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Good evening, er, friends, colleagues and those that we have yet to get to know. Uh Welcome to, what is the final BOFA Virtual Journal Club of 2024 this time entitled Achilles Heels Treatment and outcomes of insertional achilles Tendinopathy. I'm very pleased to be able to welcome as our guest speakers tonight. Uh Sebastian Baum Bach from Munich er from the Ludwig by University and also Sunil D of the Queens Medical Center, Nottingham. Um So welcome to both Sebastian and and Sunil as our speakers on as well to all of you at home who've signed on for this evening. Um We're following the traditional format. We have two papers for presentation um the er first on patient reported outcomes um uh of sorry of sorry, treatments and outcomes of insertion, achilles ton er from Sebastian's Unit. And then, or a second paper from Sunil on the er Za Osteotomy for refractory Hagland deformity. Um In each case, the paper will be presented by one of our fellows, specifically Dr Bane and Dr Gonzi. And then we will have questions from the floor and discussion. Please do submit your questions via the chat, the Q and a there are no questions. Too foolish. We're all friends here. Well, more or less anyway. Um The, I'd like to thank, of course, our two guest speakers, Sebastian Bach and Soil D also, of course, May Labidi from the IT committee who's kindly supported and is running this event tonight. And my long suffering co-chair Nigel Vasu, who is once again going to chair the second half of this meeting. So, thank all of you for your contributions so far. So um I'm afraid that we have missed one slight trick this evening. Uh Being the last one before Christmas, we should perhaps have gone a little festive. But uh I didn't think of that in time. So we don't have er soil appearing in Lincoln Green for Nottingham or Sebastian in LA halls and for Bavaria, but never mind, we will still have an excellent academic discussion. I am sure. So uh with one last thing before we continue with the papers for your feedback, please do fill in the survey which will be sent to you as an email link and that will then generate your certificate for attending this evening. Um So without further ado, um I'd like to introduce a paper by Dr Sebastian Baum Bach of the Ludwig Maximilian University in Munich, which by the way, has nothing to do with Ludwig, the mad king of Bavaria who built castles up mountains. Although he, he's also Ludwig, this is very different. Ludwig. An ancient predecessor of his um Sebastian has many interests particularly around trauma and sports injuries, around the ankle, around the syndesmosis and the insertion with kidney problems as well. So, um Sebastian's paper uh will be presented by our fellow uh Bhaskar Bazi. So let's without further, do we move on to Bhaskar first presentation, foot, ankle surgery in native Lincoln say hospitals and he just trust. Thank you for giving me the opportunity to present this topic in work for us. You no. Today, patient reported outcomes of at least. Can you know the lead Ee Hubert Porter and the senior author is Sebastian Felix Bach. This or is published in international in 2021 interaction intestinal achilles to neuropathy presents as a challenging condition with a complex and somewhat induced pathology, making effective treatment difficult to achieve. Despite advancements in diagnostic techniques, the specific causes of symptoms often remain unclear in patients. Adding to the uncertainty of treatment outcomes, surgical interventions including both open and endoscopic procedures are options that lack a clear consensus on which approach is the best results. Many experts currently regard open to pregnant using midline incision trans approach. That is as the standard treatment. This procedure however, is not the thought it risks carrying potential complications associated with it. Its invasion nature current evidence, existing studies examining with without effectiveness tend to have small patient samples leading to inconsistent reports of complication rates and variable treatment outcomes. This variability points to a significant gap in a reliable data. Emphasizing the need for larger more comprehensive studies to better understanding the true efficacy and the risk associated with me for treating I A aim of the study to evaluate patient related outcomes. Following the approach and development of all pathologies in patients with I this retrospective study conducted at a single orthopedic center included patients aged 18 years and older, older age, standardized surgical approach for primary intestinal a tenopathy between January 2009 and September 2016, the surgical technique was minimally invasive and addressed all identified pathologies when more than 50% of achilles stand down in was detached. Ref was or bomb rehabilitation varied based on the extent of detachment with immobilization protocols lasting 6 to 8 weeks, partial weight bearing at three and a return to normal following immobilization. Patient demographics, surgical details and complications data were retrospectively collected while all of included patient reported outcomes and is promise measured by four validated tools. Number one, Victorian Institute of Sports Assessment, a questionnaire ba G number two, put action index FFI. Number three, the visual or log scale who can I VA SFA? Number four short form health survey 12 dot FFI was used as primary outcome with other problems as secondary outcomes due to a non normal distribution of FFI scores. Nonparametric tests were used with peri or action applied to upon for multiple comps are presented as medium and inter range I QR for pros and deal with the standard deviations for other data results. In this study of 118 patients complications occurring 14% primary minor surgical site infections being 78% and 32 reported issues with su the main follow up duration was 50 plus or minus 35 months. The patient reported outcomes measured by foot function index F I showed significant improvements over time. Final follow. Schools were available for all full recovery rates were 62% for FFI. 71% for visual log scale put on ankle and 53%. These are ad scores. Body mass index conflict were the only factors that significantly affected the outcomes. Overall patient characteristics did not significantly impact the extent of improvement discussion. This study evaluated the outcomes of midline incision approach without the complete development in treating incisional at least 10 I in 118 patients that the power is followed by two years. Full recovery rates ranged from 53% to 71% depending on specific outcomes measured. Yield postoperative to the main factor associated with the poor outcomes of surgical infection did not appear to influence the recovery. Although other surgical techniques may reduce the risk of conflict, they have not demonstrated better overall patient outcomes. Endoscopic methods while less invasive may not address all the related to I despite some indications such as retrospective design and the absence of a comparison group, this study provides a valuable outcome data. One of the largest patients who was treated with me, I inr the learning we thought was treating achilles tendinopathy resulted in favorable patient reported outcomes in both for one and four years, post surgery. However, 30 37% of patients experienced some residual impairment with postoperative conflict being the main converted factor. The findings suggest that developing comprehensive patient registries and exploring alternative surgical techniques may help improve outcomes for in ones with I critical. This study faced several limitations. The retrospective design restricted the ability to draw causative prices and made it challenging to for all variables that might influence outcomes. Conducting the study at a single center also limit the generalisability of results as treatment protocols and surgical expert may vary across different settings. Additionally, the options of a control group such as patient with end or al approach, weaken the capacity of attributes observed improvements solely to the techniques. The follow up rate of 63 b 4% as outcomes may between patients who completed follow up and those who did not. Although through conflict was identified as a key factor in poorer outcomes, it is unclear why this was only influencing factor. Further research into other potential anatomical or biomechanical contributors could offer more insight into residual symptoms and patient outcomes. Thank you. OK. Well, thank you. Thank you very much to Bhaskar for that er very thorough presentation. And I apologize to all of you for the slight technical problem with the sound at the beginning. Um, I hope that's now solved. Certainly, I could hear it the second time around. So, um, a fascinating paper. Um, I'll give the floor now to the senior for that paper. Sebastian Baum from Munich who will, uh, take us through his thoughts and initial reflections, er, on that paper and then we'll take some questions from the virtual floor. So if you do have any questions to submit, please er pop them on the chat and then we will er put them er to Sebastian. Thank you, Sebastian, over to you James. Thank you so much. Um And thank you the both of us for giving me the chance to, to talk about our paper. First of all, I'd like to thank my coauthors, especially Rubert her, the first author, Professor Walter um for the great efforts, it's on, it's always a team effort and without the team, we cannot address any of these topics. I was asked to talk a little bit about the limitation. My thoughts on research on tendinopathy and research in general. Um Thank you very much for the, for the nice introduction of the paper and when I look at the critical appraise, I actually just took a screenshot to get it dried. It was stated that the retro retrospective design obviously is a issue. It always is. Um it was stated that it limits the causative interference and makes it harder to account for all relevant variables. In uh influencing the outcome. So my approach to research in general is what I think is really interesting, especially with foot and ankle. Once you start digging into literature, you're gonna find little we know to, to more or less none of the things we are doing. We have really solid evidence and at some point, we have to start and often a retrospective design is a good way to start. I think even in a retrospective design, and this is why I don't fully agree with the presenter, we can account for variables influencing the outcome. And I think we can even closely account for them as good as we can do with a prospective study. What we cannot do compared to a randomized controlled study. We can we have a way harder time to have equal courses that we can compare to each other but still having a retrospective study with a considerable amount of patients, I think is a good starting point. If we think about pathologies, if we think about our treatment, how we can improve it, we obviously have had a loss to follow up rate of 33%. Again, that is a risk that might bias our uh research. It can either be that the very good or the very bad did not answer our um our questionnaires that we sent to them. And obviously we had no comparison group with uh which is a other problem with the study. To me. The major problem of that paper is that the patient cohort or maybe that's due to the pathology itself is heterogeneous with respect to the pathologies present. And there was no standardized conservative treatment regime. All of these patients were referred to the clinics due to failed conservative treatment by an outpatient orthopedic surgeon. And this initiated surgical treatment for us further points that might limit the the interpretation of the study is that the refixation of the Achilles tendon was not standardized at the institution. Again, it was a single center study, but a multi surgeon study and there to to a certain degree, we tried to standardize the treatment and the diagnostic, obviously, they are not going to be perfectly the same. Um And for us, if you look at the biomechanical literature, if you detach the achilles tendon for more than 50% you're supposed to refix it because that's going to increase the biomechanical stability. Obviously, we did not quantify the degree of detachment was up to the surgeon to judge whether he or she would refix the achilles tendon or not keeping that in mind that having refix the achilles tendon that would dramatically change our POSTOP rehabilitation regime. If we refix the achilles tendon, our regime would be way more would be a lot slower, would be more similar to a rather restrictive achilles tendon rupture regime compared if we had not refix the achilles tendon, that would have made it a lot more progressive with the rehab regime. Um These are points I think we can discuss. And there's another point if you actually look at the study, we had this pretty big chord of more than 100 patients with a follow up more than four years and of almost 8080 per uh patients, we actually had a longitudinal follow up. And based on that co we not only published one study but turn out to finally publishing three studies. This again is a limitation. You, you're more uh it might be that I'm just a lazy guy, a lazy researcher. But at a certain point when you do research and you try to answer different questions, you kind of run out of the scope for a single paper. And this is what, what we actually accounted. And one more thing that we actually look into from that point of view. And as I said, initially, my predominant motivation for research is that I see a problem in the clinics and I kind of ask myself, do we have to do it that way or are we doing it the right way in general or do we have to question our approach? And if you then start looking into literature, you're going to see little evidence is there. And I think this accounts for achilles tendon like insertion tendinopathy more than to a lot of other pathologies. Only in 2011. Van Dyk actually started to classify, I per the underlying pathology and subdivided the insertion of the achilles tendon into three different compartments that would be retroocular intra and preocular. And in each of these compartments, you can have different pathologies present either on MRI or radiographs. These include pre and rich achilles, bursitis, partial tears of the achilles tendon close to its insertion, tendon, intratendinous degeneration, bone marrow edema, and the HL exostosis diursal spores or intra intratendinous calcifications. All of these two different amount had were present in our patients. On at top of those parameters, there are various morphologic parameters that have been associated to I for example, the follow Philip angle, parallel pitch lines, calcaneal pitch angle and the length of the calcaneus. But especially if you look at those radiographic measurements, they become significant in actually one study. And that was the study introducing those parameters in each and every other study. They did not turn out to be a significant influencing factor. And I think if we look at all of these parameters and that was the scope of a second study that we did, we actually tried to see does any of these preoperative parameters does have an impact on the actual outcome on our surgical outcome. And actually, we almost as we assessed 13 different parameters and none of them had a significant impact on the patient rated outcome at any time. It actually didn't even have an impact on the preoperative values when we talk about how to assess the patient rated outcome. We always look at prompts. This is what usually is asked from us to do. We need to kind of measure the outcome, try to quantify by patient rated outcome measures. We actually had several patient outcome measures. And if you look at the study, we did choose one of the weakest problems. If you look at how they are validated on one of the weakest problems as our primary outcome parameter. And that was simply due to the structure at some point in the hospital, we've set the FF as the standard outcome parameters. So that was assessed just on a routine basis from every patient. And obviously for that, that was the only parameter we had longitudinal data of. So we did set this as a as our primary outcome parameter. The FF E is uh the, the visa fr is the most valid, the best validated outcome parameter. On the other hand, if we look at those pace rate outcome parameters and that's independent within the foot and ankle ba batch of outcome parameters, we have for all of them, we see a ceiling effect and we have a proper problem discriminating the good from the very good. And this is why we get the ceiling effect. This is why we should not, this is why we should test for normal distribution. And at least from my experience, they these patient rate outcome measures are never normally distributed. So they, so we have to do nonparamedic testing. We have to talk about the mean and the median rather than the mean. And due to the ceiling effect, those, if you only look at the average parameters, they usually look pretty good in the different studies, which actually just now working on a systematic revue, looking at the long term outcome, that would be more than 10 years, 10 years plus following ankle surgery. And you're just astonished on how good the outcome parameters are if you only look at the average. And this is why I think this is another nice twist we did to the study, we did not only look at the at the out at the average of the outcome parameter or the median, we also tried to quantify how many patients did not reach levels that are considered physiological. So which had some residual impairment and and these were more than one third, 40% of the patients had some residual symptoms. This is just important for us to tell our patients the meter approach to addressing all of the pathologies present, at least in Germany still remains the most common approach. On the other hand, initially, I talked about the different the different radiographic parameters, the different pathologies that are associated to insertional tendinopathy. There is no way for us to tell which of the individual pathologies is actually causing the pain because all of these pathologies individually are present in asymptomatic patients as well. So maybe the meter approach by itself is just over treatment because we simply attack everything despite we might not have to do that. And if we then look at the data and we see that complications, for example, did not have a significant effect on the outcome. But the scar did that was the only outcome parameter that we could identify that maybe must, must make us rethink is the meter approach the right way. So addressing every pathology or is the surgical approach, just we did a midline incision right over the achilles tendon, is that the right right approach? Would we rather go para Acular? There are Y shaped approaches. There's also the Cincinnati approach which I think only is partially comparable to the other approaches because you cannot address all of the pathologies. I think this would be a first start James on, on my perspective of the pa of the paper and insertional tendinopathy. I'm really happy to, to push the discussion further based on any questions that uh might be out there. Sebastian that that's really helpful. Thank you. That was a very, very thorough um review and reflection. So, so thank you for that for your time. Um II think uh we would all concur that every time any of us delve into the literature, small heterogeneous groups case studies level four is about as good as it gets for the vast majority of things that we look at. So thank you for making a start. We do have a few questions. Um, some of which you've sort of addressed from Ben Hickey. How did your sf 12 scores compare to the general population or a similar cohort of patients who didn't have surgery? Now, obviously you didn't have a conservatively treated group in that because of the way the German system works. And just to explain to other UK people if I understand it correctly in Germany. A lot of orthopedic outpatients is done by orthopedic surgeons who don't then do the surgery. There's a sort of stage between general practice and hospital orthopedics as we would know it. So that's a, a way of managing things that we don't have here. Do you have any thoughts on the SF twelves in achilles and often in the general population? Or is that entirely unfair in the light of your study? I think that would be pretty unfair to, to, to that. Ok, to be honest, fair enough. And I, and I'm not sure that we, we at least post surgically, those quality of life scores I think are always kind of hard to assess because if, if you only have problems with your leg, when you walk up the stairs, your general quality of life is gonna be fair. So I'm not sure whether the SF 12 at least post surgically, is this a fair parameter to measure? Ok. To, and there was a question from our, um, er, eminent Guildford colleague, Matt Matt sole to us to clarify the surgery. So, um exa exactly what was the technique? So it was a midline achilles splitting approach. It was a midline incision transaxillary approach. We then would detach the achilles tendon as much as needed from its insertion and then debride anything we could find, we would take away the Heartland. If there are any dural spores, any intratendinous calcifications, we would remove these if we identify any area of severity of degeneration that we could visibly identify. We would also debride that after that, we would close the um we would suture the achilles tendon back together if it had been detached more than 50%. Um And the surgeon had the feeling that he or she had weakened considerably the insert and we would reattach it with two anchors. Um Otherwise we would do a regular skin insert, er, skin closure. Ok. And that, that, that's actually the, the midline approach is what I normally use for doing this personally. Um Did you encounter much in the way of wound healing problems? You mentioned shoe irritation long term over the scar. But what about primary healing, slow healing or delayed healing or infection? We didn't assess that, but at least in the long run, this did not have an impact on the um on the patient rate outcome. And I think for those patients who, who would have had a major complication, these as well as the very good ones, these might be the two ends of the scope that we are missing in retrospective studies. OK. Fine. I think that's a reasonable. Um The further comment from Mr Solomon is not this then maximally invasive surgery. I II think unashamedly it is, it, it would be my understanding of, of your your presentation so far. Um It, it definitely is maybe James, let me raise one point there. How we have changed our approach. I think the major issue we have with insertional tendinopathy is that we don't know what is the actual carving pathology. So ours go like with, with the next talk with, with a, with a closing wedge, osteotomy, osteotomy. I don't have too much experience with that. But what we usually do is when we have a patient with failed non operative treatment for insertion on tendinopathy of the achilles tendon, we would tell them that we do a single shot injection at the insert of the achilles tendon with just local anesthesia. And if that works well, if that decreases the pain to a degree that the patient is sufficient, we would offer endoscopic surgery and just address anything in that area that we could address. Uh um endoscopically independent of whether we see a DSAL spore if we see Intratendon calcifications or degenerative changes within the tendon, otherwise we go full aggressive. Ok, great. Um Have you thought about any other surgical approaches, poster lateral or anything like that or do you if you're going open. Do you always stick to the midline? We usually always do the midline. But as I said, that that might be the problem. I'm trying to push more into endoscopic procedures. I think it's, it's just way more beneficial to the patient. The rehab is a lot faster and if it does fail, we still have the option to, to, to go for procedures. But, but maybe we have to rethink our incision, especially if we take into consideration that one third of the patient is still suffering residual symptoms from the skull. Ok. That's fine. Sebastian. We must move on. Um So thank you very much for sharing your time, your experience with us. Uh do feel free to stick around and join in the discussion for the next paper for Zade. Um So I'll hand over to my uh colleague, Nil Vas Kuti to introduce the second half of the session. Thank you, James. Uh Thank you, Sebastian. Uh We'll move on to the second paper. Uh This paper is on Zaric Osteotomy. So, the title is Zaric Osteotomy, a good treatment for Refractory Hagland Deformity. This is from the Nottingham team. The senior author is uh Mr Sunil D. Uh Sunil D does not need any introduction in any foot and angle uh circles in uh in UK. Um So he's um just retired after a long career in Nottingham University Hospitals. Um He's, he was a past both first president, I think it was 2010, if I remember right, that he was a first president. He's quite well published. He's at least in this region. He is a good two person uh for a lot of uh senior orthopedic surgeons with any problem cases. Uh He's uh trained so many fellows who are all well established consultants all over the country. Um This paper is being presented by um Senior Register on the Well Rotation uh Mister Gianluca Gonzi. So I'll hand the stage over to uh J Luca who will present the paper. And after that, we'll have uh a discussion with the senior author. Listen to his thoughts and reflections. Good evening. My name is John Luzi. I'm finally a registrar training in the Welsh scenery and I'm interested in the I thank the training the German Club for giving me this opportunity to present in this evening's China club on the social. And I'll be presenting a paper on a good treatment option for a fracture deformity which was published in 2023 by, by Sun. So this is related to insertion achilles tendinopathy. Um This is a degenerative process involving insertion of the achilles tendon and can be associated with a bursitis and he pro and deformity. This can be found in up to three in 1000 of adults and as high as 52% of male endurance runners. The treatment options predominantly non operative in the form of eccentric achilles stretching exercises and occasionally extra corporation wave therapy. Uh operative strategies include soft tissue surgery in the form of achilles tendon, debridement, attachment and occasion in transfer. This can be associated with um uh relatively high complication. Uh in a systematic review, this can be as high as 23% and with a 3.1% major complication of the kidney rupture and and deep infection. Uh So Xanax is to me, uh was originally described in 1939 by an American surgeon named of. Yeah, it is a deterrent process involving insertion of the achilles tendon and can be associated with bursitis and he prominence and deformity. This can be found in up to three in 1000 of adults. Uh and as high as 52% of male endurance runners, the treatment options predominantly non operative in the form of eccentric achilles, stretching exercises and occasionally extracorporeal wave therapy. Operative strategies include soft tissue surgery in the form of achilles tendon, the bride and detachment and occasion. And this can be associated with um uh relatively high complication in a systematic review. This can be as high as 23% and with a 3.1% major complication rate of the kidney rupture and deep infection. So to me, was originally described in 1939 by an American surgeon named is Z and originally described this for patients wearing pie heats with what he termed the killer bursitis in which he proposed the dos of closing were just over the OS CAL, the effects can be summarized into three effects. And by performing a dorsal closing or gas, you reduce the heel prominence by tilting the posterior prominence anteriorly. This acts also by elevating the insertion of the achilles tendon uh similar to an effect by an achilles lengthening. And it start to reduce the pinge between the fibers of the achilles tendon and the posterior surface of the OS Calcis. As part of my review, I've looked at some biomechanical studies. And in summary, there are three main papers that uh demonstrate this and one studied by Paracet, a cat study and also called G did reduce the retro pressure by up to 44%. It did reduce the posterior strain in the uh the strain of the posterior fibers of the kidney tendon. But this did not reach statistical significance and it did elevate the insertion of the kidney tendon around 3.4 millimeters. A vertical simulation study shows the radiographic by, by the hotel in the radiographic implications following as the do you wish to follow this can be by 14 degrees and the cal pitch angle by 4.6 degrees. Um is a clinical biomechanical study showed that um the ankle dose effect can be improved with a dose of closing gastrectomy on the osis by around 7.27 degrees. And they've also reduced the and their series by 5.5 degrees. And I put the reference is below. Um So going back to the paper, this um this was published in curious journal in May in 2023 in essential for single surgeon series. And the experience with X for refractory hads deformity. Um This involved 19 patients, approximately 20 heels. All patients in their study had six months of conservative treatment with modified footwear and physiotherapy. All patients were assessed with an MRI scan to exclude alternative causes of posterior healing. A last review, weight bearing radiograph was taken pre and postoperatively and the Fowler and P were measured on the PAC system. The Man Manchester Oxford foot questionnaire was used preoperatively on the third month. Post operative mark was assessed by a telephone follow up by the study authors and the statistic analysis was performed with the student T and AP correlation coefficient and going to the operative description by the authors is as presented in their paper. Um As an approach, extended lateral approach to the oscal was performed. The 10 was not visualized or debrided and the apex of of your was planned posterior to the attachment of the plantar fascia um in which 22 limbs of the soy were performed the vertical limb. And uh second of around 10 millimeters from uh the vertical limb and the dorsal closing wedge was uh excised in maintaining the integrity of the plantar cortex. This was then stabilized with a two hole one per tubular plate. Um The post protocol uh was six weeks, normal weight bearing in a plaster followed by six weeks weight bearing in a boot and then returned to normal footwear at the 12 week mark. Uh going to the presented results and the patient demographics, the average age was 53 with a range of 24 to 74 with a male female ratio of 7 to 12. Um There were no major past medical history represented by the authors and the authors state that all patients were I stated fifth and well. And the clinical outcomes, as mentioned earlier, the word foot questionnaire was used and the higher score indicates a worse outcome. And there was improvement in all domains from foot pain, walking, standing and social interaction with the total reduction points of 108 in the autistic. There were no wound or any complications following the procedure. The authors also give us an indication from the radiological outcomes and improvement in these parameters with an improvement in the foul Philip angle and also the the pitch angle of around 1.3 degrees. In summary. Um This paper shows that uh the cystectomy is a safe and effective procedure, refractory, symptomatic ags deformity. This is associated with low rates of interim postop complications and patients had a sustained clinical improvement at the 12 month follow up. And the authors state that while an improvement in the fall of Philip angle does lead to patient related scores, the authors state that they focus should be on the patients symptoms rather than radiographic measures. The authors also acknowledge a limitation of study with small numbers and this is a single surgeon case series. Thank you very much. Thank you. Thank you J Luca. Um for the nice uh concise overview of that. Um I'll uh and the stage to uh the senior author Mr Sunil, um who will give us his reflections um of his experience and the paper. Thank you so much. Hey, thank you Nigel. Um Good evening everyone and thank you both for, for your invitation for choosing this paper. Uh Thank you John Luca for your presentation and all the attendees. Um Some of whom, of course, I know. So look, this paper isn't um scientifically, we all recognize up there with the best. So it was, it was a couple of um um trainees who um wished to look at this um uh aspect of treatment for insertion achilles tendinopathy. And by the way, we seem to have far fewer numbers than, than the German group. Uh Certainly um not in the 100s. Uh I it is, it is a condition that occurs um less frequently than say achilles tendinopathy, of course. Um Nevertheless, it's a, it's a condition that really has bugged me over the years uh in terms of how to manage it best. Um Just as a background. Um uh The midline approach with the achilles tendon splitting approach was what I did for several Um Well, for the first decade of my practice as a consultant. Um and that was purely to debride AAA really nasty looking tendon with lots of uh new bone calcification. Uh and or um Calcaneal tuberosity changes. Um But I was never very happy with the outcome of that. And I think the, the Sebastian's paper really bears that out when you have a third or more patients actually struggling um after surgery. Um It, it can't be a very happy place to be in. That was my background until I was introduced to the Zic osteotomy by a friend and colleague from um Zurich um Pascal rubs. Um and he mentioned this procedure way back in the north at a meeting to me and said that it's, it's something that he's found that works pretty well for this condition. And he was really seeking a better alternative than having to take the achilles tendon off. And of course, since then, I have been utilizing the ZAD procedure. So coming back to the paper, we had a couple of trainees who wished to um study this in, in further detail. And one of the things I said, look, um you're not going to find tons of patients with this procedure, but what may be useful is if you studied a group with from before and after, um then you might be able to get a handle on, do they actually do? Well, I know in my hands, I am much happier with this operation for this condition um than um anything else that I've tried and you can, you can prove it or disprove it. Um And so that's why we got and Mox E had just come in then. And so we started using the Moxa FQ for, for subsequent patients till the trainees left. And then um they subsequently wrote the paper. So I think the follow up is, is off about six or seven years um between the last patient that was done and by the time the paper was accepted for publication. Um So, so overall, this is just a reflection of how you can utilize a retrospective study, maybe to prove to yourself and to your general group, the point that something that you've been, you believe in um may, may actually have the results that you think um are, are valid and that substantiate your, your reason for doing that procedure. It's also very true. And, and what Sebastian said earlier was that the pathology is complex in certain achilles tendinopathy um involves the tendon, the bone and the other soft tissues around it. And I was always reluctant to operate on it. Um uh with a view to how much can you take. It's not just a case of taking off the um the excess bone that's formed around there or a bit of disease tendon because the biology has to be much more complex than that to cause all of those changes um very different to uh as we know to achilles tendinopathy, which is limited to the tendon and maybe the paratenon and the surrounding soft tissue. So, so this insertional issue was always something that, that really bugged me with the, with the zan osteotomy. It was quite evident to me right from the start that if you took a, a wedge of bone away, which was superiorly based, then, then it actually reduced the bump at the back, which was one of the main issues that patients came with because that was the painful bit, rubbing on shoes. And that was very obvious in, in the first few cases that I did that, that bump was reduced quite substantially by moving the posterior bit of the calcaneum forwards. The other thing that was quite obvious was that you actually increased the, the dorsiflexion of the ankle. In other words, this, this, this resulted in a small lengthening of the achilles tendon. And you know, when you think about these things and, and you look at your results and you're happy that your patients are doing well. One of the reasons on reflection that we thought that the, the, the the procedure worked was it reduced the tension on the insertion of the achilles tendon. And that must be a factor because there has to be um uh something to do with the vascularity with the tension at the insertion, causing all sorts of issues. And if you look at some of the MRI scans, you see the substantial amount of um bony changes that occur at the insertion sometimes within the calcaneum, a lot of bone bruising around that area other than um uh tendon tearing, et cetera. So, having, having um done a few of these, we then uh said about um looking at where to place the apex of this osteotomy. And again, um from the initial stages, it was obvious that the best effect on the posterior bump was when the apex was actually more posterior um ie towards the back of the heel um than towards the middle of the calcaneum. It also reduced the tension on the plantar fascia. So plantar fasciitis became much less of a problem fixation of the approach to the osteo is is very straightforward, very simple. Um doing the osteotomy again, is an extremely simple thing to do. You take out a wedge, you can measure the superior uh amount of uh the base of the wedge that you need to take out and then closing the osteotomy, leaving the post or the planter um cortex intact. You then just simply dorsi flex the foot and the osteotomy closes very nicely, almost like a book. And then you fix it with a very simple fixation method that we had a very cheap fixation method, which is a two hole third ul of plate. Later, we'd also introduced a derotation screw because one of the patients had a fall and then um twisted their osteotomy around. So, so um we introduced a derotation screw for that purpose, which was just a cortical screw, a 3.5 cortical screw. Uh and then postoperatively, they are in a plastic cast for six weeks and they mobilize after that, if they need, they can uh you can provide them with a boot if, if they struggle to mobilize. So, so overall, I think with the paper has shown that the proms are good on these 19 patients. Um Clearly they're not the whole cohort of patients, but these 19 were studied by uh uh by uh our two trainees who actually then went on to write this up and, and submit the paper. And II think there is a place for this because a uh you don't take down the achilles tendon. We've never actually exposed the insertion of the achilles tendon in any of these patients and they haven't come back with rip roaring um tendinosis or opathy or um tendon ruptures afterwards. Um Thankfully, we've not had any major wound issues with um this approach and um you know, and or a problem with DVT stroke P ES following this procedure. So, as things stand um for a clinical diagnosis of insertional achilles, tendinopathy, substantiated by X rays and um and an MRI scan, uh this is our standard uh go to procedure. Now, nothing follows your, your, your, your good results and long follow up. And I've been doing this now for a very long time. And I remember last year when I was disappointed to see one of my original patients come back with quite considerable calcinosis at the insertion of the achilles tendon following azotic osteotomy about, I don't know, 15 years back. And at that time, we did take down because the lump was so extensive and into the achilles tendon, there was no way that we could have reduced it simply by doing a ZIC or repeating the Z. So we had to take the achilles tendon off to remove that quite considerable amount of pain. And, you know, I've got it in one of my own presentations as, as a, as a um sequel, a long term sequel, perhaps of uh a the condition and perhaps even um the procedure. So, so things, things of course, are never perfect, but by and large. Um this is a procedure that uh does give patients good pain relief gets rid of that posterior bump um to a substantial extent and its complication rates are completely within acceptable limits. Um So, I don't know, as, as a journal club, as a paper, people can make up their own minds about how the, how scientific the paper is, but as a procedure for this difficult condition, um uh uh we, we've shown that patients actually do have clinical improvement. Thank you. Um Thank you. So that for that nice overview. Um Can I ask, you know, you talk about your case selection. So you, you mentioned in your paper six months of failed and non operative treatment. So um is that non operative treatment in your unit? Um by with your physiotherapy team, I asked this question specifically now because a lot of patients come to us from a variety of providers now because from the GP, they go to an like team, the M SK team physios treat them, some of them, uh, treat them with just physios. Some of them with the orthotics, some of them is shockwave treatment. So they come to us after varying amounts of, of non operative treatment from various providers. So it's difficult to standardize that, isn't it? Some of them come two months after the problem starts, some of them come to us a year after the problem starts. Yeah. Have you? So, it's exactly the same in, in Nottingham as well. So, patients came, um, um, came from all sorts of providers. Um, some of them we treated in our own unit as you would rather than send them off to, um, um, for surgery. Um, but a lot of them came after many more months of conservative treatment and having tried orthotics, um, shock wave physio, um, et cetera, changing footwear, changing jobs even. Um, so they weren't just particularly in the unit treated in the unit. Um, and, um, and, you know, they almost inevitably had quite substantial irritation at the insertion, big lumps, um, at that area and were struggling. A lot of them couldn't actually put their heel down, um, completely and, and, you know, a, a bit like, um, osteoarthritis, they go through phases. Some of them, you know, and, and then they have a period where things are kind of more bearable and, and, and the whole cycle repeats it. But most of them, in fact, in all of them, we wouldn't go straight to surgery, have had all sorts of conservative treatment. But it, it's interesting, you know, where, how do you define the condition, the definition of this? Um including there, I say Hagland deformity, you know, um where you get, you get this, this large posterior uh prominence um base and on the basis of that, all the radiological um measurements have been done. Now, we didn't find a huge amount of difference in our pre and postoperative um calcaneal pitch angles. And I can see why we didn't find that because our apex was so far posterior that it wouldn't actually affect the pitch of the angle substantially. And the fo fler angle is prone to measurement error. In fact, if to xy um ratio in my view. And then certainly in my hands, when I tried it latterly, uh since its publication uh uh of measurement in our patients, I found it a pretty variable um uh index to measure and base my treatment on. Um So, you know, we, we didn't, we didn't measure that in our patients. So if you for, for the or II, I'm sure this is something that's gained traction laterally. And eve gives a very good talk about it about measuring the xx um length of the superior part of the calcaneum. And then the overall length of the calcaneum coming to a uh an xy ratio um which, which then determines what sort of treatment he's gonna give the patient. But again, that depends on how good your x rays are and where you think the the edges of the bone are. And, and, and that can be quite a tricky proposition to be like that. So I think that answers Mr has or oar's question, I'll go to another question from the chat box from uh Matt Sole. Uh So Matt Sole is a term of any relevance in 2024. And he uh he's uh picked up one of the slides showing a big spur um but possibly no true Hagland. And he's asking, is it relatively rare for a prominent Calcaneal tuber prostate to be the only or the main problem? Well, I fully agree with Matthew uh in that, in that um when you find this prominent um bit of the bone at the back of the calcaneum, we always excise it. So, you know, through this approach, it's very easy to do. You just take an oblique um um cut through this bit and, and, and that's not a problem, but it's not always present. And I think I agree with Matt again, that, that slide, which showed that huge amount of calcification around the back. Um uh Sometimes that can be, that can be the, the, the only visual pathology on an X ray rather than a Hagland deformity. I mean, the, the term Hagland it's been described, people have used it over the years. So I II don't see any particular reason to disregard it, but it's not inevitable that it uh it's not the only pathology in there. That's the recognition that the pathology is much more extensive and much more biological than a simple mechanical irritation from a prominent bit of burn on the front end of the tendon. I think it's much more than that, which is why it's so tricky to treat um by simply debriding that bone. Yeah. Thank you. Let me see if there's no other questions. So again, um ca can I ask regarding your approach, your incision has the extended lateral approach been your go to approach for these cases because you know, there there's always been this question about, I mean the problem of using this approach for Calcaneal fractures. Most people after the heel trial, people are going away from the ex interlateral approach and going to minimally investing approach for the Calcaneum. So do you still doing that? I understand that this approach in a trauma patient can cause problems and has caused problems. But this approach in an elective patient shouldn't by and large cause problems. So, so I think they are completely two different things. So you can't blame an extended approach for, for if it's not used in, in the right scenario, in the right environment. Um It's a, it's a really good approach. What, what can perhaps supersede it is an Mis Calcanea lost Omy. And I think Anthony Perreira wrote a paper on that several years ago on mis osteotomies. And I think, I think there's a place for that. I'm also reminded of uh Paul Cook doing Malc Osteotomies and getting a non union. Now, you know, you've got to really try very hard to get a Calcaneal Osteotomy non union. It's a bone that wants to unite and as long as you fixed it properly. So, so for me in my hands, um uh this, this has worked really well. Uh I think it's a, it's a pretty um good approach. It's a pretty safe approach. Um But people who do a lot of mis stuff, um you know, whether you can mobilize patients faster or not. I don't know. I don't like the mis fixation of a cal osteotomy because you've got to go through the insertion of the achilles tendon again to put your screws on. Uh unless um people have found other ways of doing it. I don't know. But, but I think, I think it works. Thank you. Thank you very much. Um I think we've had a very lively discussion with both the papers. We're just five minutes past uh nine. We, we had a slight technical features, so with a slight overrun. So thank you very much uh Sunil and thank you very much Sebastian. Um I'll let uh James take over and uh close the session. Ok. Well, well, thank you very much uh to, to all of our speakers, to Sebastian, to Sunil, er, to Nigel for Charing and to me for the it and once again, I apologize for our little technical hitches there. Um So there you have it, ladies and gentlemen. Um the the hot Poch for sort of the of insertional achilles tendinopathy. Are, are you, are you a zec osteotomy? Are you a tendon debrider and, and, and splitter? Do you swing both ways? Maybe there's a role for everything. Um But you, you've heard it all here tonight. So um thank you to our, our senior authors to my co show me. Thank you particularly to our, to fellows presenting Baskar Baa and Gianluca Gonzi. And of course, thank you to all of you uh for joining us this evening. I hope you have a good evening and uh we will see you all again. I hope in 2025. So uh thank you very much and uh good night. Just the final thing is do do fill out your survey and then you'll get your certificates but probably no Christmas Cracker or special present under the tree. Take care. Thank you very much. Thank you very much.