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Good evening friends, colleagues and any enemies that may have found their way to the webinar. Uh Welcome to tonight's BOFA Virtual Journal Club, which er, is on the vex topic of the diabetic foot patients with diabetes, of course, do not suffer exclusively from the problem specific to their condition but are also vulnerable to the whole plethora of foot and ankle problems that affect the general population. Um Tonight, therefore, we are not going to be revisiting the well worn paths of diabetic foot ulcers or the Charcot foot specifically, but rather taking what Robert Frost, uh the American poets might have described as a road less traveled by. Um, and instead, we'll be considering the management of two common er, pal problems in patients with diabetes. A as follows our usual both us format. Tonight, there are two papers the first on managing caves feet in diabetic patients from Professor Kawata Venu of the King's Unit. And the second on the management of acute ankle and hindfoot fractures in diabetic feet from Mr Alex, we in the, from the Park group. Um As usual, uh each paper will be presented in the form of a summary and I hope critique by one of our BOFA fellows after which um the senior author will share his reflections on the paper with us and then we will take questions from the floor. Please do feel free to submit any questions. Uh You like do this through the messages tab and then the relevant ones we pulled over to the Q and A. So submit through the messages tab. Please. Uh Don't be at all afraid as, as always in both of us, we're all friends together. Well, more or less, this is not the new society um to, to obtain your certificates at the end you don't need to do to initiate any action. You will be emailed a feedback questionnaire. Uh Please just fill that in and you'll receive your certificate before we go any further. I'd like to thank uh all of you for joining us tonight, particularly those that have moved from another webinar and who've probably already had their fill of diabetes for one evening. Um Also our presenters, uh the fellows, Amir Seoi and Hossam Fre uh our senior authors, Professor Venu. Um and Mr we my core Nigel vasu who's long suffering but still keeps coming back for more. And as ever the it support mail Labidi and Tom Ankers who peddle away um merrily in the background, keeping the show on the road. So uh our first paper is on the management of cavovarus feet in diabetic patients and it comes from the King's unit led by Professor Venu Kapu and his long time partner in crime, Professor Mike Edmonds. Um Ny's work on the diabetic foot is vast and just about as all encompassing um as the disease itself. So I won't attempt to summarize it. He's published on just about every aspect of it um at a personal level. Um uh I would like to add that Venner is a mean cricketer um and also a thoroughly good egg. Um I've had the privilege of knowing him since we were registrars together on the Old Southeast Thames rotation. Um That's a few years ago now, but I would like to point out there's no truth at all in the rumor that that predated the discovery of diabetes back in the 19 twenties, sorry, discover insulin back in the 19 twenties. Um So without further ado, let's have please the first presentation uh Mr Amir Sdui with the paper on management of KVAS Foot in diabetic patients. That's it. The paper to discuss today is managing cavovarus feet in diabetic patients that's published in 2023 in the foot and ankle clinics. The authors presented an overview of the cavovarus feet in patients with diabetic neuropathy and described three stages of disease and its management. The etiology of the cavovarus foot can be classified into idiopathic subtle cavovarus feet, which is the most common, the familial non neurological one which has no muscle weakness and the neurological cabo vs feet which can be further classified into progressive and non progressive. Diabetes generally causes a flat foot and rocker bottom deformity in the charco neuroarthropathy. But with cavo virus deformity, diabetic neuropathy is a result of motor involvement with exerbation of the stronger muscles, uh tibialis, posterior Pernas, longus, castro soleus and plantar fascia. The condition can be more complicated in patients with diabetic foot because of the bone and soft tissue loss, the rigidity and stiffness from prolonged immobilization and the lateral ray amputations which can further erb the mid foot deformity. Important things to focus on when assessing these patients obviously, with the history and the creation of progression of the velocity. The complicated diabetes is an important thing to check peekaboo sign for subtle C virus foot. The Colman block tests to assess the flexibility of the hind foot virus. Noting any callos hemorrhagic blisters and ulcers and assessing the motor power and vascular status. Imaging includes weight bearing x-rays, weight bearing CT or CT with 3D reconstruction. Uh MRI to assess the extent of Osteomyelitis and vascular uh assessment. The management principles include preoperative medical optimization by the multidisciplinary diabetic food team vascular optimization and in the presence of infection. A stage approach is indicated and that will be discussed later. Classification now is based on the etiology of the deformity. So three stage classification is described. Stage one is the non neurologic virus feet and that is further classified into A AND B depending on the flexibility. Stage two is neurovirus foot without hind foot, charcoal neuroarthropathy. And that again is classified according to the flexibility. And then stage three is the red cap virus feet with hind foot Charcot neuroarthropathy. Uh for the treatment strategy. Stage one, that is characterized by normal power of the pes brevis and tibialis anterior. If complicated with diabetic neuropathy, then there is usually slow progression of the deformity and we not callus under the bony prominence due to sensory neuropathy for stage one A, that's idiopathic subtle C virus feet and that's usually flexible. Um You know, the calluses under the first metarsal head, under the lateral border of the foot and under the middle metatarsal heads from calf tightness. Um Non operative uh uh treatment would include accommodative uh shoes or custom uh or for operative treatment in stage one A. Uh it's usually flexible deformity uh indicated by positive common block test. Um So it's um advised to start with the Peroneus longus brevis stenosis plus or minus percutaneous plantar fascia release and then treatment for the plantar flex first ray uh depending on the flexibility. Um Also for the hind foot, lateral closing, wedge plus or minus translation, calm oot uh may be indicated for a stage one B, the tibialis posterior usually tight and that will cause apparent midfoot, supination, um rigid, hind foot virus and plant reflex first grade. The treatment is usually a stage one A uh for the midfoot, supination tibialis posterior transfer or corrective bony osteotomies, uh could maybe be indicated for stage two. the neurovirus foot uh without high foot shock or neuroarthropathy. Uh deformities are usually similar to the CMT and we will note that there is imbalance in the muscle strength stress fracture can be noted custom orho or TC uh can be used in the pre um ulcerative stage and to settle the soft tissues. Um If the deformity is uh flexible like in stage two A, then we treat it as stage one, hand, soft tissue and bony procedures depending on the flexibility for stage two B, it's the deformity here is usually rigid. Uh So we start correcting the hind foot alignment through lateral closing wedge plus or minus translation of calcaneal asom and release of the tight media structures. And if the ankle is unstable, then TTC fusion is performed for the midfoot, uh supination and abduction, then uh lateral column closing wedge plus derotational osteotomy um is performed and that is uh fixed with a compression screw and neutralization plate. Uh Peroneus longus to brevis stenosis and first tray plant reflection correction as per stage one, a tight acute tendon um is uh treated with percutaneous or open lengthening clothing of the toes um with toomy or P joint fusion depending on the flexibility or stage three. The deformity is rigid but with hind foot, charcoal neuroarthropathy. Um ulceration is noted under the prominent lateral malleolus, lateral border of the foot. Um Here two stage approach is um indicated. Uh The first stage uh antibiotics are usually stopped 14 days before surgery. Uh trans uh lateral malleolar approach, excising the lateral malleolus. And another anthro medial approach is um is used joints, prepared, disease, tail is excised and debridement is performed antibiotics, eluting calcium preparation is used soft tissue procedures as well as corrective osteotomies as indicated. Fixation is usually a 3.2 millimeter threaded wires or external fixation. And depending on the skin condition, either a primary closure or negative is used um for uh the second stage. Now, that's usually 4 to 6 weeks afterwards. Uh TTC uh fusion through a nail plus calcaneal uh tibial compression screw, uh then mid deformity correction uh is performed and that's fixed with intramedullary beams and plates, uh back slab and normally bearing TC um used for 6 to 12 weeks to summarize neurotic Cvis foot associated with diabetic peripheral neuropathy results in rapidly progressive deformity which is flexible to start with, then becomes rigid very quickly. The surgical treatment is based on flexibility of the joints and progression of calluses, preoperative medical and muscular optimization is critical deformity correction followed by stabilization with an internal or external fixation method based on the stages of the disease. The internal fixation method is the preferred option for the authors. Thank you very much. Thank you very much. That is very well summarized. Um I'm Vena Cava. Um So II in, in this paper. Uh it is um not a case series, it is like a level five evidence uh paper looking at um certain types of presentations of um kill virus feet. And in this particular example, those associated with diabetes. Now, we know that um diabetic peripheral neuropathy can result in Charcot neuroarthropathy that uh contributes to certain type of uh specific deformities and then uh certain predictable progression uh now kill virus feet in the background of diabetes. Uh also uh develop similar type of disease progression uh to various extents. So that if the diabetes develops significant motor neuropathy, even uh settle vo virus, uh deformity or familial non neurological ko vs, deformity can develop this disease progression due to the associated motor neuropathy. I think it is very helpful for the treating for an ankle surgeon uh to become familiar with this concept. And that was the main uh thought behind uh writing this article. Um So the A LA carte approach normally used for the surgical correction of virus deformities are applicable to this group of presentations too. But uh with an added dimension of diabetes and the diabetic uh peripheral neuropathy and the motor neuropathy components. So, hence, uh these presentations were staged that way. Uh So that yes, stage one, even subtle uh K OS deformity when it develops diabetic motor neuropathy can still progress to stage two and stage three. Um So that is the main thought process behind uh staging these and again, giving different, um, surgical uh treatment principles using that a la carte approach for these presentations. Ok. Thank, thank you very much for sharing that. Um, I'd remind everyone attending, please feel free to submit, um, any questions that you may have on the topic and we'll be happy to discuss them. Um, uh, if I can, uh, kick off, um, venu um, you clearly, this, the whole concept here is about the progression er in the diabetic foot which is different to, to non diabetic patients, er and other types of neuropathy. Um just is there any way you can, it may be a very unfair question. Is there any way you can give some idea of, of the apparently non neuropathic stage ones? You know, how often do they progress on to the, the the twos or the threes? Is there, is there any any estimate or, or rule of thumb? You can give us there in terms of I'm thinking in terms of how one would counsel a patient preoperatively? That that's a very good question, James, I don't think there is any published evidence on that, but from our observation and Mike Edmunds has done um um well, uh he hasn't published but he has done a series of observations. So by and large, once the these patients develop loss of protective sensation means uh sensory neuropathy and they, these group of patients tend to develop very rapid progression of the deformity uh due to even, even with subtle motor component James because even though, uh, some of these non so called non neuropathic Kor s feet, uh I think it usually means that we don't know where that neurologic hidden neurological component is we, you know, we just, we hound perhaps, um, manage to, um, you know, identify that area. So, uh, so perhaps, uh, my best guess, uh, is about maybe 30% of them develop reasonably, uh recognized um visible progression of the deformity. Yes. Ok. That, that, that, that certainly, certainly makes sense. Um And have you identified any predictive factors that might guide as to who's more likely to progress? Is it intimately connected to diabetic control or are there any other factors in terms of disease pattern that, that you would say, well, these ones are much more likely to go on than, than the others. And therefore, maybe we'd do a, a more draconian correction at the beginning. Correct. Now, uh if they develop persistent uh callosities, despite optimal offloading measures, we take for that particular deformity, uh even subtle K os deformities with um in a custom insoles or high ankle boots. If they still develop callus, it means that there is still a significant uh neuromuscular imbalance and those are the ones, perhaps we, we shouldn't wait until they develop skin blistering and an ulceration. Um And then we, you know, if there is a visible deformity that is not responding to optimal offloading measures and the OC continues to progress. Perhaps those are the ones we should proactively, um, address surgically. Yeah, that, that, that, that certainly seems, er, ee entirely logical. Um, can I ask you a couple questions? Um, I just, um, the, the stage threes, um, do you routinely excise the whole Talus? Right. That's a very, very interesting question. So, yes. Er, at the beginning, James, during our early, um, earlier surgical experience, we used to uh do routine talectomy for all these patients because you know, these deformities, unlike uh unlike our regular shock court presentations, uh those um stage three diabetic care varus deformities are present with very, very, very, very rigid component. You really there is no um uh you know, flexibility at all. So the only way by which we can correct the deformity completely is by doing complete uh talectomy. But that was the case uh probably about 15 years ago when we started doing these procedures. Uh and we were not doing adequate soft tissue balancing component in those days. But now what we do is we first release um tip post completely and the uh and the tendon sheet as well completely delta, all the media structures are released and then see how much deformity correction we achieve. And based on that, we do further tailor segmental resections to achieve, you know, no complete deformity correction. So it is quite less common nowadays that we go for complete talectomy. So start with the soft tissue corrections and see how much deformity uh correction is achieved. And then based on that the distal tibial and part of the talar body resections to achieve normal alignment. Yes, that's, that, that, that, that sounds eminently wise as a, as a progression of, of practice. Um uh I think certainly, um, many of us over the years have fallen into the trap, particularly when we first start out doing complex diabetic foot as to thinking mainly or over focusing on the bones and not thinking enough about the fact that the soft tissues are also hideously compromised in, in, in these folk and, and often very rigid. So, yeah, so, so it's fair to say then that in essence, you, you release all the soft tissues and then take as much bone as is needed from the tailors to, to get your correction. True. Ok. That's great. Thank you. Uh We have a question from er Tamar Kamal er venue. He, he says you mentioned that your perf preferred method of correction was mainly internal fixation. So that inherently means that you've tried external fixation for correction, possibly frames. So, was there any major difference in outcomes or, or? Well, I guess the to the subtext is, did you try frames and didn't like them and therefore have moved on? Correct? Yes. Uh uh uh about 18 years ago when we started the service, uh we started off with uh external fixation and there's no doubt that the external fixation uh technique. Um Well, and the equipment available in those days, um didn't used to be as good as we have now, but still, we have seen major uh failures. But our treatment goal at, at that time and even now is to achieve complete bone fusion so that that segment deformity correction becomes permanent. And uh so we didn't achieve predictable um bone fusion uh with an excellent fixation. The deformity correction was excellent, all the angles uh normalized, but we didn't achieve predictable bone fusion. So we had 70% failure rates and then we shifted into fixation. So obviously, if there is an active infection, one would recommend using a an external fixation but just to achieve deformity correction and bone fusion, we feel that internal fixation, particularly the modern, using the modern internal fixation. Um you know, devices, the bone fusion outcomes are far better. Only um exception is exceptions are two exceptions. Number one, if you consider doing bone transport as well, which is very, perhaps challenging in this group of patients. And also if there is active um deep infection, II certainly agree trying to do brain trans, but I, I've never been ballsy enough to do that in this group. Um The just out of interest. So you're, you're certainly right about the hardware. Things like dynamization washers have made a difference to frames and union rates. Um The um you quoted a 70% failure rate with the old style fixators. Um Roughly what's the failure rate with internal fixation in this very challenging group? Sure. OK. That's a very, very good question. So, our recent published series uh had a bone fusion rate of uh the ankle, hind foot segment of about 90% hindfoot segment. Uh When you do a combined hindfoot plus midfoot reconstruction, the nonunion at the hindfoot Medford junction uh is still higher. Um So, and out of uh about 270 reconstructions we had done so far, we we have lost uh limbs in two patients. So uh quite an acceptable level of amputation rates, functional outcomes. It it means, you know, patient's ability to mobilize full weight bearing either in, in shoe or a form of brace. Uh about 93 to 95%. So functional, it is very good bone fusion, hindfoot component is excellent, not, not far off the non-diabetic population in point of fact, good point. Yes. The the biggest difference is metal work failure, James still we do see uh screw breakage. Uh Of course, the incidence has come down quite significantly. And, and, and we have published our experience in that component in that area, you know, the the principles how to be uh adjusted or altered slightly to reduce that complication rate among these group of patients. But despite that, we still see about probably 10% metalwork failure rate. And can I ask how long you keep these patients non weight bearing from a a hind foot TTC fusion, yes, isolated hind foot TTC uh in the presence of, you know, obvious peripheral neuropathy. Uh it is almost never less than three months if there is diabetic peripheral neuropathy, three months. And that is a kind of. But if the patient happens to have diabetes in the presence of a neuromuscular hindfoot, deformity, but noncomplicated diabetes means no measurable peripheral neuropathy and you know, no nephropathy, no other endo than failure for that patient. You know, it is between 6 to 12 weeks, but perhaps somewhere in the middle about two months in those. Interestingly, unlike Charcot group of patients, the neuromuscular deformity isolate pure neuromuscular stage one and two deformity, patients actually throw AAA good amount of not callus but bone healing response. Uh perhaps the, I don't know, neuropeptides are more active. Uh in comparison to the Charcot group in Charcot group, you really it is such a such a slow motion, such a slow process of bone healing response. Whereas in this, if you achieve perfect optimal boners position the standard long segment, uh rigid fixation kind of construct and the bone healing response is actually pretty good if they have uncomplicated diabetes. That's, that's, that's, that's reassuring. I think that's quite an important take home message actually. Er Mr Camal, by the way, thank you for your comments and says he won't share them with Mr La. Er so no bun fights in the King's tea room um this time around uh a further question, I think uh just as we draw to a close for this section from Andrew Kelly, it was mentioned that progression can be rapid. Um How long can surgery be delayed for attempts to improve the HBA1C? Uh first question and his supplementary. Um Do you have an HBA1C threshold for uh operating? Very good, very important questions? We have actually um recently um done a study which was submitted to the, well, which will, which will be presented at the uh at, at, at, at a major uh orthopedic meeting in, in a couple of months. Then we looked at the H HP A1C levels in our reconstructed um Well, diabetic foot reconstruction group of patients pre op and POSTOP. We do not canceled patients because of uh just purely based on the HBA1C levels. Uh 40% of our patients have uh come with much, much higher HBA1C levels about the national, you know, uh guidelines. So we proceeded with surgery and the outcomes uh complication rate between the um the acceptable threshold below the acceptable threshold and above the acceptable thresholds. What are they saying? And the POSTOP HBA1C level reduction at 12 months, POSTOP was quite marked in the raised group compared to non race group. So the conclusion was that we should not delay surgery in this group of patients if uh I II, you know, if the HBA1C level doesn't drop despite your medical treatment? Ok. And why do you think the H ONE C went down so dramatically postoperatively in these folk, the mobility levels improved. That's that one year POSTOP. So the reason why the HP A1C doesn't drop pre op in this group of patients uh is that, you know, their activity levels are markedly reduced and the you know, metabolic demand from, for example, recurrent infections or ulcerations, casting and all those that these events disturb the, you know, the, the the the metabolic control uh mechanisms in the body. Yeah, once they heal, once they regain their normal mobility and they see quite a dramatic improvement in their HBA1C control. Well, that, that's, that, that's marvelous, a very assuring I think. Um it's, it's nice to know it's nothing at all to do with change in lifestyle like my lovely diabetic Charcot patient that used to bring cream cakes to the clinic every time she came for a total contact. Um The um I think we probably have now to move on as time time has expired. But uh thank you very much for, for joining us for sharing your, your great experience on the topic. So I'll now introduce uh hand over to my colleague uh Nigel Vu who's going to chair the second half of the webinar. Nil James. Hello, everyone. Um So we're going to the second paper in the, this virtual J club. So it's, it's uh related to a topic that most of us are, you know, will encounter in your, in your trauma and orthopedic practice. So, ankle fractures, um it's for an orthopedic surgeon, it's a bread and butter of your trauma practice. Um But once you have a diabetic foot diabetic patient with an ankle fracture, the whole picture changes. And over the last 5 to 10 years, there's a greater awareness on the problems that these patients can have. And now we say a diabetic patient with an ankle fracture should be managed like a like a diabetic foot or it should be managed like a um diabetic chaco. So this paper is uh from um Alex V at group. Um Alex is familiar to everyone in the foot and ankle circles and Alex is an active presence in all in, in a lot of the diabetic foot meetings. If you've been to the to jam band uh performance in the meetings, Alex is an active person there as well. So this paper is being presented by Mr Hosam. I'll hand over to Mr Sam to press in the paper first and following this, uh we'll uh hear from Mr Alex V on his thoughts and reflections over 2%. Hello, I would like to thank both of us for this opportunity to present at this Joiner club. My name is Joan Fri. I'm a foot and anchor fellow at Royal Bo Hospital. I'll be presenting this paper about managing acute ankle and hand foot fractures in diabetic patients. It was published in the foot and ankle clinics in 2022. The authors, Mr Fo and Mister we are from Friendly Park Hospital, ankle fractures are among the most common injuries seen in emergency departments worldwide. While hind foot fractures such as those involving the talus and the calcaneus are less frequent but equally significant. The incidence of diabetes in patients with ankle fractures ranges from one in 20 to as high as one in seven. The aim of this paper is to review the pathophysiology of diabetes and Charcot arthropathy relevant to ankle and hind foot and how this might influence treatment and review the current evidence for the treatment of ankle and hand with fractures in diabetic patients. When we look, when looking into the pathophysiological aspect, diabetes affects various organ systems leading to complications such as peripheral neuropathy, nephropathy, retinopathy and peripheral vascular disease. These conditions increase the risk of infection, impaired wound healing and slow, slow fracture recovery due to reduced collagen sent. This is in peripheral neuropathy when assessing diabetic patients with ankle and or handful fractures. A comprehensive approach is crucial. This includes a detailed medical history, evaluation of the mechanism of injury and thorough clinical examination. Special attention should be paid to soft tissue assessment, peripheral neuropathy evaluation and foot circulation examination, optimizing glycemic control is paramount in diabetic patients undergoing orthopedic surgery, monitoring H HBA1C levels and involving a multidisperse. The risk of complications. Effective communication with patients about potential complications is crucial when considering treatment options for ankle fractures, for displaced, for undisplaced or stable ankle fractures in uncomplicated diabetes, conservative measures such as close contact casting and weight bearing restriction may be enough. However, close monitoring and vigilance for early displacement is important. Slank. And colleagues in 1998 showed that 60 non displaced ankle fractures with diabetic neuropathy treated by casting up to nine months with non with bearing up to six months, resulted in stable with a lined ankle. Only one patient developed, developed Charcot. The outcome is different for displaced ankle fractures which are treated inoperatively. Lo and colleagues in 2017 did a retrospective review on 28 diabetic patients with displaced ankle fractures, non operative treatment resulted in 21 fold increase in complications compared to surgical fixation within three weeks of injury. Most common complication in non operative group was the loss of reduction. The loss of reduction often occurred within the first six weeks. Charcot changes developed in early as as early as eight weeks when discussing operative measurement of ankle fractures in diabetic patients preoperatively, it's important to elevate the limb to reduce swelling before surgery. Typically taking 7 to 10 days. The fracture schoen ital in 1995 used multiple tetra corticals in the mutic screws fixation to enhance stability with extended immobilization and protected weight bearing wage. Ital in 2011 showed that complicated diabetes. Patients had significant higher risk of overall complications. However, distal fibri plates and multiple tetrac cortical screws had fewer complications compared to other techniques. Primary ankle arthrodesis could be considered when the articular surface extensively injured. A UBS case series reported an 82% success rate with primary arthrodesis. In 17 patients. IBO and colleagues reported high limb salvage rates. About 96% unacceptable union rates. About 80 88% using rich grade hindfoot, nailing, prolonged immobilization after ankle fractures was advocated by shital in 1995. And my apologies. Uh Everyone that we seem to have uh temporarily lost the um uh sound for presentation. Um hopefully while we uh get back going again. Um we had actually for our diabetic ankle fracture patient who were allowed protected weight bearing at two weeks, post injury or surgery. They report 25% complication rate in the surgery group like w dehiscence and 8% in the nonsurgery group. Laros of reduction and malunion despite complications, evidence supports, evidence supports early weight bearing and select patients with fewer comorbidities. Rosenbaum Ital conducted a survey in 2013 among the American foot and ankle surgeons. The majority preferred enhanced fixation methods with 8 to 12 weeks of non weight bearing for displaced ankle fractures, undisplaced fractures are typically treated with a plastic cast treatment. Plans for talus fractures depend on fracture pattern, presence of this location, soft tissue condition, peripheral circulation status and risk of avascular necrosis. It's important not to miss not to miss early fragmentation phase of sarcoid arthropathy, which might mimic talus fracture, radiographic, radiographic radiologically, background information, trauma, nature and presence of peripheral neuropathy neuropathy aid. In accurate diagnosis management approach involves total contact cost to maintain alignment until Charcot inflammatory process resolves especially in cases. Mi mima fractures cost changes essential for monitoring of skin integrity, tibial tiote arthrodesis in cases where hind foot instability and weight bearing threaten soft tissue integrity. There is no available literature reporting on treatment and outcomes of talus fractures and perineal dislocation species. Specifically in diabetic patients, there are different types of calcemia fractures, bone avulsion will pursue calcaneal turo and it's often an insufficiency fracture due to tight achilles tendon. Surgical fixation may be necessary for significant displacement. However, non operative management with the plantar flexion cost is suitable in case of mid body compression type fracture. Conservative treatment is advocated especially if concurrent saropsis exists. Posttraumatic symptomatic arthritis may require arthrodesis for tongue type fractures. Surgical fixation may be needed to reduce the fragment and prevent soft tissue necrosis. Calcaneal fractures could be associated with heel ulcers due to the combination of tight achilles and weakened calcaneus. They are managed through deprivement of ulcer and an infected wound and infected wound before fracture stabilization. Also trans through transection of achilles tendon to reduce the fragment displacement. It's recommended to use threaded heavy threaded wires instead of standard screw fixation in the presence of infection remaining in situ for about 8 to 12 months. Vacuum assisted closure, wound therapy for soft tissue defect management. Plastic surgery with soft tissue flap may be necessary in severe cases, primary subtalar arthrodesis using percutaneous wiring or circular limb externa fixator can be employed with soft tissue envelope. Is not suitable for open techniques to summarize in diabetic patients with multiple comorbidities. The aim is to heal the fracture. Maintain a well aligned lip be vigilant for Charcot arthropathy and minimize the risk of amputation. Augmented fixation methods are often necessary to reduce the risk of fixation failure like tetra cortical screws and locking plates. Primary fusion of ankle and subtalar joint may be considered in selected cases a longer period of cost, immobilization and protected weight bearing may be necessary. Thank you very much for listening. I think there has been some interruption technically, but we have come to the end of that uh presentation. Alex. Yeah, thanks, Alex. So, Alex um quite a um extensive uh literature review and um quite an in depth review of uh ankle and hind foot fractures. Uh and a good learning source. I thought um can we, I, can I just uh ask you to give you reflections and thoughts on preparation of this er wonderful paper. Thanks Nigel. Um Yes. So I think there were several motivations for this paper er, from a personal point of view, I was getting fed up of everyone leaving the diabetic fractures to me. So they were saying, oh no, it's diabetic. Oh no. It's neuropathic. There's a little bit of pus or whatever, there's an ulcer, there's a blister and they're all getting left. So that was one of the reasons. And I felt it was time that many of these myths about diabetic fractures doing badly, which historically, they did, uh, had to be dispelled and they did badly because people didn't pay them enough consideration. They would just be put in plaster sent away and then followed up at six or eight weeks when they'd all fallen apart and turned into a Charcot and everyone would go, oh, look, look what happens to diabetic fractures or uh they were treated with K wis because no one wanted to make a hole in the diabetic foot. And guess what if you treat an ankle fracture with two millimeter K wis I, it doesn't, you know, it's not rocket science, they fall apart. So I think there are many challenges in treating uh diabetic fractures. And I wanted this paper to show that the risks that we're all er, that the, the risks and the comorbidities that we're worried about can be managed. So, one of my contraindications for treating diabetic fractures is if there's no pulse, uh I get a vascular assessment, I will always get a, a toe pressure or A T CO2. And if that's compromised, I get vascular to look at the inflow and can that be optimized before I embark on operative surgery? The thing about um diabetic control. We all have, you know, we, we need to optimize diabetic control where we operate on them to maximize their chance of good outcome. Well, you can't wait for a fracture patient to have good diabetic control. Often they come in with the HBA1C in triple figures. You can't wait for that to happen. So that's managed, we're careful perioperative uh diabetic control. And it was just teaching that to the rest of my colleagues and to the greater and wider orthopedic community because we're all gonna see more and more of these fractures coming in. And, and also, I've known that when these fractures or, well, it's been published and shown that when these fractures are left, they invariably end up with a Charcot process uh because of the inflammatory nature of that condition. Uh and all the inflammatory mediators following a fracture in the joint. And then the whole thing just falls apart and it just becomes miserable for, for everyone at eight weeks when you, when you take that dreaded X ray and you see everything's just dissolved. So I felt that the paper gathered all the evidence from the past 25 or 30 years and it was evidence that kept showing the same thing, diabetic patients, they do badly, they do worse if you ignore them and if you don't consider their risks and um that you need to take these patients on board, mm um Adjust how you manage them and then accept some of the challenges going ahead because it's better to have um a fixed, a fixed hind foot with lots of metal in a biological leg that a patient can stand on rather than have it all fall apart and do an amputation. And we all know the dreadful figures for amputees um in diabetic amputations in diabetic patients. Uh So that was my motivation for writing the paper as well as, you know, when you get an invitation from Fabian Christ, um you can't really say no. Yeah, I mean, um one my thoughts on this. Um So regarding angle fractures in diabetics, my take is that the fact that the patient is diabetic should not affect your decision whether to operate or not. I mean, you treat the fracture on its merit, treat the fracture on its merit. But then the way you fix it should be modified and how to manage the patient perioperatively and how you protect or immobilize the patient, the duration. All these are modified whether the depending on whether the patient is diabetic because the fact that the patient is diabetic should not change your decision, whether to operate or not. That should be on the merit of the fracture. That has always been my take. I mean, the exception would be in a, in a dis vascular limb with an ankle fracture. Then your approach changes, you need a sort of an MDD approach to it. I can't remember the last time I had to fix an angle fracture in this, no, I was faced with an angle fracture in this vascular limb that that's a different kettle of fish. Um I think coming back to post, coming back to perioperative issues or intraoperative issues and technical points, I II apply the super construct principle that we're all familiar with when we're fixing and stabilizing chat feet, you go from that uninjured part, the the foot, you bypass the zone of injury. Um Depending on your aims of surgery. If you're aiming for primary arthrodesis or in the paper, I've showed some uh examples where I've just fused and sit you without preparation of the joint. You put the biggest heaviest piece of metal to span though you lock it and then in some cases you need to supplement your fixation with a plate uh for the ankle. Um So if you're doing a TTC fusion, you can put a, a supplementary lateral plate on and these patients are going to walk on them. They, it's, it's something that I learned the hard way. So I think about a year ago I fixed I II did a hind foot TTC and it all looked great. Big piece of metal, lots of screws, everything looked fantastic. But when the guy is 100 and 50 kg and can't feel his leg and cheerfully tells you nothing hurts. So he started walking and it all falls apart and it was miserable. So I revised it instead of amputating the leg and I put a plate on the side. So a trans fibular approach uh fuse everything, put a bigger nail, ream it all out, exclude infection, all that, put a bigger nail. So or if plus plus you have, you have to fix it with the heaviest metal that you can, you can get in um bearing in mind. Your soft tissues need to take that and close over the metal. And secondly, you have to protect your, your fixation as well. So I think Wic writes more recently about hybrid fixation. Now there's, there's a, some groups in this country are approaching hybrid fixation uh and putting frames on just to protect the fixation. I think there is a place for that if you have a framer on, on board with your service. However, I don't have a framing service um in my department. So I protect them using either a total contact plaster. I let I wait two weeks for the, for everything to heal. Everything's settled. I protect them and I watch them every couple of weeks. I don't see them every couple of months. I watch them carefully. I check the wound. So a a total contact plaster or a bowler iron. So a burning iron is a device that um allows the forces to be to bypass your zone of injury. Um more proximately from the heel, uh or I'd just say to them, get yourself a mobility scooter or one of those, um one of those cast scooters that you can just hop around on. So you need to protect your fixation and uh regarding methods of fixation. What's your take on uh multiple syndesmotic, the so called fibular pro tibia fixation that seems to become very, you know, become popular now. Yeah. Uh I, I'm normally four cortices anyway. Um, 22 synthes screws, four cortices. Uh So if I put in a, if I bang on a couple more syma screws or I'm al I'm always asking the registrar, er, if I'm supervising, I said, look, you need to put these across, you may, you need to make, you need to make sure they grab the other cortex. Uh Yeah, I'm pro that. There's a question in the chat box. Uh from Mr Gilla. Can we do a TTC nail without joint preparation in that often? Uh You will get a fibrous ankylosis. Um And so for the, for the one I was, for the case I was referring to, I did, I did a TTC nailing. Uh and the reason the technical reason was I couldn't do an open nailing, er, where I prepare the joints because his skin was so blistered and as a result of that and his weight and his lack of compliance, it failed. And then I went back, the soft tissues had settled by then, took it all out nailed it, put a plate on the side and then I prepared. I prepared the joints at that point. So you can, but you will end up with a fibrous ankylosis. And uh you have to watch them even close, closer at, at some point, they'll be stable enough to walk on. And uh how much, there's another question, how much do you involve your other MDT colleagues, like your endocrine uh colleagues uh at the, at the time when I'm making the decision for surgery, uh let's say they come in and I'm operating at the weekend or whenever I do it and the HBA1C is triple digits. So I say, look, we'll, we'll, we'll do postoperative sliding scale. I'll get the diabetic nurse in to see you er, before and after and we watch you closely. We, we manage your diabetes of insulin. Um, and we keep the perioperative glycemic control good because HBA1C, it takes three months for the, for the hemoglobin to turn over. So, you know, your, your diabetic medication applied around the postoperative period isn't going to have a huge effect. But ongoing during the time of fracture healing is important to get your diabetic control, right? Insulin has an anabolic effect. So the lack of insulin in an animal model has been shown to produce these, these patients, these animals, uh these rats with fractures, they produce less callus, they have lower tensile strength and then once you apply insulin to them, the callus gets uh you get better grade of callus. So you need good diabetic control, good insulin uh application to, to promote that fracture, healing as a, as a rule of thumb. However long it takes to heal a fracture in diabetics, double it easy. Uh And you might have to protect them in longer in plaster. Uh I do try and load them otherwise you end up getting disused osteopenia as well. It's a kind of a tight rope. You have to walk between protecting it completely and giving it just enough stimulus so that you get the osteoblasts uh doing some work and laying down some bone in a, in basically what is AAA catabolic state? Thanks, Alex. Next question to you. Uh Is about your, your thoughts on using topical anti local antibiotic carriers. Uh II, only apply uh local antibiotic carries, er if there's evidence of infection or if I'm worried about it or if I'm treating uh a, you know, if there's an ulcer present uh in the, in the surgical field and I've had to uh then I treat that I size the ulcer, I treat the bone. Um II use as many people know I will use cerament, either using a silo technique or squirted up the medullary canal or, or I'll apply it to the, to the fusion site. So I will apply cerament and on some occasions I've used stimulan dependent. It depends on the application, right and again, on the fixation methods. Um Any thoughts on using fibular nails in diabetics as a less invasive. Oh, I bet that was an anonymous question. It's the alter is in the chat box. So, no, I'm, I'm teasing. Um, well, actually that's quite interesting because I got asked that, uh, last week, Byer, a visiting American surgeon and, uh, I don't have any experience using a fib and nail. However, if that's your only method of fixation, it's not gonna be good enough. And I, and it, uh, because I, if you're using a fibular now for a, for a uh a, a displaced fibular fracture, there's usually a media malleolar er, injury as well. And you need to think how are you gonna stabilize the entire ankle joint instead of just putting uh a five millimeter or seven mi millimeter er device up the fibula? So I, from personal experience, I don't have any, so I can't answer that question, but II stay away from them. I've, I've, I mean, in response to that, I've used a few fibula nails. I mean, not specifically in diabetics. I used to resort to fibular nails as a way of minimally fixing um elderly patients with ankle fractures with poor skin, poor soft tissue envelope where you don't have to worry too much about an anti anatomic reduction. And uh I haven't had any disasters to be perfectly honest. Uh but, you know, there's a lot of evidence came out against us. I sort of slowly came away from that. Um And, uh, you know, it depends on which paper you look at and whom you ask. Uh, there's still a case but I wouldn't, uh, like Alex was saying, I wouldn't go, wouldn't be my go to option in diabetics because you can't get a rigid fixation. No, I think for that, for that particular population is described intramedullar fixation. And I, and I use a, I use a 6.5 or, or, or a seven millimeter, uh, partially throughout the cortical screw. You can, it's a nice easy shot. It's minimally invasive. I think if it's a high fibular fracture, then you need to think about bridging it. But for, for the elderly, uh that's what you want and it does grip, does grip that bone that the only do the nail is your locking screws with it. So, so it goes through, but it still not enough. It's still, it's still not enough. Ok. So you've got a case here for your advice uh from uh Mr Gilla. So he has got an 81 year old lady with poorly controlled dia diabetes with bilateral l of fractures. Ok. So on the left side, she has a periimplant fracture of the distal tibia uh following a previous pro uh pro tibial fixation for bal fracture. And on the right side, there's another bimolar fracture. So his question is, when do you think I can wait, be her and let me know your thoughts. Well, I think you need to fix it first, I mean, er, for the, let's take the right side with a bimalleolar fracture. That's, that's assuming that her diabetes is fine and, uh, her vascular supply is fine. I think you need to fix that, applying the, er, the super principles that we've discussed. But, II don't know, or I can't visualize what pro tibial fixation had previous that some other disclaim it on, on the left side, she have peri implant fixation of distal tibia. So she's had tetrac cortical screws on both sides on one side broken about that. What he's saying is he's, she's broken above that pro fixation. Uh Another BME fracture on the other side. OK? You need to take, you need to take that, um take the device out and then you need to put uh a long nail in. Uh I think one of I can't remember which implant company manufactures a 300 millimeter um a hind foot nail, but that's, I'd go for the longest implant. Get it into the, get a good isthmus fit on that side. And if you are taking all the metal out, then I would probably prepare the, prepare the joint surfaces as well. So you wanna do one really, really big and good operation for the side with metal in and the other side you fix as, as described in the paper. When would you weight? Bear her? Well, I think for her, you can't, she's got, she's done both sides. You would have to do, you'd have to do seated exercises just to get some load going through the bone once the wound has healed. But for her, she's gonna be wheelchair bound until she has, she has uh sufficiently conditioned herself. Proximal limb conditioning and strengthening to actually support herself with, with crutches or frame. I think that will probably be at three months. Excellent. Thank you, Alex. And uh thank you for those who have submitted questions. I mean, we could go on and on because there is a problem that's just going to increase. Uh But as we are just past 930 now, so we have to bring this evening to a close at some point. Uh Thank you Alex and uh thank you as well and I'll go back to James. Thank you. Thank you very much Nigel and Alex also for sharing your thoughts. Um Alex, I have one final question for you if you're still there, which was this marvelous paper born out of frustration? Has it actually changed your colleagues practice? Yeah, they do. They uh I don't get that phone call or usually when I'm on holiday, I'm somewhere where there's no reception. Unless you get a satellite phone, I will get a message. I don't get those messages anymore, but partly, you know, we've appointed Noi Fo and he's just taken up uh taken up the slack basically. So we, you know, we work as a tag team, er will, will pick up this stuff and do the, do the difficult fractures. But my colleagues do the straightforward stuff, the straightforward diabetic fractures, they don't leave them. No one dares to put K Ys or just in, in ankle fractures. We've got hip surgeons doing them. So, yes, they do what they, they do the fractures now. That's excellent. They've all, they've all learned that fractures, fractures that are fixed badly, generally do badly. Yeah, I mean, that's the same anywhere in the body, but you know. Exactly. Well, um thank you very much. We'll draw the session to a close. Um I'd like to thank everyone who's attended. Thank you for your questions. Uh Thank you particularly to our senior speakers to Alex, we and Prof Venu uh Gentlemen, it's been a pleasure to hear your thoughts. Also a big thank you to our fellows who presented Amer Sdui and Hossam Fre who did so under a fair bit of pressure following the fellows course last week. So thank you, gentlemen for preparing your preparations. Um Thank you as always to our it colleagues for playing the gaps and rescuing the situation this evening. Um May be and Tom Ankers and finally, thank you as always to my excellent coa Nigel Vascu who manages to keep us all on the straight and narrow. Um I wish you all a very good night. Do remember to fill out your feedback form to get your wonderful certificates. Um The next journal club will be after the summer break in September. If anyone has any passionate uh issues that need to be discussed, uh you know, uh do do drop us an email um If you could keep your personal problems to yourselves, that's probably better really. Um But otherwise thank you everyone for joining and I wish you all a very good evening. Um Good night from both US cycle. Thank you. Thank you. Good night. Thank you.