Dr. W. Hodges Davis and Dr. Jeffrey Loveland discuss recent trends in the treatment of neuropathic reconstruction and why early intervention is a key component to a successful reconstruction
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sergeant in North Carolina, Charlotte, as well as Dr Jeff Lublin, founder of Central Tennessee. Foot My Ankle on Sparta, Tennessee, just outside of Nashville. This webinar is really designed thio bring searching together who share a passion for addressing this challenging pathology of neuropathic foot and ankle. With that being said, we encourage you toe. Ask a lot of questions. There's a question section there on your resume panel. Um, encourage you to use that. It's questions like that that make this a great experience for everyone. So just a couple of housekeeping things for resume. If you haven't used it before, everyone's already muted, and cameras are automatically turned off to help minimize background, noise and distraction. Um, there is a Q and A feature. Please use that myself. Chris Robinson, Rhonda Hurst. We'll see. It will pass that along to Dr Davis and Dr Love when we can address those questions as well go through. The presentation on this webinar is being recorded well posted to our Virtual Learning Center shortly shortly after, we'll be sending out a brief survey on we encourage you toe to go through that and give us your feedback. With that, I'll hand it over to Dr Davis. All right, Hunter. Thanks. Uh, this is I love doing things particular type of webinar. And the reason is is that is that I get to see what my my good friend Jeff love lands up up doing and Central Tennessee, which, uh, which is always a challenging endeavor. Um, in addition, um, I really can give you all a kind of an idea of the learning journey that we have been going on together, Jeff. Included in this, um, and and a number of others who have decided that that we're doing too many amputations and is there a way we can help these folks? And tonight, I hope that you're going to come away with with a good, solid core of information that will give you a case for early intervention. And I'll take you through that as we go through. And then Jeff's gonna come strong with some of his amazing cases, and and I'm gonna give you just a snapshot of of the things that we have learned. Um, as we started this journey, Thio create a franchise around complications of neuropathic lower extremities. Um, So, uh, I'm not just a consultant of right. I'm a nem ploy. But I'm also a practicing, um, orthopedic surgeon. So I kind of put this together thinking. And what do we already know? Okay, so we know that shark oh is bad, and it's hard to predict. We know amputations can be fatal. We know that the toolbox we have available today is vastly improved from the toolbox that we had even five years ago. And I can promise you that we have learned so many lessons as we've learned to use and take advantage of these unique and transformative products. And then finally, I'll make a case for early intervention on. Hopefully, you'll feel the same way that that that we do after seeing some of these patients go bad. So the first is shark. It was bad. And, like Colin Powell says, bad news isn't wine. It's it that it doesn't improve with age and shark Oh, definitely doesn't. And shark owed, by definition, is progressive non infections, destructive arthroscopy with patients with sensory neuropathy. So this patient showed up here and two months later was here, so it could be a devastating change. It's been linked to many diseases and that's really, really important. But all these diseases can be associated with peripheral neuropathy, diabetes being the most common and it was described by William Reilly, Jordan in 1936 and diabetes. So syphilis, alcoholism, leprosy, congenital insensitivity for pain or what my patients call. I got a family history of neuropathy and then rheumatoid arthritis, which Mawr and Mawr is becoming something that I see in my practice. Diabetes is the leading cause. It's increasing. It's a massive, um, cost in the United States in 2012, 245 billion. And most of that is around complications of the lower extremity. You need three things to have shark. Oh, disease. I'm not going to go through all of the potential, um, reasons why we have shark. Oh, but you need three things. You need neuropathy. You need vascular. Aren t This is a hyper vascular problem and you need some kind of injury. So if you place that with trauma and other things, you can see that if you've got neuropathy and vascular garrity and get an ankle fracture than buyer beware. Um I can holds described radiographic and a natural history changes in the fourth stage was added. This is the stage zero swollen warm with normal X rays, but the memories abnormal and that's super important. It's different than infection because elevation decreases the swelling and there no systemic symptoms. Stage one is fragmentation warm, swollen red foot with osteopenia and the beginning of fragmentation, and stage two is coalitions would decrease swelling, redness, and you can see that the bone is kind of filling in. Stage three is reconstruction, meaning the bone starts looking fairly normal and even askew. Penick. Um, but it can leave you with a significantly unstable situation and set you up for this, which is instability, and the location can change the reality of instability very quickly. The most stable is the 4 ft in the mid foot show Parts joint can be more unstable. Hind foot and the ankle is the least stable. And so you have to really start thinking about early invention when you have any of these, but in particular in the hind foot in the ankle. So what happens? Progressive deformity, balance problems, alteration, secondary deep sepsis and then finally, amputation. So why do we care? And it's my belief and and the the literature really points us out. That amputation could be deadly, and my carding said he wants at his toes amputated so he could stand closer to the bar. And I think some of our patients feel that way. In many surgical service search circles, amputation is the standard for diabetic neuropathic deformity. If they've got a deformity, they're going to get a amputation. And the regional variations in the United States are astounding. How many patients come in from far away, and the Onley thing they've been offered is an amputation in some things, amputation to be viewed as a reconstructive option in non diabetics? Maybe, But in diabetics, it's really a Dessens. Here is a in hospital complications. Looking at mortality has shown that the 30 day mortality rates in patients who have had a major amputation is up to 18%. They die early, and it can be a bad as a malignancy in the university. Setting mortality after an amputation is comparable to a patient with systemic malignant disease with medium survival rates that 40 to 55 months after the first amputation. So it's just different After amputation, there's a 36% mortality rate in three years in a 66% mortality rate within five years. So this is a deadly disease that is challenging the majority. Morbidly obese difficulty with non weight bearing casting can be massively dangerous in these patients, in particular, if they're they're an unstable type. Medical co morbidity is make that even more difficult. The potential for healing is down, and they're already immuno compromised. But what about the better tool box? And that is really what the salvation system is. When we set out to do this, we're going to say we're going to design a group of implants that are designed strong enough and good enough to take care of these different patient populations. And the first group is the beams and the bolts. The beams are Kanye lated, the bolts air solid. These air super strong and and can be super long. And so we have 5065 and 70 and in both parsley and fully threaded. Um, the bolts have a solid core, and they're and they're strong, but the beams are also strong. Plating system is strong, sometimes too thick, but often could get you out of trouble when you have problem reducing these folks. And then what about the mid foot nail? It's Kanye lated. It's bigger, and it's really designed for the medial, Um, column, which is the most important thing in these patients. And here you can see the mid foot nail down the medial column, and it's significantly stronger almost four times stronger than the 70 beam and almost three times stronger than the 65 bulk. It also can provide control compression, which can take up the slack when you're going across multiple joints and then finally, is the external fixer to frame. This is a simple frame to do. It is stable and it's comprehensive. It does everything you need in this patient population, and this is the frame construct that I use in most of my diabetics. So I like to say that don't be stupid like us, but this is really the lesson learned segments. What have we learned to avoid and what have we learned to do? Well, the first is you've got to deal with the soft tissues if they have an Achilles contractor, even if you have to cut the Achilles completely, you have to take care of that. If they have answer tib laxity, you have to tighten. If they have a poster tip contracture pulling them into into various, you've got to deal with it. And if they have an Achilles contracture, either plan reflecting them or in various or even in Val Ghous, you've got to deal with it 1st. 2nd thing we learned is you've got to prepare the tail in the vehicle a joint. So here's a patient with an unstable mid foot and we did a media column, bolts and beams, and we did not prepare the tail. And Michael join because he said, the tail and Michael joints not unstable. Well, that's where they break because there is still significant motion at the T. Enjoy. You've got to prepare all the joints when you add a sub Taylor fusion. In my opinion, it's with sub Taylor deformity. It's shark oh, extending near the trans first Arsal joint. If the navicular is involved in my patients, they're getting a triple our through DCIS and in revisions. So here's one that I missed a 40 year old type one diabetic presents with increasing pain. We tried everything to get him to not have surgery. We did just the medial column. I learned a lot of lessons on this one. Did nothing to his sub, Teyla John. And look, he continues to collapse. Two years later, he's having swelling and pain. Now I'm trying to figure out what to do and what happens. But he shows up and his tailor's disappears. The instability in the sub Taylor joint, as well as the stresses on the Taylors, made the Taylors go into re shark. Oh, and so this is what he looked like when he finally came in and someone had taken his hardware out, and I ended up having to do an external fix it or on him to to salvage his leg. Sub Taylor. The closer you get to the hind foot so you can see here recurring mid foot ulcer unique playing her deformity. Fairly straightforward. But this is one that I did the sub Taylor joint, and I even added a plate because of the instability. And this patient did well and did well. Soon you cannot do an isolated media column fusion. You need more than that. You have to do something to the lateral column, and that is what was described in this this study in 2014 that showed that on Leah medial column Bolt is not enough. You've got to do more than that. And so because of that, you can't leave the Cuba or drop, you're gonna have to do something to the lateral column and maybe something to the sub Taylor joining this because I clearly didn't and left the Q board to droop. And it did. And I have to go back and do something to the Q boy because the lateral column was unstable. If they continue to be unstable when you fix them, you need to add a frame. So this is a patient, hopefully would have never let it get this bad, but you can see how horrible this this deformity is. And once I got the triple done, his ankle was so unstable that I added a frame. And these hybrid frames can save you a lot because the patient could put more weight on it. You can manage the wounds, and you can lock in your deformity correction for three months, and they tend to do better. Active ulcers could be a problem be where the patient with an active ulcer in those patients. Consider external fixer fix it or Dane Walked, which described his comparison with without wounds. And he found that the presence of a shark related wound increase the likelihood of a major amputation by six times. We found that in our Siri's with beams and bolts. Also so respect and active ulcer. What about the case? For early mention, Max Baer, who fought Joe Louis, said. I defined fear is standing across the ring from Joe Lewis and knowing he wants to go home early and sometimes with shark. Oh, that's exactly what's going on. Um, but the bottom line is this. I can't believe there was nothing that should have been done between here and here, and we watched this. This is one of my patients, and we watched it and kept putting them in a cast, and at some point we should have intervened, and that is the problem. So what has changed? What's changed is the implants, in our understanding of the dynamics of shark oh, have changed. Second, Emery can pick up stage zero disease so we can pick these patients up earlier. Finally, there fewer really good cast checks out there. And so a true total contact casts early in the process is harder to get in today's market. So Dane did a great job in this study of 2011, talking about the consequences of complacency. Manage the effects of recognized Charco. And he compared compared grade zero shark. Oh, that was treated early in grade zero charco. That was missed. And he found that if you diagnosed him early or mobilized them, whether it was an external fixer or cast versus the delay, the delay had a massive complication rate. And so when X rays show progression, we need to consider intervention. Or at very least we need to see him once a week if they continue to go bad. And so that's what this study shows. So what about how does it work? So this is a group that in 2000 started saying, Well, why not just treat them all early 14 patients? I can hold stage one fusion at presentation, and once they were done, they were all fused and in shoes. So waiting and casting may be the worst thing to do, and this may be throwing you under the bus, and I've got so many examples of this that it's scary of how many times I've missed this 54 year old deformity. No ulcer, insulin dependent history of a to a second toe and he's already deforming. He's got a drooped shark. Oh, I mean, he's got a Drew que boy. Now, two years later, he's now got a planner ulcer. He's in full blown Septus sepsis, and he ends up losing his leg. What about this 50 year old with diabetes with multiple foot infections? And basically all they did was treat the infection. But no one ever treated this guy's shark. Oh, and so now he's stuck with this. He has recently well controlled diabetes, but But this is what he's got, which is not good and not conducive at some point, should someone have treated the instability? So the scenarios that I consider early intervention to be a no brainer or trauma with definitive neuropathy, grade one hind foot instability or ankle instability that's I can holds Grade one ulcers healed, but the deformity relaying remains, and all Grade one shark Omid foot, I will watch them weekly, and if they start to do for my will, fix them then. So what about trauma in the mid foot? So this is a gal who had had a horrible Star Co with infection, and I did a did a TiVo calculate infusion and and she did well. So 16 months after the Fusion, she had a trip and fall. I got a call from the emergency room and I said, Oh my God, she's broken her tibia. But in fact, they sent me the picture and I'm going No, I'm good. She's great, No problem. But her left foot is the problem, and she's got a list. Frank's fracture on the left side. This is someone that I know is a brittle diabetic, and I also know that has profound your apathy and could go bad quick. A week later, she's already getting worse deformity. And so this is someone that I felt we need to go early, and we did. What we were able to do is is small incision to take down the joint. We put a little biologics in and then waded beams across the list Franks and she fused, and she's still walking and then shoe with this with this foot 61 year old outside facility. I had done a TiVo Taylor cockatiel fusion on her other side because of neuropathy. No one asked her whether she had neuropathy. No one looked at her other side. So they did this, which is entirely inadequate for a patient with with significant neuropathy. She casted close manipulation. Nothing helped. At four months, things were not going well. And so we discussed fusion. But I figured, you know, I can treat this. And this is what she looked like after I fixed the deltoid and used a million, um, screws across the senators. Most cysts. Well, you know where this is going, and it didn't work. She never healed her fibula. And at six months post initial injury, she had a fusion in this lady. Now I would treat it with the primary Arthur dcis. She has the history on the other side. Why not? What about progressive hind foot instability? So this is a patient. Some of the one I showed before, but only 32 years old, well controlled. She feels unstable, and this hind foot is going bad. This is a patient that need to be fixed early. And one month later, she was not. And now this is almost un reconstruct. Able to save her, tell us she ended up with the tibia, calculate infusion with a frame. And this is what she looked like it five months very short. And she lost her job because she couldn't be on her feet. What about the ulcer? Healed in the former. He remains 67 year old with a history of an ulcer. She was healed with offloading. But look at this deformity. There is no way that this ulcer is going to stay healed. And so So I fixed her and ultimately, she was able to get into a shoe because of that. So what about grade one? Short code? This is a common tale even in our facility. When we have surgeons to take care of this 48 year old diabetic history of multiple infection presents the ER with a mid foot ulcer and APS test. Alright, this guy already has an unstable situation. And so what was done? They treated his ulcer in this absent and send him back out. Well, of course, you know what's gonna happen? The Q boards on the ground and by the time he comes in after three or four hospital admissions. Que Boyd is gone. He has a minimal medial column, and now he hasn't almost un reconstruct herbal foot and has the bad sign of a wound vacuum on. So you know that nothing good has happened in here. I ended up doing media column fusion on him. Um, but he still is not where I would want him to be. So the conclusion is, early diagnosis is the key. We need treatment algorithms that define when early surgery is just better. Right now, there's so much and and those of us to do a lot of this kind of work, there's kind of a gestalt that we know this is gonna go bad and we'll see patients. I'll see patients every four or five days. Um, multi center trial may be necessary. Um, and it probably needs to be prospective, which is gonna be challenging because of the variety of ways thes patients progress. It is my belief that this is a pandemic, and the time is now to take take this on and to not be scared to take care of these patients when they come in because they need our care, and they need our help because an amputation can often be the final nail in the coffin. All right, Jeff. Okay. Yeah. I told you I was gonna finish in 20 minutes. We did. Can you see that screen or is that not on the Not yet. I just clicked on here always saying, but that work now, is it? Is it up on your screen? You have to bring it up and then push screenshot headed up here. Let's do this there. Yeah, There. You see it now. There you go. Yeah. Okay. Well, thank you, Hodges. There. That was well informed of going over some of stuff we've learned over the last, what, four or five years we've been doing these, uh, these seminars around the country and, uh, just like yourself. I see a bunch of these, uh, cases, and we're kind of a big referral center for a lot of the people around. Uh, actually whole state of Tennessee. I see him from all different parts of our whole state. Yeah. I can't agree with you even mawr with how these need to be sent to a little bit sooner and actually intervene a lot sooner on some of these patients, and we're starting to see that a little bit more and more. I rather try to have some bones that work with without versus not have any bones to work with on these patients. And that's why I try and get to some of the referring doctors who sent him over and try to get some over quicker than later. So we got some cases we go through over here, and then, uh, we may have some time for some questions. Here's a patient that came their office not too long ago. 58 year old diabetic You said her left foot was red and swollen for about two weeks. She actually saw a colleague of mine, and, uh, he took an extra this lady's foot and send me some pictures. Is this something we can fix that we need a weight on this and I'll show you the extra in a second? The biggest thing is she had some heart stents place about three months ago, so it's always a nice, challenging patient. So you see the same picture both feet, once kind of red and swollen on the left side and the right side does not look too bad. Here's the extra is he sends me over here. You can see it's a Lisfranc fracture. Dislocation on. Do you know before by 5 to 10 years ago we would not sit here and fix this? We've cast it constantly. How they dio. Well, it's been about my time. She gets and sees me. This about 34 weeks out. Now I said, Well, why don't we talk about trying to fix this? She goes on to tell me that she's got some good insurance, but she may be losing her job, and we're able to kind of get underneath the wire to get her into surgery to try to get this thing salvage for her. Because once she loses her insurance, it's not gonna be a very, uh yeah economic situation, a good economic situation for her. So when we when we prepared the whole entire meal column, and this is when we're using a mid foot nail when it when it came out, help stabilize it for this patient. So we prepared the t n, the N C. And the first start, some of the torso joints. We make a decision of the first, uh, metatarsal Fallon Joint Place the guy wear down the middle. Calm ferocity. Make sure it's in a good spot. We did a drill, and here's the mid foot nail that we were talking about that Dr Davis showed Already. We put on a little jig, and we actually place all way down the media column. It screws out into the tail list. Then we put the interlocking screw in, and there's internal compression device that actually compresses the whole media column together. Like you said earlier, it's very easy to kind of compressed multiple joints on. This area spanned this whole area, but the biggest take home on this is preparing these joints and put some biologics in there at the same time. We put a clamp on over. The second metatarsal kind of reduced it from the second to the first and whatever. We just ended up putting a small but played over top of her to help stabilize the second TMT, and we put in extra fixate er on her at the time. A lot of these cases I do I do in two stages. Um, it's just easier for aware. Hospital works also I think you don't put these these people's feet in shock and cause all these different, uh, wounded pistons or a lot of swelling along these lines. And so we'll do the entire middle column reconstruction first and then sometimes I'll come back and add a sub Taylor joint fusion, uh, halfway through or when we take off the external fix later. This is her 12 months. We end up doing a a subtitle, Refuge and Took the Frame Off and did a lot of call infusion for her. Um, she's gone on to do quite well. She's walking into crow bitch. She's very happy with this foot. The swellings all gone, gone down. She's able to walk around, do and do a lot of her things that she was unable to do before. We also did a killing me standing lengthen on her, just like Dr Davis was talking about. A lot of these. You have to do either a aggressive TL or a A complete killers to not be tried to reduce that Qantas from there. Gastric recessions just do not work for these patients. They usually comes back and we could see we got married. His ankle pretty close to being zero out here and no wounds. No Mork, you boy. Drop nice toe stability in the mid foot and she's walking around quite well. Here's our patient. This is kind of more a more recent one. This is right as cove it was hitting in our area is a 47 year old white male. He actually interesting her pop last six days earlier from seeing me. Brazil is a red swollen, painful left foot. He actually drove about six hours. Come see me from a doctor Heard about us. The unfortunate part is his left foot looks like that and his right foot. He has a dislocated navicular kind of more door slee. And so I said, Unfortunately, can't do both things at one time try to get around So we're trying to pay the worst one first. As you can see, the medial cuneiform is almost completely dislocated from where it's located, that you can see the whole Lisfranc fracture dislocations going lightly on here. So e, I think I saw him on Thursday or we got in the operating room on Friday because all the skin tenting along that middle column So we don't want to have a new wounded develop or cause a more problems for him. So we ain't doing this two stage approach. Um, trying to get that Canada form back in is not the easiest thing for this. We're able to distract out the whole first Ray. It was able to private medial cuneiform back in. We talked about possibly taking it out, but unfortunately, such a large space that was there and try to make a, uh across and shortened from that much was, I don't think in his best interest. So we did is we went in there and put it back in place way put some biologics around. Both sides of that may afford to try to get some healing across there. We put in extra on fixed later on to let this foot calm down and try to reduce a lot of swelling. I don't think that at the time of these that you should put a lot of hardware inside of there in that mistake before in the past, where we done plates and screws or some of these beams and bolts and everything just kind of fell apart on us. So these we just end up letting us calm down for about six or eight weeks and then come back and do all the internal fixation for the defendant for the definitive hard replacement. So this is where we put the experts on. Unfortunately, we lost a little bit of reduction on the list, Frank side laterally. But we're able to bring it back on the next lap when I show you what we did. The defendant fixation. Well, line back up. My biggest thing was get that video calling back where it needs to sit out because we're gonna build everything off the meal column. So after stabilizing that, we brought him back, probably about eight weeks later, when we open back up to be able to do some cases, we put a mid foot nail all the way down the middle column there for us and prepared the entire column. And then I took a A nausea Tom. Kind of curved acetone went along the base of the metatarsals, starting from the lateral side. 5432 in just kind of took a chunk of bone and broke a bowl of scar tissue and play a large clamp around the 1st and 2nd metatarsal to kind of swing this back in place once we got swung back in place. Okay, how do we fix this? So then something a little bit unusual on this one. We ended up taking some screws down the base between four and five and three and four on the metatarsals. Someone always back into the Cal, Kanye's. And once we did that were able to lock this the whole little column up for us. I did prepare a little bit at C C joint. And then, um, we also added a sub taylor fusion with him and also actually at another screw down the middle column just to try to help prevent any further breakdown on this patient. Main reason is, is, could we have to do is other, um, foot in a couple of months over here before he loses before he gets out of his deductible for the end of the year. So this is him. This is kind of final construct. That's more of Ah, what we call kind of triangulation toe lock up this hind foot in mid foot over here for him to give him best chance to keep his his limb on. There's another patient, um, 50 year old diabetic, unstable fifth, about three or four months. She was seen by one of our referring providers. He had put her in a cam boot and then said, Well, these X rays don't look too good. Let's go and see this guy eso as you can see, unfortunately, the vehicle is kind of popped out. The whole Medford's kind of sit on top of that in the vehicular and the tailors is kind of pointing down along with that calculus and the Qantas contracting over here. So you started getting kind of a pre also the lesion immediately and also plant early, kind of without navicular is and also what a cute boy is that, um, and for this poor lady would try to try to interview real quickly for her. So she did not cause the wound and have more problems on the line. End up doing a kind of a mid foot off Salome Did a tailor autonomy cut. The Taylor head off, cut across the mid foot, was able to reduce them back into a better position. We put a extra fixated on kind of compressed this all together at first, and then when we took the extra fixate er off, we're able to put some beams and bolts across there, and here's her 18 months post up. She's walking back into a pair of shoes. She transitioned from a crow boot to a double up Bryce in and down into her normal extra depth shoes. This is when we had the beams and bolts, and this one went very well for this patient. She a lot of other medical co morbidity is that unfortunately, had to try to get a walking. Soon We can and she's She's done quite well. Um mhm. So there's kind of a patient of when people, uh, didn't do a surgery early, but unfortunately, I think they chose the wrong surgery. Today there's a 62 year old is diabetic. When neuropathy had a previous O. R after listening fracture dislocation about a year earlier, um, it went to a different facility outside of Nashville. Uh, they did a good job of reducing everything they put unfortunately, bunch of I think under power hardware and, uh, some small screws across this, and you can't treat these like a normal list ring fracture dislocation on a normal, healthy patient. You know, unfortunately, he said that first when he started walking on this thing, it just didn't feel right. Unfortunately to see all the loosens sitting around the hardware of the hard work broken and this foot starting to collapse on there for him, probably if you're able to do this the very first time around for you extend this and do an entire meal call infusion. You probably got away with some of the hardware. Unfortunately, it started breaking part and, uh, with his pain. Now we have to revise this. So I took him to the operating room after about 45 minutes to an hour, getting all the hardware out, making multiple decisions, were able to kind of prepare along the entire video column. So we're gonna extend this and extend this all way down to the, uh, vehicular cuneiform joint. Be prepared all those joints. Let the one broken screen the 3rd. 30 Mt. Just because we could not get out. I actually used the jig from the list. Franking statute. Kinda compressed this together, realign everything for us, and then we pinned it in the radio, put one of Salvation plates on there. That's one of the big thick plates, and we put the multiple screws across the entire mid foot. Uh, we live in National over here, and I 40 is a nightmare for the for coming into Nashville. So we kind of call this the I 40 a traffic jam over here. This guy went on to hell. Hey, he did well, we did a CT scan about 12 weeks along, you know, appealing everything. He's back in shoes and walking around. Andi said from day one he felt this was gonna be a lot better outcome for him. So here's him 12 months out doing doing well, walking pair of shoes and back to the things he likes to dio this one were able get away without having to do a sub Taylor fusion for him. Because I think all the form of just in the in the Tarso metatarsal joints. So that's that's some of the mid foot cases. Here's ah, we're kind of getting the hind foot stuff. Here's an ankle fracture or diabetic patient that was initially treated by close reduction, and you look at the film's see It's a distal tibia fracture well aligned on their, you know, 10, 15 years ago, when we're training residency, you say Okay, just put this in Castle. Watch it. Well, unfortunately, think today. That's the That's the exact wrong thing to do for this patient. So you could see you could see where is my, uh, non displaced at the moment. This is his X rays over the next 36 and 10 weeks, where this entire thing to shark goes out, falls apart and get a severe deformity. It's unbreakable. Now, trying to reconstruct that is a very big challenge for these patients. When before you could have put a nail up through there and consider doing a possible ankle fusion. Or do a extra fix their help hold, hold stable or even do some kind of combination plates, plates and internal fixation. Help hold this thing. Place an external fixation. Hold us together So there's one of our patients. 48 year old white male with peripheral neuropathy, is not diabetic. Unstable, painful angle for about the last three months. Denies any injury to sites, but he thinks he's unable. He's unable to wear shoes because all the swollen his ankle he's also developed a wound on the lighter side of fibula that's been there for about six months now, or six weeks now. Uh, the kicker part of this is this unfortunate. This guy does not have insurance, but he wants to try to salvage his his limb. So these air X rays it brings in this evening and we kind of start looking this and go well. This is probably should be treated almost as acute ankle fracture or an ankle dislocation. You can see the calculus, a certain kind of spit outpost, eerily that Taylor's just does not look very healthy and the whole ankle joints just becoming unstable. Well, wow, hospital over here, there to get him into the facility without insurance, and I felt the paperwork out. So I said, We'll put you in a soft cast kind of see how this thing go. Stay off that, fill out the paperwork and get the ball rolling for him. He comes back in. Two weeks ago, paperwork filled out, filled out, and you look at here is the new extras we took. The entire Taylor's has broken apart. The Cal Cane uses certain kind of spit post eerily the ankles has become grossly unstable. He was able to get approved Thio from the hospital to have the surgery, so he took him the operator. About a week later, we made it stays over over the fibula laterally. The tail is kind of just fell out because there's really not much holding together. We cut the fill it out and also did a chance for cut on the tibia, that kind of doctor tibia into the Cal Kania and prepared to Cal Kanye's for Taylor calculate tibial calcula fusion. So here's a picture of a chance for cut Reposition this. We put some biologics in there to help get this thing to hell, and we put a next time fixating on because he had the wound on the lighter side of fibula. On that we were able to excise the entire fibula, which we felt that that got rid of all the infection. The table look quite nice. We bone graft it. A couple of, uh, Stein pins off. Hold this thing and then put in extra fixated on it. Compress them over the next several months. This is him with excellent fix. Later on, he did quite well I got a little swallow along the area, but we read the X fix up. Five months. You can show it's nice and stable. Nicely healed. This is him at about 18 months. Um, he's in a walking boot and and went into a double up embrace, doing well getting around. Unfortunately, he gained a bunch of weight during all this. He's got his diabetes under control. He's back swimming and doing some lucky exercises with this, uh, nice fusion for him. So we're able to salvage his limbs since he's such a young person. Here's another one. A 68 year old diabetic, their our path, the pace and got trapped underneath the tractor. Here in our town, I went to the ER. He was placed into a camp but was told he could walk on the foot in his boot. Um, when you look at the X rays, he shows it's a kind of a non displaced try male ankle fracture. Unfortunately, with him being a neuropathic, this is something that concerns us. So I think you need to watch this kind of closely, and I probably wouldn't let this guy walk. He happens to be uncle of one of one of our staff members. And so he did not come see me first. Um, he went to the doctor's office About a week later, I was placed into a castle, this x ray taken, and the doctor told him, It's not too bad you're diabetic. We don't We don't work on these people. Too much is let let this hell, you'll be fine. And unfortunately, he goes, I gotta be able to start walking on this thing. This this is just start hurting. Start to swell. Comes back to the doctor about six weeks later. And this is extras he had. And at that point, he was told the injury is not too bad, just a little bit displaced, and we think we could just keep on cast them. He didn't like the ideas, but they came and saw us. These X rays he brought with me that same day and I'm saying you're looking to go. That's not a little displaced fracture. We have a problem now if we don't need it. If we don't start to intervene with this, we're gonna have a challenge down the line. Impossible. Limbaugh's. So then a CT scans that little fracture turned into a kind of a large pylon fracture where you can see the distal tibia. Is this pulverized post Every part of the tibia is is gone. And so at this point, we chose to do a, uh, an ankle Arthur dcis on him to try to salvage this for him. We put in, I am nail up. We prepared and took down the fibula and took down the ankle joint and put the nail and put an extra fix there on top of it, which is what I do for all these, uh, ankle fusions with I am nails on these diabetic or neuropathic patients just to kind of off load this and take some pressure off of this because they do bear some way they can. They can move around with it better. He was healing quite nicely. So about 11 weeks we did a CT scan that showed about 85% of fusion along the ankle joints and at that point were able to remove the external fix later, about a week and a half later. So this isn't about six weeks out there. His original injury and remove electron fixed later. He's back and walking. He's back doing all his chores on the on the farm and get back on the tractor and haven't had a good time again. He's very thankful, thankful were able to salvage his limb form. Here's another one of our patients in the hind foot. 63 year old diabetic neuropathic patient had a previous over half in about three months earlier, Um, it was done by one my orthopedic colleagues in the area. He was doing quite well, and for some reason he decided to move the hardware. I don't know if it was because it bothered him on a lot of side of fibula or what was going on there, but he removed. Move the hardware about a week later, complaining about a pain swelling. It was unable to bear weight on this on. I got sent these extras. You can kind of see the tail. It's starting to kind of skirt literally, uh, this and this most of the starting to open up and and I think he's having a shark event over here, And he goes, I gotta do something about this. I can't I can't deal with this. Can't deal this swell anymore. So he talked to him about doing an ankle fusion for him to try to help stab stabilize this. He did not want ankle fusion. He's very adamant on that. So I said, Well, we can try something else for you. So we're trying. When we went in and did a tip fits in his most this fusion and we put a plate down there and we put a million, uh, Sunday's mocks Cruz Crestor. There's actually eight of them, But what I added was an external fixate. Er, try to help stay out, help him stay off of this. And he wanted to do very well with this. I'd like the one the doctor Davis showed earlier, where he puts into these monsters and fell apart. I think the frame is what helped him on this side to help stabilize this. And this one went down, took the X fix off about three months. He was able to do well, This is him. He's actually one of the drivers that brings all the patients, her office, the many rides, and so he was back doing what he likes to do, and we're going to salvage his leg and actually save him from heaven. They either an amputation or an ankle fusion for himself. So it's all the cases we have there to kind of show you guys. Yeah, I have a couple of questions. Way Had a question. Do you routinely get CTS on your fusions before you take the frame off or even before you let him go into embrace or shoe? Yes. I actually started doing that a lot more here recently. Especially all our hind foot and ankle fusions. Uh, those get CT scans on all those patients just because I wanna make sure we actually get a fusion on here. Because if not, you're going down a bad road. I think that's the thing that you're doing now to you've been doing a lot of C T scans on those spaces. Yeah, way have for a while. Um, and, you know, sometimes it's hard with the ex fix to read them. Eso I really try toe put my most distal tibial um, my most distal tibial ring a little less close to the ankle if I'm concerned about the ankle so that I could read the C t. Yeah, we try to keep that spaced out quite well for a lot of people, especially for using those nails. That's why I use some of those struts from the Salvation set and put the long ones on there, especially. It was like 152 100 millimeter net now, and it gives us a lot of space, and you will see those things. Yeah. Um what What about if you if you've got Mitt Tar Sula transfers, Carcelle, um, and you've got that plan our old that big planner. Also, this is a question that just came in. Um, do you intentionally try to shorten the foot in order to get that ulcer healed and, uh, X fixer in fixing those, Uh, I think we're pretty much we're pretty much shorten all these feet up now, if if we can, If there's an issue through their make a some type of osteo me take a wedge out and a lot of times you could close that alteration if you need to. If it's clean down the area, um, actually, now everything is within alterations. The next fix only at first until you prove me wrong on there. Now, if it heals up and you know six weeks or so when next fixes on, we're doing good. Sometimes I will go back and put some internal hardware inside just to kind of make them feel a little more warm, warm and fuzzy inside. Yeah, so I mean, I have to say you've you've really pushed this hybrid frame Thought for me for a long time. I started with with just, um hind foot nails, tibial taylor, cal Caneel fusions and then putting the frame over the top. But now I I really do think that, uh, the idea of mixing and matching but using external fixtures as kind of the final, um, the final bow on the present. Onda and Aziz, Much of my patients don't love and external fix it. Er I absolutely know that my results are better. Yeah, I can I can tell you that unequivocally there was a period of time where I could only use in fixed in the hospital would not let you use um x fixes in that time Friday. I think I think that about six of them and 3 to 6 fell apart relatively quickly. And I said that point I was about five years ago There's no way we're doing. You get a combination of both. That's only way I'll do these things now. Okay, Um, questions saying, Are we suggesting that in the shark, a patient with diabetes stage one so early fragmentation, um, that, you know, is has an unstable picture to it. Um, will you fix those in stage one? Do internal fixation before an ulcer, And then they had an ex fixing those, so I actually, that's a good question. We just did one yesterday and a lady who had a medial cuneiform that fell apart. Um, the C T scan did not pick it up Interesting until we got into the O. R. So a lot of those, yes, we will fix those, but I use a lot of those that that's kind of more of a hot stage. One is just X fix. Only because I've been burned before. When you try to do all this fancy, uh, internal hardware and prepared these joints, everything just disintegrates and falls apart on you. So I think a lot of those if you can calm those down with the next fix for six or eight weeks, and if you want to go back and put the internal fixation in to kind of help you out or take the X fix off and then do your internal stuff Have no problem with that. Um, with a lot of these with these alterations, they're kind of starting out. We like to prevent from the alteration starting. Try to get to these things sooner than later. Um, so here's a question. What do you do later in the later stage, in the presence of an all star infection? How do you stage when infected with an ulcer and shark? Oh, do you? Do you just do it one stage and and treat him the whole time with external Fix it, er, or do you get the infection under control without an external fix there? Or do you get the infection under control with an extra on, fix it there and then come back and do internal fixation? I think I do more of accommodation. Let's let's go in there, Excise. What we think is the infected bone excites the entire alteration out of that area. It's gonna be unstable that point. So that's why we have put next six on treated, You know, if you need IVF box for six weeks. Eight weeks. We got put beads in there, whatever your dealer's choice of that is, and then come back and some of those they start healing and they do very well in a CT scan. Looks good. I don't go put in fixing it. Just leave me alone and let him, uh, coalesced themselves. Okay, Uh, I just just a real quick question on on biologics. And we've talked about this a lot over the years. Um, what is your routine that you use for biologics? Do you put a will you put another incision on a diabetic to get autograph? What do you What do you think? Works the best in the diabetics? Well, I mean, we definitely use some type of biologics to help stimulate this process for them a Z you know, we have a paper that should be getting published here pretty soon. Between the three of us we have, it's a 223 different joints. So we looked at in 98 patients. We had a 97% success rate of fusion on these, But the six non unions we had they were using augment. That's correct. And the six non unions we had were all in the ankle joint, which, unfortunately, is a different animal every time we're talking about ankle joint fusions and trying to sell these patients. But I think you need some type of biologics help stimulate this process and allow these things to hell for you. Um, I don't I don't really see clearly you get autographs or higher up. I don't do that. Um, it's unfortunately out of our school of practice in our state and don't have anybody will come in on that day, but a lot, all of ours, this augment we place in there. Yeah. You know, argument has shown through the long term studies that it will stimulate patients that have not as good stem cells like people over 60 like may. And and that's been proven. Um, I get the feeling that diabetics of the same thing you've never seen Augmon make make the hyper vascular ity worse. No, I have not. That was one of concerns. I think Pincer was talking about one time was he was worried about to make the hyper vast clarity, and these bones will just get so washed out, just fall apart. I have not seen that. Okay, next question is how much metal is too much is the question Will the body of a patient reject the metal if you put too much metal in it And, uh, because I know you're you're of the mode that if you if you think you're done, but one mawr so one more screw. Yeah, I guess you can see some those ones we did. There's a lot of hardware inside there. I kind of feel that the belt and suspenders for these patients And the reason why I feel that is we had a guy here not too long ago. I'll show him in. One of our revision talks is I did a whole nice shark Oatmeal column sub Taylor fusion, but even put down a boat down his 2nd and 3rd race. Just hold everything together. His middle column fell apart in the vehicle, just disappeared on us. And when I went in there to revise it, the only thing holding together was the big the bolt down the second ray from completely collapsing long. The whole Taylor, the vehicular joint. So I think there you can if you can fit the hardware in there, I don't think it's a problem. Just beware of some of the things you're using. We're putting these mid foot nails in. There's only so much room left in the Tailors. And so when I do the meal calm, I don't do the subject at the same time, because I think we're asking too much of that. Taylor's I don't do not want to fall apart. Does that make sense on that? But you're kind of, but you'll you'll add a next fix and then come back and do it right. So you protect the tailors with the next best? Exactly. I think that's working out quite well because we're gonna have a series of those patients, and it's done very well. We have not had the disappearing Taylor's on those lines. I'm always impressed for Ohio State Big 10 guy. How how quickly you learn. That's very impressive. Um, alright. Another question. Jeff Incision alot approaches for bolts and beams across the med foot. Are you doing joint prep to C C T N sub Taylor joint or just spanning the deformities? So the meal column I'm using making a decision is not our big, full thickness incision like we used to for these place because I used to be a big plate guy. So we'll try and make some smaller incisions over those joints. Prepare. I You have to prepare the entire media column to make this thing work for us. So you gotta You gotta be able to get all the joint cartilage out or what's remained out of there. My subject, er joint I do to go in there, I do scrape by the poster and middle Fiset, um, and try Thio drill as much as we can to prepare that and get that spot Weld or a nice poster and medial for set fusion the C C. I don't see that as much. I think that's more of a stabilization. So most of my ccs I don't fuse. I don't go on prep those unless I really think we have Thio. Yeah, unless unless there step Yeah, I mean, my feeling that the C C is if I can get it up, if I could get the q buoyed up. But if I can't, then I'm gonna have to stick a saw in there, or Burr and and then you're gonna almost doing Asiata me to get it together. Moving. Yeah. I think the biggest thing is trying to that triangle. You know that the sub Taylor screw the middle column screw. And something that will let our column It's more of a triangle. Yeah. Yeah, well, it looks like a triangle. Um, it's kind of interesting how you know, we we used to spend a lot of time getting the beams in the lesser metatarsals and now are feeling if we get a great media column stabilization with the mid foot nail a sub taylor and then something one or two across the lateral column thin that that tends to be enough. Where you need the fusion is the medial column. Yeah, I agree with you. I think that the the invention of the mid foot nail or some type of large device we put down that middle column now I think that locks it up. Where you don't have to do is much for that second or third t m t s. And I think the biggest seconds. Just trying to stabilize that loud column so you don't get that cute boy drop that little deviate somewhere kind of shift laterally on you. Yeah. Specific questions about that. Will you dio cc fusion without a subtitle Effusion to prevent the calculate cube are dropped. Um, no, I think you need to do both together. I think when you do the sub Taylor Fusion, you're also protected media column and the tailors from fall apart. If you don't get a complete tm fusion or N c fusion three only time I'll do it is in a true Lisfranc, right? So it is. It is more distal than most of the ones we see. So if there's no involvement in the navicular, then I will do an isolated CC Um and, uh, you know, a lateral column Media column My media column. I think in some of those you can even stop it. The navicular. It is so rare for me to see that it's almost a trauma that's got a standard list. Frank, that goes bad. Like I showed, showed you in my my dog. I don't think you need to span enough of that so that that uniform falls apart. Maybe you have some more stuff to help hold it together. That's That's the District my feeling on there. Yeah, no. And I agree. And that lateral column will well be the Death e. If you don't do anything on that because that's the worst thing is your is your 10 months out. You see him on your schedule and you come back and go. What's this ulcer? And now you're having to deal with with an ulcer, which which you, which is as as we've shown, it's It's the it's you don't you don't want to deal with an ulcer if you could get them before they also write, your success rate goes up dramatically. Yeah, I learned. I learned that the hard way, probably about 12 years ago when I let you kept on also rating already keep boy. And finally I pushed up, infused They're allowed column, and she never had alteration again. Yeah, it's it's amazing how much we've learned. You know, one of the rial fascinating thing is how much I thought I knew when we started this project, and but it has been kind of fascinating. I see a lot of our friends on the on this and how much we have learned together. Andi, how much we've I think, Move the field forward and and and it's it's interesting when you talk to folks who do this stuff, Um, everyone's kind of come to the same conclusion by the school of hard knocks. Um, it's just hard. It's hard. Thio, unless you've you've got in your butt kicked a few times, It's hard to really convince that this might be something you want to start early and doom or right, adding the external fix it, er it's you know, it it takes another 30 minutes, but But, boy, it could make a difference. And just when you think you know everything about it, you get very humbled in a case. Yeah, well, that is that is true. And, uh, I will say that there's nothing. There's nothing that will bring it to your knees like Charco. But there's also nothing that will make you more curious. And, uh, so I love. I love the young folks who are
