have advocated to push treatment until they reach maturity. Next I'm going to move to hallux regidus, which is less commonly tested on the OITE. This is arthritis of the first MTP joint characterized by progressive loss of motion. It's the most common joint to get arthritis in the foot. Females are, again, more than males with positive family history in 80% of cases. Usually becomes symptomatic in the fifth or sixth decades of life. And look out for inflammatory conditions other than post-traumatic. In the clinical exam, it's important to talk to patients. They may be complaining of stiffness and pain with ambulation. Exam is going to give you the clue to what the treatment should be. The most common finding and examination is limited passive dorsiflexion. The normal dorsiflexion is about 70 to 90 degrees. They'll have dorsal osteophytes. They develop compensatory interphalangeal hyperextension, which can manifest by callus under the IP joint. They have pain with range of motion, which is crucial to analyze if it's been a determined range of motion versus throughout the whole range of motion. And they can also have some sensory finding due to irritation of the dorsal digital nerve. This is the most famous classification by Kauflin and Chernus. And for sake of ease, in the test purposes, you have grade zero, basically mild stiffness, normal findings. They won't put that in the test. And then you have mild disease, which is stage one and two. You have mild to moderate pain. The key is no pain with mid range of motion. It's only at the terminal range of motion. Some osteophytes with some joint space narrowing. And then stage three and four, which is disappeared disease, more constant pain, pain through mid range or throughout the range of motion and more osteophytes with excessive joint space narrowing. Treatment again, non-operative is the first line of treatment, grade zero or one disease. Patients are advised to do activity modification. That's why I choose orthotics. I know that the Morton extension orthotic has come out on the test a few times. And then they can get steroid injections. As far as surgery, I'm going to focus first on the two procedures that are commonly performed and are going to be the answer to the test. One is dorsal colectomy, which is shown in this figure here. You take the osteophytes from the base of the proximal phalanx and from the metatarsal head. And you take up to the dorsal one third of the metatarsal head without jeopardizing the function of the MTP joint. It's indicated in a mild disease, so grade one and two. Don't do it when you have pain with mid range of motion because that indicates severe disease. In severe cases, the answer in the test is going to be MTP arthrodesis. It's the gold standard with more than 90% fusion rate. If they show you a division case or for some reason a case with inadequate bone stock, the answer would be MTP arthrodesis with structural bone block graft. These are other procedures. Don't pick them on the test. They're never the answer. Moberg osteotomy is a proximal phalanx dorsal closing wedge. It's usually done in combination with colectomy. It's a decision you make interactively after you do the colectomy. If you're not happy with the range of motion and you want to get some more dorsiflexion, you can do it. MTP arthroplasty, there has been several types of arthroplasty, whether it's metal implants, silicon implants, and recently some hydrogel implants. Again, they are not going to be the answer. They are indicated in patients with severe disease who wish to preserve their motion. I think the only way, or previously the only way they got tested is if they show a case that failed. So the answer would be to revise with arthrodesis with a bone block because you lose a lot of bone when you insert these implants. And finally, Keller resection is just a resection arthroplasty. You shave the base of the proximal phalanx and the metatarsal head, and it's in elderly, low demand people. Again, these are not going to be the answers. It's going to be either arthrodesis or colectomy. So with that, I conclude. Thank you everybody for tuning in. The one thing is make sure to pull up some x-rays for congruent joints so that you can recognize it when you see it in the test and good luck to you all. Thank you, Dr. Abousai. This was excellent. Actually, we have a question from the audience. Dr. Pescoia is asking, can we go over the congruency of the joint again in Halox valgus? And I know this is a very, very intriguing concept for the residents. I know you're going to have to jump to your slide showing the congruency again. I'll probably emphasize it as Dr. Galli, our next speaker, gets her slides ready without sharing her screen. Yep. One second. Getting to it. Yep. Here it is. So again, if you look at these marks, the X and Ys, these are the most medial and lateral aspects of the articular surface of the proximal phalanx and the metatarsal heads. And if you draw those lines in any x-rays, this is an example of a subluxed joint. This is an example of a congruent joint. You can see they match very well in a congruent joint. And again, it's tricky because sometimes you're in the OITE, you don't know when the foot and ankle question is coming and you're rushing. So just try and follow the algorithm, arthritis, hypermobility, congruency before measuring the angles. If you get your eyes used to recognizing congruent joint, hopefully you guys will get that question correct. Okay. For the sake of time, I think we're going to be moving on. We have two other questions that popped out. I do have them and we'll try and get to them at the end if you don't mind. I would like to move on with our next speaker, Dr. Sarah Gally, out of Ochsner Health in New Orleans. Dr. Gally, please unmute yourself and proceed. And I promise that if we have time, we're going to get to the other questions at the end. All right. Good evening, y'all. Thank you so much for having me. My name is Sarah Gally. I'm down in New Orleans. We have successfully dodged, thankfully, safely three hurricanes here. So it's been an exciting first year of practice. I'm here tonight to present to y'all about two variants on kind of the foot spectrum, pes planus as well as pes cavus and the associated pathologies with which it comes. Notably, posterior tibial tendon dysfunction and sharp joint pain. So I'm going to go ahead and introduce myself. My name is Sarah Gally. I'm down in New Orleans. We have successfully dodged, thankfully, safely three hurricanes here. So it's been an exciting first year of practice. I'm here tonight to present to y'all about two variants on kind of the foot spectrum, pes planus as well as pes cavus and the associated pathologies with which it comes. Notably, posterior tibial tendon dysfunction and Charcot-Marie-Tooth. So just objectives for this evening. This is really aimed at being a high yield review to get y'all prepared for the test as well as pattern recognition in clinic. This isn't intended to be a comprehensive review, but if you have questions, something piques your interest, a lot of my content was pulled from a combination of some great resources and reviews in Foot and Ankle International, as well as Foot and Ankle Oedipedics, as well as lecture slides that are available on the Physician Resource Center resident lecture series for y'all. So first getting to pes planus and posterior tibial tendon dysfunction. So what does the posterior tibial tendon do? It is a hind foot inverter. It's a component of the deep muscular compartment, and it functions to invert the hind foot. It functions to do this through mainly its attachment on the navicular, but it has bunches of other attachments as well. And what it does is it takes our flexible show parts joints, which are parallel when they're relaxed, and it inverts the hind foot and makes those joints divergent. When those joints become divergent, the hind foot becomes inverted and locked. When that happens, that provides the rigid lever arm that then allows the gastroc to propel the heel up and propel the body forward. So it makes the foot a rigid lever arm for propulsion. Then the posterior tibial tendon relaxes during heel strike, and that gives us the supple hind foot that allows us to accommodate the ground. What happens when the posterior tibial tendon is dysfunctional? It can be anything from tenosynovitis to degenerative tearing to full ruptures. What happens is a constellation of things that begins to both change the function of the foot as well as the architecture of the foot. So you lose some of that arch stability, so some patients come in with arch pain. They may develop some spring ligament pathology. They also may come in with that inability to lock the hind foot and lock show parts joints. Their propulsion is less efficient, so they get calf fatigue, calf tightness. And then really the most common reason I'm seeing these patients is as they fall into that hind foot valgus, the calcaneus starts to deviate laterally, so they can either get symptoms of subfibular impingement from the calcaneus abutting the distal fibula. And then as that calcaneus slides out laterally in the valgus, that then takes away that medial support for the tail or head, and so that's where you see the talus start to drop. And that brings us to kind of the physical exam. What do you see? So an examination of any foot and ankle patient is a standing examination. It's a barefoot examination. They come to you with two feet. You should examine both feet. My assessment of the patient involves looking at their hind foot position, getting behind the patient. You're looking at both the hind foot and the forefoot. So in the hind foot, you're looking at the valgus, what you see here with these lines drawn here. And then you're looking at the forefoot. That forefoot is often abducted and you see what's called the too many toe time. So that's part of that standing examination. Then while you've got the patient standing, you ask them to do a heel raise. I first have them do a double limb heel raise just to see if they can do it. So then when you're assessing that double limb heel raise, you're looking at do both hind feet physiologically invert? Or does some of this valgus correct? Meaning it's a flexible deformity when they go up on their toes. Then the other aspect of it is, can they actually go up on a single limb heel raise? That's assessing that ability of the posterior tibial tendons to work and work efficiently or work dysfunctionally and cause pain. Then your bench tabletop examination, that's a seated exam. You're going to do a full foot and ankle exam. You're going to assess all the motor groups. But for the tests, things they're going to look at that help you with staging this patient, deciding what to treat is looking at their gastroc and their Achilles complex. So you're doing a silver skele test. What that is, is a test looking at do they first have Aquinas? Does their foot dorsiflex past neutral? Then you're looking at does that dorsiflexion change from when the knee is extended to when the knee is flexed? When that knee is flexed, you're taking out the gastroc. So if their foot dorsiflexes more when you dorsiflex, then that's telling you they have a gastroc contracture versus if they don't gain any dorsiflexion from bent or straight to bent, that tells you they have an Achilles contracture. You're looking then, this picture here on the bottom left, when you hold that hind foot reduced, so when you're taking the valgus out of their hind foot, you're looking at then how is the forefoot position? Is this medial ray elevated? Then you're looking at does the medial ray have excessive mobility or hypermobility as we just heard about in the last lecture when we were talking about bunions. This is another time this will come up, first ray hypermobility. Listen for that in these test steps. Then you're going to look at your x-rays. Assessing a flat foot is really a foot and ankle set of radiographs to assess this. You're looking at the lateral radiograph to look at this collapse of Mary's angle through the tail and avicular joint, but note, don't always be full. It doesn't always occur through the tail-avicular joint. It can also occur through the first TMT joint or the navicular cuneiform joint. Again, as our previous presenter pointed out, you're going to look sometimes for that plantar gapping, which is a hint of that medial column hypermobility, that medial column instability. Then you're looking at your AP radiograph. What you're looking at on your AP radiograph is that abduction deformity. The way we measure that abduction deformity is here at the tail and avicular joint. You're looking at how much uncovering or lateral deviation of the navicular is there that's leaving your talus uncovered. That comes into play as we talk about the grading and the treatment options of this pathology. First of all, general good OITE principle tip. Don't operate on something that doesn't hurt. Don't operate on something that hasn't tried bracing. That's really true in both real life and on the test for posterior tibial tendon dysfunction. First of all, it's important to recognize that not every flat foot has posterior tibial tendon dysfunction. There are people that are just born with flat feet and asymptomatic flexible flat feet don't have posterior tibial tendon dysfunction. They don't need treatment. When you have someone that gets into the realm of having posterior tibial tendon dysfunction with a flat foot and with symptoms, you then get into what are the non-surgical treatment modalities that you look at. When you're talking about the flexible flat foot, you're talking about inserts or a UCDL, which is a type of insert that really supports that medial column that's falling into valgus. It posts it back up and tries to swing the foot back around. When you're dealing with a rigid flat foot deformity or a flat foot deformity that's progressed to ankle arthritis or ankle valgus, you're then looking at more of an ankle support brace. Most commonly, the answer for that is an Arizona gauntlet, which is a type of ankle foot orthosis or AFO. Then getting into the surgical treatments of this. The way I think of posterior tibial tendon dysfunction is I have always broken it down in my brain into the flexible and the rigid. When you do that heel rise test, does the hind foot invert? Can you manipulate the hind foot into inversion and eversion or is it fixed in that hind foot valgus? If you're dealing with a flexible flat foot, your surgical solutions are going to be more focused on joint sparing techniques. When you're dealing with a rigid hind foot, you're focusing on more joint sacrificing techniques because the joints are deformed and stuck in those deformed positions. You need to go to the joint level to correct their deformity. It's pretty rare that I think they're going to test you guys on stage one, which is tenosynovitis. The radiographs are normal, but they have symptoms of posterior tibial tendon irritation, dysfunction. Their MRI may show fluid and tearing of the tendon. Treatment of that is highly variable from anything from tenosynovectomy to repairing the tendon and transferring the FDL to support that repair. Really where the testing hits the ground though for you guys is stage two, stage three, and stage four. Stage two, the big differentiator in stage two is they have a flexible hind foot. You can move the hind foot. When they go up on their toes, they have pain, but the hind foot still inverts. You're going to go to your AP radiograph. This is the differentiator. Is the talus covered or uncovered? If the talus is covered or at least uncovered by less than 30%, you're focusing on realigning the calcaneus, so correcting that calcaneus out of valgus. You do that with a medial displacement, calcaneal osteotomy. Then you're going to repair, debride the posterior tibial tendon that's dysfunction. Then you're going to support it better with an FDL tendon transfer. That's what these radiographs are showing is the location of that FDL tendon transfer where you transfer it into the navicular. If you're dealing with a stage two B flat foot, that's the flat foot that has an extra positive too many toes sign. They have a lot of abduction deformity, a lot of uncoverage of that talus. You need to do something to swing that foot around. What they're looking for on the test is you're going to do what we just spoke about for stage 2A with the addition of or in substituted by a lateral column lengthening. That lateral column lengthening is going to lengthen the anterior process of the calcaneus. By lengthening that, you're swinging that foot out of its abduction and hopefully improving your tailored head coverage. You're doing that with, again, the posterior tibial tendon debridement and FDL transfer. Then we get into the rigid flat foot deformity. This is something where the subtalar joint, the talonavicular joint, plus minus the calcaneocuboid joint are involved. The algorithm for this is if it's painful, if it's deformed, use it. For me, and I think for most purposes of the test, they're looking for a double arthrodesis. The reason they're looking for a double arthrodesis, i.e. the talonavicular and subtalar joint, is because if you think about what the deformity is, the person's in a ton of abduction. You correct all that abduction, you're distracting the calcaneocuboid joint. One, it's really hard to fuse a distracted joint. Two, distracted joints don't rub on each other. They don't hurt. A lot of times, you can get away with a double arthrodesis for this pathology. Then we get into a place where lots of foot and ankle surgeons debate. We have whole symposiums to talk about this, but for the purposes of the test, I would like you all to recognize that not every ankle valgus went from a stage three flat foot that was rigid to a stage four flat foot. It's not one, therefore two, therefore three, therefore four. You can have ankle valgus with a flexible flat foot under it, that's the 4A. You can have ankle valgus with a rigid flat foot under that, that's the 4B. The treatment that you do, again, focuses on the foot. If you have a flexible flat foot with ankle valgus, you do a flexible flat foot procedure. Either that stage one procedure or that stage two procedure, and then you address the ankle valgus. Addressing the ankle valgus can be anything from a deltoid reconstruction to fix the deltoid that's insufficient, making them swing into valgus, or ankle arthroplasty, as you can see here, where they did calcaneal osteotomy, first TMT fusion, ankle arthroplasty. Alternatively, you have an ankle valgus that has a rigid flat foot underneath it. You need to do rigid flat foot procedures, i.e. stage three procedures. Then at all costs, we try to save the ankle joint because patients don't do well when you fuse their tibia to their talus, which is then fused to the navicular and the calcaneus. That's a hard foot to walk on, and so at all costs, we try to avoid panteller fusions. There's also other pluses that come in. When I said when you're examining this patient, you're looking at multiple different things. A couple other buzzwords to look for. If the patient has that compensatory supination, meaning when you hold the hind foot reduced, their first ray is elevated, you have two options. If their medial column is stable, you're going to do a cotton or a plantar flexion osteotomy to bring that down. Alternatively, if they have first ray hypermobility, you're going to do a first TMT fusion. Have that ring in your bell from the last talk. We just heard hypermobile first ray, first TMT fusion. You need stability of the medial column. Similarly, other thing they may test you on is when you did that silver-skeeled test on the patient. If your silver-skeeled was positive and the patient has Aquinas, they need a gastroc lengthening. Alternatively, if they have Aquinas and their silver-skeeled was negative, they need a tendo Achilles lengthening. With that, tons of information, tons of things that we debate about in the foot and ankle world. For the purposes of the test, only treat symptomatic flat feet. Always go with conservative treatment initially. If it's flexible, try to do joint sparing surgery. If it's rigid, go to your joint sacrificing surgeries, your fusion operations, and fuse the joints that are involved and avoid a Panteller fusion if possible. With that, we'll transfer it from flat foot to high arched foot. It's a company, Charcot-Marie-Tooth. The biomechanics of a high arched foot and Charcot-Marie-Tooth. Generally speaking, you have a weak peroneus brevis as if it's attached on the fifth metatarsal base and you have an overactive peroneus longus attached to that metatarsal head. That's pulling the metatarsal into plantar flexion. This is my pictorial representation of here's your foot tripod, so to speak, looking at it from the back. Then as that first rate plantar flexes, you shift the weight onto the lateral column of the foot and shift them into ferrous. What is Charcot-Marie-Tooth? That biomechanics on steroids. First of all, understanding that Charcot-Marie-Tooth is a motor and sensory disease. They're not always going to give you Charcot-Marie-Tooth. They may say hereditary motor sensory neuropathy and a buzzword needs to go off in your head. They're testing you on Charcot-Marie-Tooth. There's lots of names for it, so just know those names. That's an easy way they quiz you. What's going on is in addition to the weak brevis, the overactive longus, you have a weak tibialis anterior, so these patients have a foot drop. Then they also have intrinsic weakness of the toes, so they get claw toes. I bring this picture back from our last talk on flat foot for the reason being is that these patients often have hind foot varus. What does that mean about their hind foot? We talked about how a hind foot in varus from the posterior tibial tendon is often rigid, so these patients often have a very stiff foot from that hind foot varus. When they present, it's called the cavovarus foot, so it had components of cavus, components of varus. That cavus, that plantar flexed first ray, often drives them onto their lateral column, so the lateral column overload. That peroneus longus is passing under that, and so you get often peroneus longus pathology. Then on your x-rays, you see this increased calcaneal pitch from that over plantar flexed first ray. Then we get to the varus. What's going on with the varus? They get recurrent ankle sprains because they are, again, loading onto the outside part of their foot. They have a stiff hind foot because their chauffeur joints are kind of stuck in inversion, so they're stiff. They get the peekaboo heel, which is what we see when their hind foot is in varus, and you look at them from the front here. Then what they get is the opposite of tailor head uncoverage. They get tailor head overcoverage from that tight posterior tibial tendon, kind of pulling the foot into a deduction as opposed to the abduction that we saw with the flat foot. This is what they're going to test. This is part of your treatment algorithm. This is something that also can differentiate the patient. When you're doing your physical exam on a cavo varus foot, you want to know, again, is it flexible, is it rigid, and is it forefoot or is it hind foot driven? Again, I bring these little pictographs back. What you do with the Coleman block test is you place a lift underneath the lateral border of the foot. If it's forefoot driven, that allows the first ray to drop, so that plantar flex first ray is neutralized and that should correct your alignment. If you go back to this picture I draw with the plantar flex first ray, if you elevate the lateral column, all of a sudden the tripod is restored and their foot is straight. If they have a rigid deformity or a hind foot driven varus, you lift up their lateral column, nothing's going to happen. They're still going to be in varus. That's the big test is Coleman block tells you flexible versus rigid and forefoot versus hind foot driven. When we take that and go into kind of how we treat this, this is, again, orthotics and non-operative treatment. The OID wants to know, do you guys know how to recognize non-operative and operative treatment patterns? This is another time where the non-operative treatment comes into play for understanding that. First of all, there's a large spectrum of just a subtle chi arch foot to Charcot-Marie-Tooth. Not every cavus foot is Charcot-Marie-Tooth, but the non-operative treatment that you start with is a lateral post orthotic. Again, thinking of that Coleman block, elevate the lateral column and then a first metatarsal recess. You're essentially building an orthotic that does what the Coleman block does for these patients. That's the orthotic answer. Lateral post first metatarsal release. Relief, sorry. Surgically for these, it's kind of a potpourri of options that are out there, but the big thing is recognizing the patterns, recognizing what's dysfunctional, and again, using that Coleman block information. If there's perineal tendon tears, you're going to repair the perineal tendon tears. If there's a lot of cavus, a lot of forefoot driven deformity, you're going to consider a plantar fascia release. If they have a flexible forefoot driven pathology, you're thinking tendon transfers and a first metatarsal dorsiflexion osteotomy. You're taking away that forefoot driven plantar flexion by dorsiflexing the first metatarsal. Then often, you're going to do a longus to brevis transfer to take away that overpull that the longus is doing to help correct that deformity. If they have a hind foot driven varus, you're then going to go to the hind foot to do your correction. You're looking at a lateral displacement calcaneal osteotomy plus minus a posterior tibial tendon release or transfer to take away some of that overactive pull that's throwing the foot again into stiff varus. Then, not dissimilar to what we talked about with the flat foot, if you have a rigid deformity, you're going to need an arthrodesis procedure. In this case, it usually is a triple arthrodesis to get your correction of the rigid cavo varus deformity. With that, if you guys are interested in more references, these are kind of what I pulled from. There's some great resources out there. We will jump- Dr. Galli, thank you so much. It was an excellent presentation. We'll ask you to stop sharing your screen and we're moving on to Dr. Justin Tsai, Rothman Orthopedics, New York. Dr. Tsai, please unmute yourself and share your screen. Sure. Let's see here. All right. Thanks for tuning in today, guys. We're going to be talking about Achilles tendon and lisfranc injuries. I had no disclosures relevant to this talk. Let's jump right into it. We'll talk about Achilles tendon injuries. The Achilles tendon is the largest and strongest tendon in the human body. As you know, it's made up of contributions from the soleus more anteriorly, as well as the two heads of the gastroc. They combine to form a broad tendon, inserting on top of the calcaneus. One interesting part about the anatomy is that it actually undergoes a twist starting about six centimeters proximal to the insertion, where basically the soleus, where it starts off more anteriorly, ends up more medial, and the gastroc's in the more lateral. This twist has implications in its weak point above the calcaneus at about six centimeters, combined with the blood supply. It's important to keep in mind the bursa around the area. The two ones relevant to the Achilles are the retrocalcaneal bursa, which is anterior to the Achilles, in between the Achilles and the calcaneus, as well as the subcutaneous or Achilles bursa, which is between the posterior aspects of the calcaneus and the subcutaneous tissue. It's important to keep in mind the sore nerve as well. It crosses the Achilles tendon at the point above the tip of the fibula, above 10 centimeters. This is especially important when you're doing a more proximal procedure like a gastrocnemius turndown, where you really are going to run into it in your field and have to protect it. It's important to keep in mind also it's above the level of the peritonon. If you're able to dissect the peritonon and put some deeper tractors, you can be fairly sure you're protecting it in cases like doing a gastrocnemius recession. In terms of the blood supply, it's fed by two major arteries, one of them being the posterior tubular artery, which supplies the more proximal and distal aspects of the tendon. The perineal artery has a weaker supply. It supplies that mid-substance area, again, centered about four centimeters from the insertion. This is the area we call the watershed zone, and it's, again, combined with that twist makes it more prone to injury. The way the actual blood supply reaches the tendon depends on the location. Approximately, it's fed through the musculotendinous junction distally. It goes to the bone-tendon interface, but for the rest of the tendon, it's really done through a structure called the peritonon. This is a sheath. It's not a true synovial sheath, but it's a thin membrane that you can actually see, through which the blood flows into the tendon. That's why it's really important to be mindful of it and preserve it. Whenever you can, sometimes it's not possible, preserve it and repair it at the end of the procedure. I won't go through this too much, but you hear a bunch of terms relating to inflammation in this area. Tendonitis is a misnomer, even though we all know what it means. There's very poor blood flow, as we indicated in the previous slide. If you were to take a section of, quote-unquote, tendinotic tendon, it's not necessarily going to show a ton of inflammatory cells. What most people refer to with tendonitis is actually a combination of tendinosis, which is an asymptomatic degeneration and a regional focal loss of structure, combined with inflammation of the peritonon. In the end, we all know what you mean by tendonitis. I think it's an okay term to use. Obviously, retrocalcaneobursitis refers to inflammation of the bursa. Insertional tendonitis refers to inflammation at the insertion. As with everything, in terms of the pathophysiology, it's a combination of both extrinsic and intrinsic factors. Those combined, along with repetitive trauma, lead to injury, scarring, and then further propensity for injury. On the right side here, I've listed more of the risk factors for a rupture. You want to keep in mind that you see this more in males in the third to fifth decades. You've all heard of the association with fluoroquinolones, as well as steroid injections. Finally, repeated microtrauma as well as a risk factor for a rupture. In terms of the history of physical, it's pretty direct in this case. The mid-substance cases are going to have sometimes a distinct nodule that's pretty tender, whereas the insertional ones are going to be more tender right at the insertion. This could be as a result of a Hagelin's deformity, which we'll talk about next, which is enlargement of the posterior superior aspect of the calcaneus. The actual size of the Hagelin's can be distorted by the calcaneal bursa right behind it. This is the first or mitral calcaneal bursitis, which is an important differential, which is tender really more right anterior to the Achilles tendon itself. I always get x-rays for these. In terms of what you're looking out for, you really want to look out for calcification, which is always indicative of a more chronic inflammatory process. A Hagelin's deformity is an enlargement of the posterior superior aspect of the calcaneus. It can be hard. Obviously, the one on the left side here, it's pretty obvious, but sometimes it can be hard to tell what's a Hagelin's or what's not. I think it's beyond the scope of the OITE, but in general, if you draw a line parallel to the undersurface of the calcaneus and do the same up top, the true Hagelin's will project above that. Whenever you see something like a fleck of bone more approximately, like this here patient of mine, you want to be mindful that there could be an abulsion fracture there. So you turn to your MRI. An MRI is useful in these chronic cases, which will usually demonstrate thickening as well as a fluid signal in either the tendon or the bone itself. Non-operative treatments are pretty much the same as in any other orthopedic condition. You want to start them on some NSAIDs, some heel lifts. Physical therapy, one buzzword that's frequently tested is eccentric exercises, which again is contraction of the muscle while at the same time lengthening the tendon. This is usually more effective in your mid-substance cases than your insertional ones. I don't think they'll test things like PRP and shockwave therapy. These things have good evidence either way, but no definitive showing it definitely works. One thing to keep in mind is that in general, if something's not working for six months, if no surgery hasn't been effective, then it's less likely going to be effective past that. Surgery, pretty straightforward from a conceptual standpoint. You want to take out the tendon that's affected. And when you're looking at tendon and tendinotic tendon, it's pretty easy to see what's healthy tendon and what's not. The concept that will likely be tested is whether you use an FHL transfer or not. And in general, we use the 50% rule. If over 50% is removed during your debridement, then you should consider an FHL transfer. And the reason the FHL transfer helps with your surgery is that it adds biomechanical strength. There's been multiple studies that have shown it increases the load and the failure with any percentage of tendon that you remove. And it's a beautiful transfer because it really sits right in front of the Achilles tendon. So it's pretty easy to harvest. And especially if you plan on using an interference screw, you don't have to get much length. You can harvest it through the same incision. There's a concept that also that's a big muscular and well-vascularized muscle sitting right in front of the Achilles. So if you consider suturing the front of the Achilles to be a back of the FHL, it can add some biology to your repair as well. Now, in terms of insertional tendonitis, you wanna do the same thing. You want it to breathe the tendon and you can access the tendon through multiple different ways. You can make a midline split. You can go from lateral, from medial, or through a window. If possible, and it's not always possible, you wanna leave the attachments intact on either side of the Achilles tendon insertion. This just preserves tension and you don't have to worry about over-lengthening or shortening when repairing it back down, which is usually done using a double row technique. Before you actually tack it back down, you wanna perform your calcaneal exostectomy. And this is two purposes. One is it removes the Haglunds, which can irritate the anterior surface of the Achilles. And you wanna make sure you get enough on the medial and lateral aspects. Otherwise, the patient will continue to feel their deformity. And this also provides a bleeding surface or reattachment. And finally, the same concept applies, even though in these patients, it's usually older and in older patients. And for the most part, I almost always perform an FHL transfer. You just wanna be mindful, especially if you're using a double row technique and interference group of the FHL of your trajectories and your real estate. Now, moving on to rupture. You know, most patients will either hear or feel the pop. They'll a lot of times feel someone kick them from behind when there's no one there. Pain is kind of variable. Most patients will have pain at the time of injury, obviously, but that pain can dissipate quite quickly. And you can quickly run into a situation where patients come in and they said they remember something back a couple of weeks ago and all of a sudden the pain resolved and they didn't think twice about it. They're gonna be weak, however, and especially immediately, they'll have ecchymosis in the area. When you examine them, again, acutely, it's quite easy to feel a gap. However, as time goes on and as you get some bridging scar tissue and some swelling, that gap is not as easy to assess, especially with a patient that's uncomfortable. They will, however, most always have a Thompson's test, which let me just see if this video works. Basically, you squeeze the calf and in a torn Achilles, you will not have a corresponding plantar flexion response. They're also gonna demonstrate a decreased resting plantar flexion compared to the contra-lateral side. So you get them on their belly, have them put their knees up like this. And on the picture on the right hand side here, you can see that the side that's affected is the right side because it's an increased dorsiflexion. Let's move on here. So in terms of imaging, again, I always get x-rays because you do wanna rule out an avulsion, which is a much different treatment than a simple Achilles repair. But in the acute cases, advanced imaging is not necessary for the most part. Your clinical exam should be pretty obvious, especially if it's the first couple of days, first week. You reserve the MRI or ultrasound for more subacute or chronic cases where you wanna have an idea of the gap involved and level involved, as well as how much the true gap is after you debride the tendinotic tissue. So this is likely to be the tested topic. And that's the question of how you treat these. So the ultimate question is whether you treat these with surgery or not. And in terms of non-operative treatment, what you're doing is you're bringing the tendaments together not with an open incision and using suture, but by putting them into Aquinas. And the positives are you avoid the complications of surgery. It's a lower cost for the most part, and generally it has good results. There's a study done by Willits et al, which is quite a prominent study, which compares surgery to no surgery, in no surgery using a special protocol where they use accelerated rehab and functional bracing. And they really found those two to be equal in terms of the results, whether that be strength, re-rupture, satisfaction with surgery. Now, traditionally, the negatives of non-operative treatment has been the fact that there's been a higher re-rupture rate. And correct me if I'm wrong, but I have yet to see a study that hasn't mentioned using a accelerated rehab protocol where it's demonstrated a equivocal response. So traditionally, higher re-rupture rate and decreased strength. And the reason why this is is likely because a lot of times you can't bring the two tendaments together reliably just by putting them into Aquinas. A lot of patients even acutely develop a gap, a lot of fraying at the ends of the tendon where you're, in essence, lengthening them, treating them non-operatively. So, you know, in my hands, that's why, especially for young, healthy patients, you advocate for surgery and its benefits. I don't think they'll test open versus percutaneous. There's been multiple studies, and each study you read has slightly different results. You know, the one study that's kind of obvious demonstrates better cosmesis with the percutaneous or mini-open technique. They will likely test, or are highly likely attesting the late presentation. So we define this as being greater than four weeks or a gap of greater than 2.5 centimeters. And in general, when you reach that standpoint, you have to at least be mindful that you may need to do this. Sometimes, you know, with a 2.5 or three centimeter gap, you can still do a primary repair, but you have to be mindful and counsel the patient that you might need to do one of these procedures. Generally, from 2.5 to five centimeters, you can rely on a procedure called a V-yplasty, which basically lengthens the tendon or using a V and converting it to a Y. After five centimeters, you can start to actually get the tendon, pull off the muscle, and you can end up with a free graft, which is not optimal. After five centimeters, you want to rely more on your turndown, and you can really get a pretty decent amount of length using this procedure. You can see here, this is one of my patients who had a huge gap after we debrided the really tendinotic tissue and chronic rupture, and you have pretty much the entire length of the gastroenteritis fascia to use. It's important to keep in mind the clinical practice guidelines. I won't go into this too much since it's somewhat obvious, but these are the consensus and moderate findings or moderate consensus findings. You want to rely on your physical exam and include two of the four ones listed there. You want to be more cautious in patients that are diabetic or neuropathic or who demonstrate or who smoke. And the last one's, I guess, one of the ones that is less obvious, but has a moderate consensus, which is basically that if you're going to operate on these patients, barring some unforeseen circumstance, you generally want to start them way very early, two weeks or earlier, and you want to use some kind of a protective device that also gives them some sort of mobilization post-operatively. So we'll run through Lisfranc injuries. The anatomy of the Lisfranc complex consists of three joint complexes, the tarsometatarsal articulation, the inner tarsal or the inner cuneiform joints, as well as the proximal intermetatarsal articulations, which is the articulations of the base of the metatarsals. And there's really two types of constraints. There's the bony constraints as well as the soft tissue constraints. The bony constraints are built in. It's what we refer to as the keystone complex or the recessed complex. The second metatarsal sits more proximal than the first and the third, as well as more dorsal. And this confers by itself great stability to the joint complex. From an anatomic standpoint, there's several ligaments in the area. The first is kind of the transverse intermetatarsal ligaments that go between each of the bases from two to five. But the same ligament does not exist between the first and the second. And what we have to bridge between the medial and middle column is the Lisfranc complex, which is, or the Lisfranc ligamentus complex between the medial cuneiform and the base of the second metatarsal. And there's three such ligaments. One is the dorsal, plantar, and the one we classically refer to as the Lisfranc is the inner osseous ligament, which is the strongest ligament. Keep in mind the blood supply or neurovascular bundle and its proximity to the complex here. You have your deep peroneal nerve as well as your dorsalis pedis artery. And this crosses and dives deep a couple centimeters distal to the second metatarsal base. You just want to be mindful of this not only during your surgery, but also it has the potential to cause compartment syndrome in patients with high energy mechanisms. So in terms of mechanism, you can have a direct injury, which is the crush to the dorsal foot. However, most are indirect and you'd be surprised at how low energy some of these can be. Basically, they all involve some kind of force directed to a plantar flex foot. And what happens is the dorsal cortex fails under tension. And then the direction of displacement really depends on the subsequent direction of force applied to the plantar flex foot. Obviously, these patients are going to have some midfoot discomfort. It's walking may be possible, but running and jumping is certainly impossible. The pathognomonic sign you want to look out for is this plantar ecchymosis. They'll be tender in the midfoot and certainly they'll be quite tender or painful with a stress exam, which we'll talk about next. Imaging is difficult, right? There's the theoretic answer and there's also the practical answer. Weight-bearing views a lot of times are not possible, but that's probably what you should start off with and you want to compare it to the contralateral side. A stress test, again, something theoretically you should perform first, but again, especially in the acute patient is going to be quite uncomfortable for the patient. And what you're going to look for is some sort of diastasis between the first and second tarsal metatarsal articulations or columns that don't really line up to one another. And there'll be a, especially if they show you a normal foot, you should look for a side-to-side difference. They're showing you the normal foot for a reason. If you see a flex sign, like is shown on the top right picture there, that's a pretty indicative of a Lisfranc injury. And they mentioned a cuboid compression fracture. You can think about, there's enough of an abduction force to cause a compression fracture of the cuboid. You have to be highly suspicious for a possible Lisfranc as well. In terms of your advanced imaging, CT and MRI both use each with their advantages. The CT scan is, the disadvantage is that it's a static exam and certainly more subtle cases, it may not give you the information you need to dictate treatment, but it can certainly show to quite good detail the articular combination, non-displaced fractures, as well as for surgical planning, size of screws, the plates you might wanna use. An MRI is really useful for, the same thing CT is, but also for more subtle injuries. So on the bottom left here, you can see where the white arrows are, that all three ligaments have been torn in this case. And most likely clinical exam in this person is gonna be consistent with an unstable type injury. Whereas in the bottom right here, you can see how with the arrowhead, the interosseous ligaments intact, whereas the plantar ligament is torn. And this might be a more equivocal case. In terms of treatment, the only role of non-operative treatment, and they'll give you clues, is when you're dealing with a stable type injury, whether on weight bearing views, stress exam, MRI, CT. If you're getting the sense that are leading you toward a stable type injury, then you can treat these patients non-operatively. And that's generally with a boot or a cast, progressive weight bearing. Whereas an unstable injury is gonna necessitate treatment, surgically of some type. And in terms of surgery, it's generally done to reduce the risk of post-traumatic arthritis, and collapse of the midfoot. First off with high-intensity cases of polytrauma, you really wanna stabilize, the other stuff first, but you need to reduce these to allow you to get back in there on a timely basis. So you can close reduce them and use temporizing K-wires or an X-fix, and it come back later once the skin allows. The test concept will likely be ORF versus arthrodesis. And this probably stemmed from a nice study done by Dr. Lyon-Kuncia, where they looked at 41 patients with a pure ligamentous injury. So no evidence of any bony injury or fractures. They divided them in half and really followed these patients up to 43 months. And they found that almost uniformly, the patients that underwent open reduction internal fixation did worse. They had lower functional scores, a lower percentage of them went on to meet the same level of pre-injury status. They were less satisfied and underwent a greater loss of correction over time. So if you see the choice between ORF and arthrodesis, you gotta look for whether there's a fracture or not. And that's a pretty easy algorithm to keep in mind. Last part of the lecture here, we'll just talk about some technique pearls. Basically, you wanna mostly use a dual incision approach. And that's because sometimes even just with a medial approach, even just that medial or middle column involvement, it can be a little bit difficult to reach over to the lateral aspect of the second metatarsal base. So it always helps to at least have a lateral incision just so you can access that base as well as address more lateral instability and injuries if they're out there. You also wanna assess for intercuneiform instability. And this is another thing you wanna see on your x-rays or look out for. Top left picture demonstrates what we call proximal variant. In this case, the force of the fracture or force of the injury has undergone or went through the intercuneiform and exited out the NC joint. And in these cases, you have to address the intercuneiform instability by putting a screw across the plate or whatever construct you decide to use. And in general, you wanna stabilize from medial to lateral. Once you stabilize the medial column or the first TNT joint, this allows you to reduce the rest to it and provides an easy way to think about it. Again, I don't think they'll test about plates versus screws. Screws traditionally have been used. They're less likely to cause hardware irritation, but they also to some degree do destroy the joint. You're putting a screw across a joint, it's gonna leave with some degree of joint destruction, whereas dorsal bridging kind of avoids that issue, but it is more likely to be prominent dorsally. In general, you wanna take this out, right? If you're not gonna fuse them, you should plan on hardware removal, although sometimes this is not done in practice. And this is another heavily tested concept. You do not wanna use rigid fixation for your lateral column. The lateral column is a mobile construct and you're gonna really lock them up and cause them discomfort if you use a rigid fixation. So you can pin them or use K wires for a couple of weeks and take them out at four to six weeks. And in general, that should be enough. For those of you, again, still with us, we have a 25 to 30 minute live Q&A session. We have three speakers with us to round it up. Those of you who are applying to fellowships this year, we're in a little bit of a dilemma of what's going on with the pandemic, how to apply and what the interview process is gonna be like. We thought of putting in the last 25 to 30 minutes with one of our current fellows who's gone through the process of the fellowship year to tell us what his experience is. One of our residents who's just finished his interview season and matched and would like to give you the feedback of how he thinks this new process is gonna be. But for those of you also interested in foot and ankle as a subspecialty career, we're gonna start by Dr. Paul Toulousan out of the University of Michigan for a five minute talk about what's nice about foot and ankle. And then we'll hand it over to our current fellow and current president to give us more insight. Dr. Toulousan, it's all yours. All right, thanks for having me. This is gonna be less academic and a little more propaganda and we should be able to make up some time here. So why pursue a career in foot and ankle surgery? I do have a couple of disclosures, nothing relevant to this talk. When I was a resident, one of my senior residents, Bobby Endu, who is a foot and ankle guy in Philadelphia, well, he was my senior resident at the time and I asked him why he was going into foot and ankle and he said, I've always just figured I'd find something that nobody wants to do and just be really good at it. And that was motivation for me. But the good thing, the things I love about our field is the variety. I definitely don't get bored. I take care of patients anywhere from 10 years to 100 years old. Some of them are athletes, some of them are sedentary, moms, dads, laborers, little old ladies, you name it, take care of everything. And then, so it's not to bash on joint replacements or anything, but I'm not seeing 75 year olds with arthritis all the time. Now, as far as the pathology, I see all sorts of stuff. Congenital problems, and even just with bunions, there's congenital bunions, traumatic bunions, all sorts of different flavors of bunions. But congenital problems, club foot, that kind of thing. We see spory injuries, bunions are our bread and butter. We see tons of trauma from the toes to the knee almost. We deal with arthritis. Infections, probably not the coolest thing, but in any subspecialty, really, you're taking care of infections. Just diabetic foot pus, it just gets its own reputation. Trauma people, they deal with infected non-unions and all that stuff all the time. So you're never gonna get away from pus. And to be honest with you, as an attending, pus is not as bad as it was when I was a resident doing consults. And then you do some weird stuff too. If someone's got an OCD lesion of their third metatarsal head, what do you do? The answer's not really in a book. So you get to do weird stuff and no one's gonna criticize you for it. So you can throw some de novo in there. This is a list, in our Epic system, I've always kept a list of different surgeries that I've done. And I mean, there's a little bit of redundancy in here, but not really. And so these are all really just the different surgeries that I've done over the past six years. And again, I just definitely don't get bored with what I do. you know, another nice thing is that we're always needed. Um, you know, there's not a whole lot of competition. Um, and there's lots of jobs out there. So, um, you know, if you're going into hand or something, I haven't, uh, you know, looked for jobs in that field. But, uh, from my friends that have done it, you know, it's, uh, it's not that it's hard to find. Not that you can't find a job, but it's definitely a lot harder than if you're a foot person. Um, and, uh, it's rewarding, you know. Uh, you get someone who, on the left side here, a guy who really couldn't walk at all because he's got ankle arthritis. I fused his ankle. And then, um, you know, eight months later, this is him walking. And, uh, I mean, that's just a great feeling knowing that you can do that to people. Um, and, uh, even healing wounds. You know, you take this person, everyone's telling you to cut their leg off, and then you get their wounds to heal. Um, you know, and then they, they're fine until you cut their leg off. But, um, anyway, so that's, uh, pretty satisfying. Um, you know, another thing is just our society, um, our group of people. I'm not going to say that we're normal people because we're all a little weird. But I think we're probably the least weird of the other subspecialties. I mean, um, I'm sort of bashing here a little bit. But, you know, everybody, you know, spines got their own reputation. Hands got their reputation. I think the reputation of the foot, foot, uh, surgeons is that we're all just pretty cool people. So, um, anyways, then you, uh, you know, as far as your, your practice, you can make it what you want. You know, some people say they don't want to go into foot and ankle, uh, because, you know, they don't want to deal with bunions or hammer toes or forefoot. If, you know, once you get into practice, you don't want to do forefoot. Um, and, uh, same thing with all the other things. Um, you know, now that I've, I'm sort of deep into practice, uh, or getting deeper into practice, I've decided I hate ankle replacements and I'm just not going to do them anymore. So, um, and then all the other stuff, uh, I don't mind. And then, uh, you know, also depending on your practice, um, you can do plenty of other stuff that isn't just foot and ankle. I mean, I take a good amount of call. Um, and, um, and basically it's my hobby. It's my way of getting away from foot and ankle surgeries and, uh, you know, doing femurs or tibias or hips or whatever. Um, even washing out shoulders, you know, that stuff becomes fun for me because, uh, cause I'm just around the foot all the time. Um, and, uh, I'll stop there and, uh, we'll move on and answer some questions and stuff. Thanks a lot, Dr. Toulousan. Uh, I encourage you all to write any questions in the Q&A box, uh, for Dr. Toulousan and the upcoming speakers. Uh, moving down the ranks, uh, we have Dr. Pierce Ebal, who's a current fellow at the University of Houston, uh, Texas. Uh, and he's going to be telling us a little bit about the fellowship here, uh, with general, uh, you know, uh, lines of how the year goes in general and specifically about foot and ankle. Uh, hi, everybody. Hope everybody can hear me. Uh, I'm Pierce, I'm one of the fellows, uh, at, uh, UT Houston, uh, here in Texas. I'm just going to run through some, uh, you know, basics of fellowship year and if there's been any changes, obviously, with, with things going on with COVID. And then, you know, uh, as your fellowship year goes on, some things that you should be focused on, and this is, I think, good for no matter what specialty you're going into. But overall, uh, fellowship is a great training year. It's like an extended elective. Um, many fellowships are, uh, really have less admin responsibility than during your chief residency year and really increased autonomy. You know, you show up in a different place and people expect a little bit more of you, but that's a good thing, uh, in the operative sense, as well as taking care of patients. Um, so meetings and courses, except for this year, uh, really are another great thing in fellowship. You know, most fellowships encourage you to go to as many meetings and courses as you can. Uh, and in foot and ankle in particular, you really see a lot of different ways to do something. And then you meet a lot of people, you know, the society in and of itself is, is not really big. Uh, it's, it's small. Uh, everybody knows each other. And meeting people at courses, whether they be attendings or co-fellows, uh, really can, uh, help you find jobs, um, learn a new way to do something, solve problems. Uh, and it's really a great thing. Um, and then moving to a new city, you know, anybody who gets to spend a year in a new city, there's so many things to do. It's almost like an extended vacation. Uh, and that, that's certainly the case here in Houston. Um, as far as the impact of COVID is concerned, honestly, I don't think we've noticed much here in Houston, despite, uh, it being kind of a hotspot city right at the beginning of the summer. We're in full swing. Cases are, are running at full tilt and clinics are full. So, um, really I'd say the impact is more with the virtual courses and meetings. And while you're not, you know, getting that, uh, hands-on time necessarily in the lab here in the fall, we're shooting obviously for the spring with a lot of them. You, you still are getting the virtual courses. One nice thing about that is, is you're able to go back to these recorded lectures and something that's, you know, highly technical that, you know, somebody who's, uh, kind of built their career off of a certain procedure is, is teaching. You're able to go back and dissect that a little bit and, uh, take that to the operating room with you or ask your attendings here in town. Um, and for those of you, no matter what specialty you're going into next year, planning ahead, obviously we want to say that everything's going to be a little bit back to normal, but you know, it may not be. And, and so planning your living arrangements, uh, if you have children, educational placement for them, if they're of that age, I would just encourage you not to sit on that, um, because it sneaks up pretty quick between, uh, boards and, uh, some of the stuff that goes on at the end of the year of your chief year. So Matt's going to touch on this a little bit, but finding the fellowship that fits is, is going to be very interesting this year. Uh, obviously through kind of a virtual interview process, I would just say, ask questions, ask as many questions as you can really, you know, this is your one chance to figure out everything and, and, you know, reach out to the fellows there. Uh, they'll give you straight answers and honestly, probably most of the attendings will as well, but figure out your case numbers, your varieties, your complexities, uh, what your research responsibilities are or aren't. Um, if you do have said administration responsibilities, uh, if you have to take call and then, uh, whether you have a co-fellow or not, I think that's, you know, something that's really actually pretty important to have a co-fellow. So, and then check out the city, you know, certain places are not for everybody. So, uh, reach out to folks that do live there currently. Uh, when you're in fellowship, you know, something you may want to actually ask while you're interviewing is, is just your opportunities to plan your practice. I mean, not everybody knows what they're going to head off and do after their fellowship year, but you know, it's a year to fine tune your skills and there's a lot of things to learn in foot and ankle. It's not, you know, joints, not the same four things over and over again, so to speak, not to rip on them too much, but, uh, and then, uh, you know, your appropriate autonomy. There's some things in foot and ankle that don't come around all that often, you know, big deltoid reconstructions, revision, total ankles, learning from the master of your program. Uh, you know, that that's the time where you can really take it all in. You may not be necessarily the person who's, uh, revising the tibia portion of your, of your total ankle, uh, revision, but you know, you can certainly, uh, learn from their steps and then, you know, get ready to practice. And it's coming up quick, you know, building case cards and notes, like we said, a lot of different procedures, a lot of different implants, steps, post-op care protocols. Uh, and then coding is a little bit different in foot and ankle. You know, it's not a, it's not a knee replacement. It's not one code oftentimes. So understanding what codes are properly used and go with which ICD-10s, uh, and, uh, you know, that way when you get into practice, you're doing things properly. You're okay for board, uh, collection, uh, and you're not going to get hot at it or anything like that. And then, you know, once again, going back foot and ankle, a lot of problems, uh, to, to know in the office setting, it's not the same x-rays over and over again. Uh, there's different scoring systems, different protocols. So kind of start dialing things in on how you want to run your office smoothly. And there's something to be learned from all environments. Uh, we're pretty fortunate here in Houston to have employed academic and private, um, attending. So we get to learn a little bit of a different perspective from all of them. So then finally, uh, relationships, you know, you have new mentors. They're, they're, they're busy. So respect their time, help them out, trust their judgment. Also, you're going into a residency program in a lot of places. Uh, the residents have already been there, certainly the chiefs, the fours and whatnot. They know how the place runs, trust their judgment. Uh, and remember, you know, you're there for a year. Uh, you have an opportunity to, to shape and mold, uh, you know, interns, twos and be the fellow you always looked up to when you were a, uh, a junior resident. So, um, job hunting, keep your ear to the ground. I mean, uh, I've always been told the best jobs are word of mouth. Um, you know, maintain your relationships. You've got co-residents who may have been your chief when you're a second year, their practice needs a foot and ankle, uh, person. Your residency attendings and mentors may have, uh, friends of theirs that are in other cities that need somebody. Your fellowship mentor people know tons of tons of people and industry as well. Uh, when you go to industry courses, uh, there may be, uh, other vendors or other places. They, they know, uh, a large practice or, or a academic center that's might be starting to look for somebody and it might not be posted yet. And you can kind of, uh, jump the gun a little bit and then keep an open mind. I think, uh, some of us train in academic environment and, uh, that's kind of all we, all we know. Um, but, uh, you never know. You may enjoy private practice and those who maybe were trained in a, in a community setting or by a lot of private practice. Physicians may like the, uh, the academic environment. So I would encourage anybody who's starting to interview or a cheat towards the end of their chief year. Um, you know, go on a lot of interviews and then trust your gut. It doesn't feel right. Uh, if you're showing up and everybody's in their late fifties and early sixties, you should probably wonder what's going to happen when they start to retire. And it's just you. So, uh, if it doesn't feel right, it probably isn't. Um, and just touching on, on my personal experience, uh, uh, as, uh, Dr. Uh, I was able to find a job simply from a, uh, uh, a close college friend who is a orthopedic resident, uh, elsewhere. Uh, once again, just keeping, keeping your ear to the ground. So it can be something that, uh, fortuitous. Uh, it doesn't necessarily have to be, you know, uh, through the job boards or anything like that. Um, I guess my final thoughts with this are, uh, uh, a nice, uh, manuscript by, uh, Dr. Route, who's, uh, uh, obviously very well known and is here at UT Houston. Just what he, he expects from an orthopedic traumatology fellow. But really this, this paper, uh, can be expanded to any type of fellowship. And I think it's a good read for anybody, no matter what stage of residency you are in. So, uh, I'll leave everybody with that and, uh, try and answer some questions as Matt goes through his, uh, slides. Thanks a lot, Dr. Ebaugh. Again, uh, UT Houston, sorry, I said U, University of Houston. UT Houston is an excellent program. No problem. Uh, and, uh, I, I do encourage everybody, uh, still with us to shoot you some questions in the Q and A box. Last but not least, uh, we have Dr. Matt Conte, uh, resident of the hospital for special surgery, New York. Uh, and he is going to give us some advice, uh, from a former applicant who's matched into, uh, one of, uh, again, top spots in the country. Uh, we're, you know, gear, gearing the, uh, the discussion again towards his experience and what he thinks is going to be like with this upcoming season with the virtual interviews. Dr. Conte, please. Thank you. So I'm going to just discuss what I think are important when looking at a fellowship and then some, maybe some advice for this year. Um, and so more importantly in my disclosures is that I'm not an expert in foot and ankle fellowships. After all, I only matched one and there are plenty out there. Um, and I have my own biases. Um, but this is kind of, this is like a compilation of the advice that I was given while I was going through the process. So, um, we should just start by talking about what the best foot and ankle fellowship is because everyone wants to go to the best one. But unfortunately, uh, in my experience, there is no best or perfect fellowship. There are simply just a lot of excellent ones out there. And so I want to start with this because when I was going through the process, I kept thinking to myself, okay, as I compare one to the other, which one is the best? And I think I came to the conclusion that there is no one that's the best. There's just the one that was best for me. And also just what does the best mean to you? And so most likely you spent your life trying to get into the best college you could. And then you tried to get into the best medical school that you could. And then you tried to get into the best residency and match the best residency you could. But now there is no best fellowship. So you really have to find the fellowship that fits your goals. And so now it's more of a you're interviewing the fellowships and trying to get a feel for what best fits your goals. And so you have to sit and kind of meditate and ask, you know, what's the right program for me? And close your eyes and imagine, importantly, where do you want to be in 10 years? You know, if you want to be in private practice in 10 years, that may be a different perfect fellowship than someone who wants to be in academics. And maybe if you want to be in a large metropolitan area, that's a different fellowship than in a smaller town. Because in a large metropolitan area, you may need to have a specific niche practice rather than in a smaller town. You may need to be able to do everything. So if you want to be, you know, commonly we always talk about if you want to be the total ankle person in your large metropolitan area, then maybe you definitely need to go to a place that does total ankles in order to make that part of your practice. And very obviously different fellowships are different. So each program has a slightly different culture. Do the attendings get along? How do they treat their fellows? Are they inviting their fellows over for dinner? Is it a very professional relationship? Are there alumni events? Those are things I considered when I was looking into the culture of a program. And a teaching style. Are you just being left in a room on day one because you're running the attending second room? And maybe that's great because you're doing a lot of cases on your own. The same time you're also going to fellowship to learn from someone and see how they do it so that you can apply it to your own practice. So you have to find some kind of balance and decide what you need. And then emphasis and bias. Is the program well-rounded? For example, does MIS really mean maximally invasive surgery to the program rather than minimally invasive surgery? Because no one there does minimally invasive surgery. Do they prefer ankle arthrodesis over total ankles? And I'll say that there are some places out there that the fellows are doing very few total ankles across their fellowship. And so if you want to be the total ankle person in a large metropolitan area, then that's not the fellowship for you. And keep in mind that the biases of your attendings will become your biases. And so after each fellowship interview, I wrote down notes about the different aspects of each program and I kept it in a Google sheet. And I just kept these categories consistent and I listed them here. And so location, attendings, mentorship, OR experience, academic time. Like what type of didactics does the program have? Do you have lectures in the morning? Who's giving the lectures? What kind of research experience do you get? And then like perceived reputation of the program. What do other people in the foot and ankle world think of that program and of those mentors? Overall thoughts I had and feel. And then I just jot it down because you'll forget the call schedule, the rotation schedules, and any additional notes I had. And then there's other factors in fellowship to consider. So like I said, it's no longer about the best fellowship, but what's best for you. So if you have a significant other, what works best for both of you? Or if you have children, what works best for your children? And will your significant other move with you for a year? Or does he or she have a career back home? Do you want a job in a certain part of the country? Maybe you want to apply to programs in that part of the country just to meet people on the fellowship trail. And overall, you want to be happy in fellowship. And so the perfect fellowship is found right here in between what you identify as your professional goals and your personal goals. And so what type of program will get you to accomplish your professional goals? And some of that is what are your areas of weakness? If you went to a program where the attendings were doing a lot of cool things, but maybe you weren't involved in all of those cases. Maybe you want to go to a place where you have a little bit more autonomy in the OR. Conversely, maybe you want to go to a place that has a little bit more research if you want to pursue an academic career, but you went to a program that didn't allow you to do a lot of research. So maybe understanding your weaknesses gives you the best opportunity to figure out what you want to do for a year to accomplish your professional goals. But personally, you also have to decide what's best for you and your family because being miserable for a year, one, isn't worth it. And then two, trying to leave Friday so you can on a Friday because you're five hours away from your family and you want to run and see your kids or significant other for the weekend. Maybe that's not worth it because that takes those five hours commuting back and forth a couple of times a month or 10 hours back and forth is, you know, it takes away from time that you can read for cases or do research. And so, you know, I think you'll be more successful if you're happy. You'll be more motivated to read, prepare for cases and work hard if you're happy. And then just a few last common questions that I think I want to address in this was, how many fellowships should I apply to? Because I didn't really know the answer to these when I was applying last year, but I applied to about eight to 10 is probably the right number for foot and ankle. Obviously, it really depends on subspecialty. And so foot and ankle is, people will tell you that it's less competitive than other subspecialties, which is true. There are definitely more spots than applicants. The thing that I always found really annoying about that was that if you want to go somewhere really badly, there's a limited number of spots that program, but you don't need to apply to like 20 or 30 programs. I think you'll get most people get most of the interviews that where they apply. And I think you start to get tired after seven or eight interviews. I was getting pretty tired. Some advice for virtual interviews. I think it'll be good because it'll save you lots of money traveling around the country is pretty expensive. But obviously downside is you don't get to meet people face to face or see the area. And so, like Pierce was saying, I think you need to try to figure out ways to compensate for that and reach. And if you're in between a few programs towards the end, maybe start reaching out to either the fellows or people that you know that live in that area, or even if you have a chance to visit it just to see the area. I'd start considering now how you're going to set up your room, because it's obviously, it can be a challenge if you're significant others working at home at the same time and you're trying to find a quiet space. So figure out how you're going to navigate that. And then also remember to talk slowly just to give interviewers enough time to interrupt you to actually have a conversation. You know, it's hard over Zoom because it's hard to interrupt someone like you normally would in a conversation. So just make sure you have enough pauses and because you want interviews to be like a really conversational. To prepare for interviews, I would say you just need to spend some time researching the programs beforehand, and at least know who the attendings you're going to be working on, working with are, and what their academic interests are. And, you know, from HSS, right, if you're working, if you're coming here to interview, I would encourage you to know that Dr. Demetriopoulos is one of the most prolific total ankle people in the country. You probably want to know that before you start talking, you know, with him. Or if you want to talk to Dr. Delanne Ellis, that their research interests are like flatfoot. I think if you know that going in, just doing quick couple minutes of researching the attendings and pubmitting them, that's really important. And you can do that the night before. And then during interview day, I would say that for foot and ankle fellowships, they're extremely conversational. People just want to get to know you. But the hardest, and this is true of any interview, the hardest interviews are always the ones where the interviewer asks, OK, I've read your application. What questions do you have for me? So make sure you have lots and lots of questions prepared, because in foot and ankle, that's like the most common first question you'll get is just, you know, what questions do you have? So if anyone has any, if anyone else, if anyone has any questions for me and just wants to reach out to me individually, I know that we're running out of time. Feel free to email me and I'm happy to set up a phone call or shoot you back an email. Thanks very much. Thank you so much, Dr. Conte. In conclusion, I would like to thank all attendees, especially the ones who hang out with us till the end. Please give us your feedback. It's very important for us how we can improve, how next year's webinar can get better. Do claim your CME, just like instructed at the very beginning. I would like to thank all our speakers and members of the Young Physician Committee for donating their time and effort and doing such a great job on these talks. I thank the OFAS, the board and the staff for putting this together and guiding us through the hassle of coordinating all our efforts. And thank you all for, again, a great evening and looking forward to seeing you again. You all have a good evening. Bye bye.

foot and ankle injuries

treatments

RICE

physical therapy

NSAIDs

orthotics

surgical intervention

Achilles tendon

complications

recovery

diagnostic tests

foot and ankle fellowship program