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Good evening. All. I hope you can see me and you can hear me uh A ve very warm welcome to part two of our Master Techniques webinar series. This is number 12 Master Techniques uh webinar uh BOFA. Uh And we have the two speakers who gave an excellent talk on Mal Union falling ankle fractures. And we have invited them to talk about malunion following Calcaneal anillus fractures. Uh Before starting the webinar, I would just like to uh do a couple of housekeeping announcements. The first one is that you can put your questions through the Q and A and after the two talks, we'll have time for discussion and I'll present those questions to Nichols and Stephan, our guest speakers. Uh The second uh announcement is that once uh we finish the webinar uh immediately you should receive a feedback form. And once you have filled it in, then you will be awarded the certificate of attendance for the Master Techniques of BOS. Um As you know, we alternate master Techniques with general clubs. So the General Club uh for BOFA is next month and then we'll be back again in June with another episode of master techniques. So let me um invite uh our first guest speakers. Uh NCOS Goglia, a very good friend and colleague uh member of the Education Committee of uh uh European Society, uh great educator, uh and likes dealing with complex uh reconstruction and deformity correction. So NCOS is going to talk today about how to deal with malunion following calcaneal fractures. Uh And I'm going to hand over to him once he's ready. Uh Thank you, Manish honored to be invited again for this uh Mas Technique series. And my topic today is my Union of Calcaneal Fractures. And uh those of you who are familiar with the UK uh Heel fracture trial uh and that publication in the British Medical Journal uh uh about 10 years ago now might think, why is it, is that topic important? Do we uh do we have problems with Mal Union since there is no difference in clinical outcome, whether you fix calcaneal fractures or not? And actually what this uh study highlighted the high infection rate with surgery. And if you look at the front page of the British Medical Journal of uh 10 years ago, it says surgery provides no benefits. However, it does not say that the results of treatment, whether operative or non operative uh were quite bad and the outcome scores uh were are about 60 to 70 out of 100 and the s of 36 score of, of general health I would say is similar to that of patients with chronic illness. And actually what this uh trial, which is scientifically sound uh show that uh whether you operate or not these uh uh patients with calcaneous calcaneal fractures do not do well. And that probably takes us 100 years back. Uh with that statement in the uh J BS uh uh in a different era that said the these people have serious problems. The patient with a mild unit Calcaneal fracture is typically this type of patient who comes and says, well, one shoe must be bigger than the other. I have instability. I have constantly pain, I'm limping and there is impingement and, and uh on the outside of the leg. However, uh you have to bear in mind that this a fracture like this was excluded from the hip fracture trial because that type of fracture was uh fixed uh and was excluded from the trial uh as well as these structures which constitute an orthopedic emergency uh that can result in soft tissue problems and these should be fixed as emergency surgeries now. And uh just a few words about the trial to avoid any confusion, whether we need to do anything about these patients with calcaneal fractures. There was uh as highlighted by other uh ations selection bias in the trial. As of uh 2000 patients with calcaneal fractures and 500 were eligible to only 7.5% consented to participate some had uh a treatment preference and for some others was there was a reason why they were managed operatively or non operatively. So, uh yes, the study uh the methodology is OK, the results are valid but the interpretation was wrong in the way it was presented in the British Medical Journal uh a few years ago. And it does not say what happens to these patients who have a malunion, whether treated operatively or nonoperatively in the long term. Because what we we know from other studies, the result of a subtalar fusion in a patient who has a normal uh uh calcaneus. So the shape is normal and the mechanics is normal is much better than the outcome of a patient with am uh calcaneal fracture. And remember this fractures in the first place when we have the acute fracture. First of all, we have a high but injury to the cartilage in the joint. And that is likely because osteoarthritis in the subtalar joint and then we have a high energy injury to the bone. And that changes the, the shape of the calcaneus, the shape of the whole foot, the the mechanics of the foot, it causes impingement on the outside with the perineal tendon, sometimes neuropathy in rarely known union. And this is how we assess these fractures before or after surgery with this uh two dimensional radiographs or uh uh more accurately with a 3D imaging. So, with a CT scan and what we will see when we see in the acute phase. A noscal fracture is that the pill will go into various or valgus. There will be loss of the uh can the lateral wall is likely to be bulging uh on the outside, the width of the heel increases. Uh And uh uh overall, there, there is a difference in the shape of this uh bone. So if it is uh left to unite in that position, uh it is very likely that we will get subtalar uh joint, arthritis, impingement of the peroneal tendons, impingement of the uh Calcaneus uh onto the fibula. The ankle joint will not function normally because the uh shape of the hind foot uh and the mechanics have changed, the insertion of the achilles stone will be elevated and the gastroc. So uh complex will be weak. Uh The calcaneus is generally uh short and that uh affects the uh windless mechanism. There is various old vuls deformity and the leg is likely to be shorter. And as I come back to that picture, the typical patient with a a Calcaneal fracture malunion uh who has a wide heel on one side, swollen leg, painful, unstable, lots of the time. And he says there is something clicking on the outside and uh symptoms associated with impingement and pain. And in 1996 Stevens and Sanders came with that uh malunion classification type one is those those uh uh patients who have a lateral exostosis or uh extra bone on the outside of the calcaneus and arthritis affecting the lateral part of the subtalar joint. On some occasions, the whole of the subtalar joint is affected and sometimes the Calcaneal body is uh malun, but it doesn't say a lot about any uh subtypes of this type. Three. What sort of differences in shape we have? And then uh uh the, these uh authors reviewed some uh uh cases they operated on and they uh recommended for type one. So when there is uh only the uh the later half of the Subtalar joint affected, you do uh you don't fuse, you do a cystectomy and perineal tendonitis which you combine with an arthrodesis. If the whole of the subtalar joint is arthritic or with a bone block arthrodesis and osteotomy. If uh you have a malunion of the bone and out of the many cases they treated uh a fair amount was available for follow up. And as you can see in about 10% of patients, they did not fuse the subtalar joints or did joint preserving surgery. 90% received the subtalar joint fusion and the fusion rate was 93%. Now, uh uh Stefan Rummel and uh doctor came with another classification about uh which is uh a lot more comprehensive, I would say about 20 years ago. And they said type one is those structures where the subtalar joint is incongruent. So I would say arthritic. So if you have incongruity and virus or vuls of the hind foot, that's a type two. And in addition, if you have loss of the height of the calcaneus, that's a type three. And if there is any translation of, of the, of the calcaneus to the lateral side, uh if you see that bulging of the, of the, of the bone, it's a type four. And when you have a malalignment at the an joint is a type five and there are various treatment options. Uh One problem, as we said is the perineal tendon impingement of the neuropathy. If there is metal work from previous surgery, you can remove it. You can do an exostectomy of that extra bone on the outside debridement and repair of the uh uh degenerate the peroneal tendons and sometimes neurectomy. If there is stiffness, malalignment and arthritis, then you have to choose between uh joint preserving surgery versus arthrodesis. And with, for joint preservation. If you have, let's say one part of the subtalar joint affected, you consider an osteotomy or debridement of the scar tissue within the subtalar joint, uh possible arthroscopic or you go to an arthrodesis. And then you have to decide whether you do an in situ in situ arthrodesis or whether you want to uh uh uh uh uh destruct the uh I would say the hind foot using a bone block and whether you have to add an osteotomy to correct varus or valgus and do not forget that with all these operations, you, you may have to lengthen the gastrocnemius or the achilles tendon. Now, how do we decide whether we fuse the subtalar joint or not? Uh uh let's say selective injections, are they really selective? Is that accurate? I would say because there is spread in the surrounding joints probably best to use a SPECT CT scan to see where the pain is coming from, see which parts of the hand foot are really hot on the skin. Uh Let's look at this case. A patient has had a minimal invasive surgery for fixation of a calcaneal fracture. And there is some lateral hand foot pain localized in the sinus tarsi region. Uh We do a workout with the CT scan. We see a little loose body, possibly a screw causing the problem and some irregularity of the uh incongruity of the subtalar joint. One, he has to decide whether uh depending on the symptoms, I would say mainly whether they, they that joint can be preserved by just removing some uh extra bone, removing the screw or removing the scar tissue from, from the sinus tarsi. I wouldn't say there is any strong evidence to recommend that this is a really uh successful operation, but it can be considered an option for some patients, especially if you're not convinced that the there is really uh arthritic, uh a really arthritic joint causing the pain and there are some minor impingement symptoms. Uh different patient with um calcaneal fracture. In the past both medial and lateral hind foot pain across the subtalar joint. There are no metal implants as you can see that was treated conservatively. And one can see that there is some irregularity of the uh subtalar joint without any obvious malunion of of the calcaneum. Uh The subtalar joint is created arthritic whereas the bone joint is normal. In a case like this, one can consider an in situ arthrodesis, whether you do it arthroscopically, which is an option for in arthrodesis or open. Uh it doesn't matter. Uh And that can solve the problem. That was a type one, I would say a type two is the arthritic joint with varus or valgus small union, which again, you may be able to correct through the joint and even this procedure can be done arthroscopically if you are uh uh experienced enough, if you are able to correct, I would say minor virus or valgus through the joint without any major additional procedures. As you can see in this case, there is arthritis, there is valgus alignment, but there is also high a loss of height of the calcaneum. I don't think that you can treat it arthroscopically because you may wanna distract that hind foot uh and to, to, to get rid of the loss of height. So to increase the height of the hind foot by inserting a bone block and that can only be done through an open uh procedure to improve, not only the pain, but also the overall mechanics of the kind fop for destruction of the disease. Uh The case I showed you, I think at the beginning with a, a patient who is a smoker has, has had quite uh uh o only nine months before a calcaneal fracture in very bad pain. He's limping and he feels his hind foot is unstable. Something needs to be done about it. And unfortunately, this fracture was left untreated even if he is a smoker that could be reduced quite easily, even with minimally invasive surgery. Uh and he's a young patient with devastating pain, a wide heel, but without any clinically obvious virus or vuls deformity of the hindfoot. Uh And in this case and bearing in mind, he is a smoker. So maybe high risk patient for complications with major surgery. Uh Sinus Stasia approach is probably be preferable. And uh what I did here is I removed the bone from the lateral aspect of the calcaneum, used it as bone graft to, to do a bit of destruction. You see uh that we uh uh II go one slide back on the uh on, on the upper right, you see the FHL tendon on the medial side, incisions and you destruct the joint, you put the bone grafting there. Uh And uh you fix it the usual way. I used three screws here because I was a bit worried about the patient being a smoker or in other occasions where there is a significant virus or VGOs alignment, uh what we uh call a type four according to sweep. And Raul, then you have to add the uh Calcaneal osteotomy, uh medializing or lateralizing depending on the uh deformity. Uh And it in a little bit more detail in this case, again, young patient calcaneal fracture one year before treated nonoperatively in a lot of pain, uh lateral wall bulging and uh valgus alignment significantly on the heel. And so I decided to go for a major uh operative reconstruction here with uh Calcaneal osteotomy through the same L shaped incision, prepare the subalar joint. You see the uh translation, the ization uh of the heel there. Uh We remove that extra bone from the outside, nice to bone which you can use as bone block to put it in into the sub joint and do your destruction arthrodesis um as well. So, osteo correct varus or valgus, take the extra bone from the outside uh to distract the hind foot and do uh sub arthrodesis. Now, uh as I said before, do I always have to use? There is not much in the literature. Again, this uh authors from China show that uh uh only in 10 out of 100 and 27 cases, they uh they attempted joint preserving surgery. It depends really how bad the Subtalar joint looks on the imaging. And again, if you do joint preserve with surgery they recommend that you remove the lateral, uh you do a exostectomy and the v shape uh osteotomy to change the mechanics of the hind foot without fusing the subtalar joint, uh like in this case, correcting varus or valgus if needed. Uh But I would say in the vast majority of cases, you have to do a subtalar joint, arthrodesis because the subtalar joint is uh affected in the vast majority, I would say in 90% of the cases according to the literature. And that's uh my experience as well. So if you attempt joint preserving surgery in some minor minor uh uh in cases with minor arthritis, you might, you have to remove metal with an arthroscopy, lateral exsect toy plus minus osteotomy if there is virus or valgus and if you do an arthrodesis, you have to decide that it sits your orthodes or do I do a corrective orthosis if the shape of the Calcaneal body is affected, if there is loss of height, if there is significant varus or valgus. So what do I do? I uh when I see a patient is the pain coming from the joint or not? So that I base well, I do a clinical examination to see if there is just localized pain in the sinus tarsi or whether there is pain both in the middle, medial and lateral aspects or across the subtalar joint. And they do my MRI possibly spec is and maybe guided injection. Although not convinced that helps a lot. Then if the joint is stiff, if the subtalar joint is stiff, even if there is no significant arthritis, I have a patient with a uh hand foot that is stiff and painful. I can make it pain free and stiff. So I think it's probably best to do an arthrodesis uh to be, it's safer, I would say because you did one operation not to worry that the patient will develop tear joint problems at a later stage. And then if there is varus or valgus, significant varus or valgus, how much is significant? Uh I don't have the answer. The literature doesn't have the answer. You are the Calcaneal osteotomy, medializing or lateralizing calcaneal osteotomy. And if there is a lot of height loss of height, you do a bone blocker uh destruction uh arthrodesis most of the time. Uh So the take home message, I think Calcaneal fracture malunion is a big problem. And the best way to manage this is to try and avoid by doing uh surgery in the appropriate patient in the first place. And I would say with the uh techniques that are available uh these days with MS surgery and the sinus tarsi approach that is associated with a lot less risk of infection. Uh Any patient care is suitable for primary uh surgery. Uh If his uh calcaneus fracture looks bad enough and it is a big problem because it does not only uh uh the calcaneal fractures do not only cause arthritis but also uh change in the shape of the calcaneus that causes all the problems. Thank you for your uh uh attendance because that was brilliant, really, really good talk, take home messages and I will be, I'm sure there will be some questions we'll which we'll discuss afterwards. So let's move on now. And the second talk of the session, uh we are privileged to have Professor Stefan Ram with us who I would say is a master of mal Union of ankle and hindfoot. He has done a lot and a lot of publications as you have seen, Nichols has used this classification. Um Stefan is um a professor of foot and ankle surgery and the head of the University Hospital President. He's also a visiting professor in Child Un in Prague and is the Vice president of the General Foot and Ankle Society. So, Stefan thank you so much for uh coming. Uh and, and, and speaking to us uh on, you know, the male union of ankle and hind foot. So please educate us about the male Union of Talus Structures. Thank you. Thank you very much and uh thank you for the kind invitation. I hope you can see. Yes, we can see the full screen. This is the little town I come from a little smaller than London. Uh but a lot of foot injuries, a lot of construction and a lot of hiking in the regions around. And uh unfortunately, also we see a lot of male unions following talar fractures. The talus is a bone that you usually don't want to break because it is, it is all trouble. It is surrounded by joints by essential joints for the foot function. And even if there is a fracture that is outside the joint, a classical talar neck fracture, even then if it's malaligned, then automatically we have uh significant pressure re distribution through the adjacent joints and we will have trouble down the line and uh automatically we will have a three dimensional foot deformity. If you watch talus fractures long enough, no matter if they are treated well or not, the posttraumatic arthrosis rates will go at some point, maybe at 10 years, maybe at 20 years to 100%. That doesn't mean they will all be symptomatic or require secondary fusion. This is about 20 30% but it's a significant number. And the non unions typically arise from technical problems or from patients that have not been treated. Operatively. Avascular necrosis is a common problem after talar fractures. And we have to distinguish between necrosis that leads to a collapse like in that case shown here and necrosis that will automatically appear. If you do an MRI scan, a few weeks after a talar body fracture, the blood supply through the talar neck will be disrupted in any displaced fracture. So there will be some kind of necrosis in parts of the talar body which will not be clinically significant. And then of course, we will have a whole bunch of soft tissue problems around the talus if there is a malunion. So professor who was my mentor and I we tried to do a simple classification also of the tailor man. Sorry for the missing. Yes. And um so type one is a male union. So some part of the joiner of the body, there is a male union, but it's solid. Type two is a nonunion and type three is any of those with a partial necrosis of the talar body that does not lead to a collapse. Typically, that is about one quarter, one third of the talar body. Type four is a total necrosis of the talar body with collapse or with impeding collapse. And type five is septic necrosis or additional infection, which of course is the worst thing that can happen. So let's start with a simple one. This is the classical malalignment of the talar neck, the so called sea foot. In this case, obviously, the sea foot is a bit more pronounced because we have some metatarsal fractures that are are united. You can see the cat here. So it is all already kind of solid, but there is also a significant deformity in the hind foot as you can see from the clinical image. So this was a polytrauma patient, everything up to the level of the ankle joint was treated nicely. And then at the talus, uh the diligent stopped and uh just the K wire was run through or two K wires, one obviously dislocated. And this is the position of the talar neck, which is a significant varus malalignment of about 30 degrees. The joints are fine so far, they are in a bad position, particularly the t regular joint. And you can see on the media side, there is that typical zone of comminution which leads to a various malignment in the majority of cases where there is a malalignment at the talar neck. So what to do extra articular deformity, we can do an extra articular osteotomy. And there was the fear that if you do an ostectomy of the talus, this might disturb the blood supply. But if the initial fracture did not lead to a full necrosis of the talar body and you go with the osteotomy exactly along the same lines and you are careful with the soft tissues and with the blood supply, then no necrosis will appear. So here you can see the bone block of almost one centimeter was brought in from the medial side. This is the patient. One year later, you can see there is some uh still some change in the radiolucency of the talar dome, but the talus holds and uh the patient has a well aligned foot and uh we did care about the metatarsal which healed nicely with that uh axial mal union. But as long as they don't have a sagittal Mun obviously, this is very well tolerated by the body. This patient now is 10 years out. He has some arthritis but still walks around with all the joints there. Now this is a alignment of the post body and a nice example why it is also good to know the anatomy of accessory bones. This patient was treated in that torture machine here like a Spanish boot and the inquisition uh because uh he was suspected to have an ankle sprain and even with patients that only have an ankle sprain, we don't do this anymore here. It was tested, the ankle was stable, of course, because the fracture was in the talus and the patient was diagnosed to have an austrinum, but this looks quite big for nostrin and the patient also had a significant pain and an adequate trauma. 67 weeks later, he uh someone did a CT scan because he can had continuing pain. Even though he had quite some physical therapy. You see that multifragmentary fracture of the posterior talar body, you can see that the intermediate fragment is already firmly healed to the talar body, the posterior fragment because it's uh dislocated has not healed. So, uh at this point in time, we needed to do a formal osteotomy of that intermediate fragment and just the debridement of the posterior fragment. And then with the help of a distraction device of the femoral distractor, we could see into both the talar uh the tibiotalar and the talar calcanea joints to make sure that there is anatomic reconstruction of the talar body. And this is now the patient with the healed fracture and he is going on to full weight bearing. This is a very interesting case. This was a young waiter. He fell on stairs. He did not uh walk for quite some time, didn't work. And uh he came three months later because he still had pain. And then this obviously non displaced fracture that was not recognized initially now, started displacing. And uh these are the x-rays four months later here you can see and also in the CT scan, you can see the large step off of about four millimeters in both the ankle and Subtalar joint. The patient had relatively mild symptoms, but we said to him, ok, if we don't do something, now he will go on straight to ankle and subtalar arthritis and then a complete hand foot fusion. So we went there at um a little less than five months and we did an osteotomy. You could nicely see the form of fracture line and with the osteotome and uh then go all the way through the uh to the subtalar joint. The reduction of the subtalar joint was controlled arthroscopically because it was not nicely seen from the margin. And um then the fracture was fixed uh with screws, we put some bone graft uh onto the talar neck in that region where it was already a mild cyst and the screws in the media meters are just from the osteotomy. So you see the pre op and POSTOP CT scan, you see the reduction, you see the thinning of that small defect, that bone graft from distal tibia. Yeah, the axial and coronal CT scans. And this is the patient 2.5 years later. At that point in time, he didn't have any secondary arthritis. Of course, if we follow him long enough, we will see it. At that time, he had a almost free function of both the ankle and subtalar joints. So the effort was worth it. In that case, this is a really sad case. Uh This young lady uh was not put into that torture machine. The doctor decided to torture her by himself to make sure that the ankle is stable. Of course, the ankle was stable, but it remains uh ridiculous by this fracture, dislocation of the talar body with the complete dislocation in the subtalar joint and the subluxation in the ankle joint has not been seen. Finally, two weeks later, someone saw the fracture and decided to do some fancy thing, minimally invasive or percutaneous surgery of the talar neck fracture from behind because there is one study from the eighties that uh pretends to show that uh screws from behind are stronger than screws from the front. But uh the bad thing was the fracture wasn't reduced. So the patient had still that large step off in the ankle joint. So ankle motion was restricted and the Subtalar joint was still completely displaced. She was walking with that kind of boot, she was unable to bear weight and uh was miserable at that time. And when we went back, we could save the ankle joint. But at that time, the subtle joint was already gone. So, uh the only thing uh to do was a sub effusion, which is not the best solution in a 16 or then 17 year old girl. Nevertheless, she had a straight alignment here. You can see that huge step in the ankle joint. She had a straight alignment and a good function of the ankle joint at uh almost two years later. But subtle motion of course was restricted forever. Here's an interesting case, a medical doctor um from internal medicine presents 3.5 years after bicycle accident, continuous pain, not much to be seen. A little arthritis in the X ray. And uh in the CT scan, you can see a non union at the tail or neck with very little displacement. So we went there. It was, it was Hans Sws case. He went there, debrided it and put bone graft inside. And because he was a medical doctor, he was very interested in healing and particularly worried about avascular necrosis. So he, he kept sending us MRI scans which showed that everything was uh in place and everything was fine. So this is him. 2.5 years later, the arthritis of the ankle has not gone. But on the other hand, it hasn't progressed at that time and there was no sign of avascular necrosis. Here. We can see a patient that was completely neglected with a displaced fracture. You can see the step off again in the ankle and subtalar joint at seven months, he was corrected via osteotomy. Um He presented two years later with osteophytes. Uh So with ankle arthritis, uh we removed the screws and did some uh colectomy from the front and he came back 14 years later. So 12 years after that second surgery, no pain, the only thing that bothered him was that he couldn't get his foot um beyond neutral. Uh So despite the arthritis that was clearly seen here, he just wanted another osteophyte removal which we did. He's now about 20 years out or more. And this is the very first case that was done by Hans Spit. Came to Dresden in the 19 nineties, a young male motor vehicle accident, this obvious dislocation was reduced immediately, but then the second step was missing. So six months later, he presented with uh that type of uh malunion. And again, you can see the dislocation, the subtalar joint and the incongruity in the ankle joint. And you can also see in this patient that there is less radiolucency in the talar body So there's at least uh partial avascular necrosis. Still after me, the osteotomy, the talar dome looked fine. There was still some cartilage there. The patient hadn't uh put on too much weight. So he was treated with an osteotomy along the form of fracture line and secondary screw fixation. This is three years later, you can see the, the talar body at the top still looks a bit weird. So there might be some um necrosis at the top there but no collapse. So a partial necrosis and this is the patient almost 22 years later. After reconstruction, someone ventured to take the screw out, which is not fun. And uh Taylors, he uh came uh beyond neutral. So he didn't want an osteophyte. Was he was just doing fine at that point with his ankle more than 21 years after reconstruction. Now we are coming to the worse types. This was a lady, uh heavy lady with a comminate talar body fracture. Uh I treated her with uh open reduction, internal fixation. I was very proud of my reduction, but then the tailor started collapsing. Still at that time, the, the shape of the talar dome was more or less preserved, two screws were broken. There was a little bit of giving away of the tailors. And um so at that point in time, we teamed up with our vascular surgeons, we lifted, tried to lift up uh that portion that started coming down and our colleagues from vascular uh and um plastic surgery did uh free femoral condyle uh vascularized and put it in which we just then fixed with a screw. And uh this is the lady nine months later, uh with a reasonable function still, the ankle holds, we will see how it evolves over the long term. This is her, the the X ray is underweight bearing six months later. But this is a very rare exception Typically when patients present, they come like that. So 10 months after open reduction, internal fixation, there is a collapse of the talar body, the cartilage uh is gone. The ankle joint is not salvageable. And in this case, also the subtalar joint was uh not salvageable. So uh this patient uh got a high foot fusion with a retrograde nail. Still she was doing OK. But of course, the functional result of these surgeries is not so exciting. And this is the worst case, a very young patient. He was run over by a small gauge railway, had several radical debridements still. Um He developed uh osteomyelitis. Uh So he needed serial debridements uh was put in a frame and PMA beats. Uh but gentamicin were put in to fight the infection. And then finally, when the infection resolved, um he was subjected to tibiotalar calcaneal fusions, which a large chunk of bone grafting. After that uh muscula type osteogenesis. And you can see it healed, it healed in a nice uh position. Although with a very stiff hind foot, uh the patient because he was young could adapted it. He could walk 2 to 3 kilometers with the hill lift. So still the hind foot could be saved. But with a whole lot of loss of function. And this is probably the worst case we see in a very rare case of Avius straggler where there was a combined fracture of the talus, but also a fracture of the calcaneus and of the media lateral me. So it was a floating talus, an open injury. We tried to save the day with the early fusion of the ankle and subtalar joints. But still, he developed a septic AVN. So the remainder of the talar body had to be thrown out too, the flap had to be advanced. Um Again, we started the, the uh masca uh technique and then as a salvage procedure, he was put in an Elira frame and got a tibial calcaneal compression arthrodesis. So kind of a resection arthroplasty at the former Chopin joint. Interestingly, he was doing quite ok. He was not having uh pain during daily life, but of course, the hind foot with the loss of the talus was much shorter, but because he underwent more than 20 surgeries because he was a poly traumatized patient, he didn't want to have any surgery anymore and walked around with a heel lift. So these are our results after anatomic reconstruction. So, joint preserving procedures and they are echoed. Meanwhile, by some other colleagues who did the same uh things, the most important thing is if you do an osteotomy along a form of fracture of the talus and you take care of the soft tissues and the blood supply, then there's no progression of necrosis. So those patients type one and two, without necrosis, they didn't develop necrosis. And those of type three with the partial necrosis, didn't progress with necrosis. That's very important. We saw progression of the uh arthritis in eight cases. Uh So roughly one third of the cases, which probably you can also see in a taus fracture which is nicely aligned from the beginning secondary fusion needed to be done. So far in three cases, satisfaction was high, the uh uh function was much improved, which is also due to the severe loss of function after marit 10 fracture. And the results were slightly better uh in patients who had non operative management initially, which appears logical because uh if you do a surgery, you have the the worst of both worlds if you don't manage anatomic reconstruction, so you have the risks of surgery, the soft tissue damage. And in addition, you have the malunion in those patients, some more salvage options. If there's a total AVN or bone loss after septic necrosis or if the talus is just left on the street, um you can go on in severely ill patients in diabetic patients, sometimes to really uh go with sterol toy leave the talus uh out, particularly this is uh might be uh done in uh patients after severe infection. Sometimes you can leave the the PMA spacer in in younger patients. And patients with a bit more of uh functional demands. Uh custom tailor body prosthesis can be put in like in that example or uh talar body prosthesis that's combined with the total anchor. I personally don't have much experience with this variant. Of course, a pantalar fusion is the last uh exit and leads to a very stiff foot, almost like a wooden leg. So to sum up, it is of course, always good to try to save as much joint function as possible after talar me, which is not only, not always possible, you have to go early because it is not possible if there's already symptomatic arthritis. It is also not advisable in patients with poor compliance uh because they don't benefit from joint preserving procedures, procedures. And also if they don't comply with your POSTOP regimen, uh then probably they end up first and they start it and in patients with a complete necrosis in very few select cases, you might save the day or maybe save the patient some years. Um but uh free vascular graft otherwise uh correct diffusion or a total talar prosthesis. Um and uh safe uh the affected joints is the treatment of choice. And with this message, I want to conclude, thank you very much for your kind attention. Thank you, Stefan. That was absolutely fantastic. So many cases you have shown and the wealth of experience you brought in is so, so, so invaluable. Um We have a few questions from our listeners. Uh I will start with their questions first. So um Stephan that this question uh asking, what do you do with complete extrusion of the details? Do we put it back after cleaning or Bennett? I think you've tried. Absolutely. Absolutely. Yes. There was a nice, II think the, the um person asking is from India. There was a nice study by Mandy Dillon and his colleagues of total tailor dislocations. Sometimes the talus is still in, sometimes it's out, it's always worth putting it in because there's nothing like the original Taylors and my former chief always used to say, even if the dog brings it on in his mouth, he would clean it and put it back. You can still fuse it. You can maybe use part of the, of its own talus as, as a bone graft. But there's nothing better than the patient's own talus. And the results from the literature are quite amazing. Uh Of course, there are more positive cases reported than negative cases because it's always exciting if you put the talus in, that is completely denuded from all soft tissues, from all blood supply and still heals. So I guess there is some bias towards positive case reports, but there's a lot of literature that it's worth the effort. Of course, there might be necrosis, of course, there might be arthritis, but this can happen to any tail of fracture. Thank you. So, Stefan uh just to expand on that. And you, you, you obviously you've said that you don't have much experience with uh the replacement of the talus. Uh But do you think it is evolving uh with, you know, more trauma and more new techniques coming in? And you know, where, where is the line where you say, OK, this, this tell us has gone beyond fixation. Or you say every tela needs to be fixed before considering replacement, I would still fix it because uh it is the patient's own talus. And I would consider a primary fusion if the joint cartilage is gone completely and um and still the patient has his own bone. So, because what you do with the total talar prosthesis is it's a hemiarthroplasty on three joints. So it is a matter of time that this will fail. And uh if you look at the long term results, I think there are groups from Japan, from Thailand, uh about 5030 to 50% of them fail in the, in the long term. And also you uh this is only an option. If the, the, the tibial platform, if the surface of the calcaneus, uh the subtitle joint is still intact. If this is also damaged by the by the energy of the fracture, then of course, the, the the talar body processes won't hold too. But I think it's an evolving field uh probably with the new generation ceramic prosthesis that are out now, it might work better. But we have to wait for the, for the long term results. Uh And um I will definitely uh watch that closely and I also have now two patients in line who, who be considered doing this. Uh But we have to tell them it's a, it's still a bit of experimental surgery, probably buying young patients uh some time. Uh We have to wait for the long term results. Thank you. Now, one question has repeatedly appeared in the chat and I'm going to ask you both, maybe it's different with TLI and calcium. So when is it too late to operate? So we're talking about a Male United scenario and we're talking about whether we can fix it uh or we have to go for fusion and does it vary with Teli and calcium? So I will ask Nichols first and then Stephan, you can answer that from the perspective. So, well, II assume that the question is if you have a caltan fracture, which is in the acute phase, when would you consider fix it? Let's say somebody else hasn't fixed it. I have fixed a calcaneal fracture that was four weeks old and achieved a quite good re reduction. So it was quite bad. So I decided I will not leave the patient untreated because that would, I could uh would end up into a Mao Union. Uh If it was six weeks, it would have united if it is a bad uh situation, like uh some of the uh um uh cases I showed like the patient who was nine months, it wa it wasn't too long down the line from the uh acute phase. You can si would still try, attempt it at, at six weeks. Uh because then you consider it as a Mao Union. If the Calcaneus has really united and then you, you go back to the options. Which type is that? And do you do an arthrodesis or not? But uh I think the vast majority of patients are four weeks, the fracture. It, it's difficult but it has not fully united. And I II think uh uh I'm amazed by, by uh Stefan's results and I'll, I'll ask him now. Now he will answer this question. I will also ask him. I'm amazed that like you, you fixed, you were proud of fixing so nicely. Uh A tele fracture. I had exactly similar fracture that ended up in a, in a VNA bit later, but the patient was a smoker. Do you think it's a type of the fracture or the anatomy that was disrupted or is it that the patient that causes the A VN uh up to 18 months down the line where you initially uh I my experience was that the fracture has united confirmed with CT scan. Very good outcome and then collapsed at 18 months. So, and on the other hand, you fix some malunion later and you don't get necrosis. What, what do you think is important? Why do some patients do well and others do not? So first, uh I would start with Manish uh question. So uh it is too late if there is a symptomatic arthritis or if the cartilage is gone, which can be in the worst case at the time of uh the initial trauma or it can happen very quickly, particularly at the Subtalar joint. So my experience is the same as Nicos in Calcaneal uh malunion. Uh if the patients walked around uh on their man united Calcaneus on the man united Subtalar joint for a couple of weeks, then typically because uh of these shearing forces, the joint will be gone. The ankle can take a bit more and also the joint. So that is why in talus fractures, we do more corrective even intraarticular corrective osteotomies then after Calcanea fractures. And uh so the the time for fixation, it is never too late. But of course, if there's already arthritis, then you have to consider a primary fusion or an early secondary fusion. If those patients present late and I have fixed calcanea fractures also after six weeks, after eight weeks. Uh if the patients didn't walk around and then if they, they were uh injured in another country, they were lying in bed or they were poly traumatized. And then finally, they came to see me if they didn't walk around, if they stayed in bed or walked on crutches, then there is a chance that the cartilage is still there, that the joints will still be fine. And then you can do your osteotomy along the form of fracture. And now to Nichols question, of course, the cases I showed uh who are amenable, which are amenable for secondary correction are relatively simple intra or extra articular fracture. If it's a comminuted fracture, like the one that I showed with multiple fragments of the talar dome, then you're happy to put them together the first time you still have to keep your fingers crossed that there's no necrosis. But these cases, if they may unite, uh I think nobody would have the idea to, to take this apart and put it back together. So the, the, the non unions that we really treat, you see the number of cases that we collected over more than 10 years is that these are 20 cases, 25 cases. Uh We did more than twice as much fusions for male unions that had uh arthritis in, in either of the joints. Thank you. Thank you very much. Uh I think that's very clear about the different fractures. Um And, and obviously, difference in T and Calcaneum and patients walking or not. Um The other question which is, you know, we can't control sometimes and, you know, you have eluded your, in your talk. N goes that and, and, and so, I mean, what do you do? If, if somebody presents with a mal union difficult problem and patient has got issues, they can't stop smoking. What do you do? I mean, uh, you know, we know smoking is an adverse um uh feature in, in the healing. And if you do a complex reconstruction, do you do it or do you, what's your approach? I would say there must be a reason why the patient was not treated operatively in the first place. And usually these patients are likely to be smokers or have other comorbidities. Now, then uh there, there is not one approach. I theoretically, you have to do a complex reconstruction, osteotomy, bone block arthrodesis. Sometimes you have to play safe first. And if you have a patient who is high risk to develop a complication like a diabetic uh or a heavy smoker or an alcoholic or a low demand patient, I would say, then you may have to consider a more simple in situ through knowing that they biomechanically, the hind foot will not be sound but to get rid of the pain. But even then if you and if you have to do an open uh procedure, then you may have to do a sinus tarsi approach, still do an exostectomy because uh the lateral wall is bulging, impinging on the peroneal tendons and lots of the problems are coming from that side. So the sinus tarsi approach is a relatively safe approach, not had a serious wound infection like with the extensor lateral approach with which I use for more complex reconstruction. So yes, you have to consider who is your patient and who whether they will benefit from the surgery and sometimes you have to avoid doing surgery because is this patient gonna be better after an arthrodesis after an operation or is this patient not gonna benefit from that because it's the wrong, the wrong patient to do surgery? So, consider doing nothing with some patients. Thank you, Nicholas. What do you think? Professor? I think exactly the same. So there are patients um who smoke of course and uh an acute fracture. I um I don't ask, I tell them maybe it's a good, a good time uh to, to quit smoking because you can't smoke in the hospital and you just don't resume when you come home. If they present for a complex reconstruction, I try to be very adamant to tell them the complications. I always tell them your foot can be, can be turning black even without surgery when you smoke. Now I take it apart. Um You don't want that. I don't want that and uh particularly if you plan a fusion or an osteotomy. Uh, smoking is a significant risk factor for nonunion. And if you do a fusion have a nonunion, the patient will have the same pain as before. Plus the risks of surgery. So I would really demand they quit smoking. Some, do it. Some of them resume after the, the, the reconstruction has healed. Some don't. And, uh, there are some patients, they still appear reason. They say doctor, I tried everything. I'm down from a pack to five cigarettes per day. If they, then you have to really make up your mind. They have to see if the patient is otherwise reliable. And uh so II would not uh close the door uh in front of them. Thank you. Thank you very much. Both of you. Uh There's another question from audience about uh the role of lateral malar osteotomy for malun lateral telar body fractures Stephan. Um You need it less frequently only if there's really a posterolateral lesion most of the time. Um osteochondral lesion. Uh then I do uh a simple weber type B fracture. So an oblique osteotomy, some do a three part of the osteotomy to hook off the, the syndesmosis and bring it back the, this the insertion on the fibula. I just do a simple BB fracture, an oblique one that aims at the apex of the, of the lateral talar dome. Uh I put the, the screws for the plate in uh for fixation before that. So then the fixation will be anatomically and they will be quickly at the end of the surgery. Thank you. Thank you. Um a question for both of you. Uh a very general question about talus and uh calculon fractures, malunion talking about bone graft. What is your preferred bone graft option? Nichols? And then Stephan, where do you take the bone graft from? I know you've talked about the extruded lateral wall. But is that what you do or you do something else as well? Yes. In, in the complex cases. Uh well, bone graft, if it's an in situ or a primary arthrodesis, I don't use bone graft if I don't have to change the shape of the calcaneus. Uh If there is a non union, it's different, of course, because we have to enhance uh the capacity of the bone to heal. And you may use either a breast bone graft or any uh orthobiologics. But let's talk about the Mal United Calcaneal Fractures. Uh Especially if you do an osteotomy. There, there is quite significant amount of bone on the calcaneus which I use. Uh I can't remember that I have used. The other option is I res bone graft for a, for a, for a sub e fusion. If, if you, if, if you need to distract a lot, I typically use Iliac crest bone graft either as uh cancerous bones. So I just open a window, get some bone out uh or as a tricortical bone blocks in a Subtalar correction fusion. Um So, uh I prefer that over uh uh sy organic uh bone graft because it has all the the growth factors which you would otherwise have to buy for a lot of money. And, uh in my experience, I see all my patients with complex reconstructions at eight weeks or 12 weeks after surgery and virtually none of them has relevant symptoms at the donor site. So it's, it's quite often cited that people, uh a lot of patients have symptoms there. I still have to see them if you do it in a nice technique. Uh In a slim patients, there might be a dimple, there might be a scar. So this might be a cosmetic issue. But otherwise, um for me, that's the preferred source of bone graft in uh avascular necrosis. I would consider a vascular bone graft and we team up with the plastic surgeons for that. And if there's really a huge defect, then you have to think about other solutions like a talar body prosthesis or a femoral head or uh a cage, a tantalum cage, porous cage, something like that. Can you tell you very much if you do a, a tibiotalar for this or tibial calcaneal arthrodesis of the complete talus extrusion or uh A VN. Do you ever use the fibula sometimes? Yes. Uh And uh I typically, if I use it, I use it as a strut graft. So I leave it uh in the soft tissues uh in the posture, soft tissues. And I just debride the formo in this moses, I debride. Uh The remainder of the talus if it's still there and then I bring it as a strut graft from the site and then it enhances the, the whole construct. Thank you. Also. Also a very good option is uh blare fusion uh to, to shift the anterior front of the tibia down into the talus. That's also a good option uh provides more stability. Oh, thank you very much. You answered that because somebody actually asked about your views on Blair Fusion. So you've answered that. Thank you. Um There's one more question for you, Nickers about Calcaneal fractures and I'm just going to read it out to you. So, Calcaneal fracture that initially has been fixed with extensile approach. What's your incision and approach for latest Subtalar joint fusion? And they have said that they experience issues with skin issues with Sinus Tia approach. Do you still recommend Postol lateral approach? Uh like the one you use for distraction, sub arthritis in cases that no bone block and distraction is required? Uh Well, yes, if, if there is previous surgery with a lateral extensile approach, I assume they had AAA plate was used. That's why they did an extensile approach. So the plate has to come out and usually uh because this is part of the problem sometimes and there is still malunion on the lateral side. Actually, I've seen quite some bad surgeries uh with a plate and no uh reduction of the fracture. So you have to use the same approach. Uh I'm afraid uh which is quite uh uh uh yes invasive. Uh I do not, I have not seen significant problems with the Santa approach if there was no previous fracture. And II would not, I do not use a Posterolateral approach for an isolated subtalar fusion. The sinus D approach is suitable again to take the lateral wall of the calcaneus. Again, it depends on the personality of each fracture. So as I as as I showed you before, one case, there was no metal work, but I decided I had to do an osteotomy, do a major bone block distraction. So I did it through an extensive lateral approach in a patient who was young and a nonsmoker. So yes, previous surgery indicates probably the approach which you have to use a bailout would be uh to do it in two steps. So if there's a large approach and you really need a lot of correction, then it might be a good option to take the blade out debride the lateral wall, maybe save the bone in the fridge. And then come back later, four weeks, six weeks later, and then only use the vertical part of the extensor approach, which is exactly the posterolateral approach and then come from the back and then you can lift up the the heel as much as you want without having to feel any problems with wound healing. So I do this sometimes for severe deformities uh that have an extensor lateral approach with a plate still in. Thank you. That's, that's brilliant. Uh Stefan, one more question to you. We talked about all the uh talus fractures. But what about um the lateral process fractures that have been initially missed? Sometime? We see them quite often they are missed. So what's your approach? When, how long you are happy to go ahead and fix them or, or, or if it's too late, what do you do? I would never fix them secondarily. Uh We know that we can take out a lot from the lateral process, a centimeter or even more without risking subtalar instability. And there is always uh considerable damage to the joint from that shearing force that produces it's typically a subtalar dislocation mechanism. So, uh if patients have symptoms after lateral process fractures, I take it out. And uh if, if it's too much, if uh if it's not a lateral process, if it's the lateral body and there's arthritis, then you have to, unfortunately, you have to fuse the septated joint. But uh there is in my hands, there's not much role for a secondary fixation of a lateral process fracture. Take it out. You. Thank you. Um uh Nicco. Same question to you. What about the intralateral calcaneal fractures? If they are missed, you just take them out or, or they do, maybe we should, you should make a comment for uh probably the younger members in the audience. Do not miss fractures when you, it's not, everything is an ankle sprain. If you see a chemosis and swelling, especially if the foot looks a bit varus, it, it can be a telos fracture. And I have seen in hospitals both in UK and in Greece telos fractures being missed and then you end up with these complications and shoulder. So do not miss the fracture. Well, the arterial canal process fracture again, you would not miss it. If you examine the patient on presentation, it's not everything is a lateral malleolus or a possible lateral malleolus structure or a sprain. See where the pain is. If it's in the arterial process of the calcaneus, there might be fractured. They request for appropriate imaging, even CT scan. Yes, I II would say if it's a large fragment, I would consider fixing it acutely or then if it present late or if it, I tell the patient, if we do not fix it, we leave it. And if it's symptomatic, three months down the line, I remove it, I rarely had to go back and remove this fracture. So usually I if you treated the patient uh in a boot, so not, not let the diagnose the fracture. Usually they will will heal or cause some fibrous tissue and will not be a, a huge issue. But I it's a big problem. Fix it or leave it and remove it. II would say generally the same approach as, as Stephan about the uh lateral tear problem. Wonderful. Thank you, gentlemen. You have been absolutely fantastic. You have given really key messages. Uh and I'm sure that the practice of foot and ankle surgery or trauma will improve after the messages. Uh You have given the key per So, thank you so much on behalf of both us to both of you for giving your precious time being with us and dealing with malunion of ankle talus and calcaneal Fractures. Um An audience uh Thank you so much for joining and, and asking a lot of questions uh and we will see you again soon in another round of Master Techniques. Thank you and have a good night. Good night. Thank you for the invitation. Thank you, Manish. Thank you. Bye bye. Right.