How I Treat This: Insertional Achilles Tendinosis

Summary

The AOFAS Orthopod-Cast
Episode: How I Treat This: Insertional Achilles Tendinosis
Release Date: October 30, 2024
Host: Nick Strasser (AOFAS Podcast Committee)
Guests: Dr. Oliver Schipper & Dr. Ben Jackson

---

Episode Overview

This episode continues the Orthopod-Cast’s “How I Treat This” series, with an in-depth, candid discussion between Drs. Nick Strasser, Oliver Schipper, and Ben Jackson on contemporary approaches to treating insertional Achilles tendinosis. Each surgeon brings a unique practice background and evolving viewpoint, resulting in a practical exploration of terminology, diagnosis nuances, operative choices (open vs. minimally invasive), the Zadek osteotomy, pearls and complications, technical evolution, and the future of surgical treatment for this challenging problem.

---

Key Discussion Points and Insights

1. Definitions & Diagnostic Nuances

[01:25–04:26]

• Dr. Oliver Schipper:

  • Differentiates between non-insertional (mid-substance) and insertional Achilles pathology.
  • Describes insertional Achilles tendinosis as “tenderness across that broad Achilles insertional sleeve, often associated with edema” ([01:51]).
  • Recognizes overlapping presentations, including Haglund’s deformity, retrocalcaneal bursitis, bony edema, and calcific metaplasia at the insertion.
  • “It’s really that tenderness across the Achilles insertional sleeve. That’s what I’m really referring to as Achilles insertional tendinosis.” ([02:44])

• Dr. Ben Jackson:

  • Prefers the term "insertional Achilles enthesopathy" when there is calcified enthesis.
  • Pragmatic approach: for patients, uses terms like “insertional Achilles tendonitis,” “retrocachaneal bursitis,” acknowledging that these are often the “same thing” in practice ([03:44]).

2. Patient Profile & Non-operative vs. Operative Decision Point

[04:26–05:12]

• These conditions are common in middle-aged to older adults (40s–60s), often women.
• Discussion centers around patients who have failed non-operative management and are now candidates for surgery.

---

3. Operative Management: Evolving Approaches

A. Dr. Schipper’s Evolution: From Open to Minimally Invasive Zadek Osteotomy

[05:12–13:44]

• Started with open Achilles insertional reconstructions, sometimes with gastrocnemius recession; FHL transfer reserved for revisions.

• Challenges with open procedures:

  1. Wound complications: “That area at the Achilles insertion is a very slow healing area.” ([05:39])
  2. Technical difficulties: Uncertainty about “how much” bone and tendon to remove.
  3. Unpredictable outcomes: “Sometimes, people [have] residual pain at the insertion.” ([06:06])
  4. Slow recovery: “Often can be 6 to 12 months to recover, especially if you include a gastroc recession.” ([06:13])

• Transitioned to the minimally invasive Zadek osteotomy after exploring MIS techniques with colleagues.

• Zadek Osteotomy Defined: “A dorsal closing wedge calcaneal osteotomy...removes the posterior superior corner (Haglund’s area) and detensions the Achilles—about 8 degrees of dorsiflexion gained without a gastroc recession.” ([07:14])

• Key findings:

  • “These patients, oftentimes, their pain was gone at like their two-week appointment, their six-week appointment… just kind of wild.” ([08:18])
  • Recovery has “cut in half: three to five months” compared to open procedure.
  • Perceived as a “first line option” for most patients now; open reserved mostly for revision or extensive disease.

• Literature: A newly accepted two-year study showing “98% satisfaction, 4% complication rate, significant improvement” ([10:44]).

• Technical critique: The challenge is “how do you generalize this to everyone?” to reduce variable outcomes across surgeons ([12:58]).

B. Dr. Jackson’s Experience: Mixed Outcomes with Zadek, Leaning Toward Open

[13:44–19:55]

• Initial experience with traditional open split Achilles approach (taking off a large portion of calcaneus, suture anchors).
  • Wound complications are “real”; longer, less predictable recovery (6-12 months).
• Tried Zadek osteotomies: Mixed results—complications such as technical errors, thermal necrosis, plantar heel pain, hardware issues.
  • “I would say I’ve had very mixed results. I think some of it’s probably technical. So to me, I wish there was a little bit more … definition about exactly where you do your V cut.” ([14:48])
  • “I feel like my ZCs just don’t get to that hundred percent range that an open does.” ([16:48])
• Professional honesty: Trending back toward open in part due to complications and less-satisfying results with MIS, acknowledges a learning curve, hopes technique will improve with research and systematic refinements.
• Plans a comparative study of push-off strength post-op (Zadek vs. open).

---

4. Technical Pearls for Minimal Invasive Zadek Osteotomy

[19:55–30:29]

• Schipper offers detailed technical pearls:
  • Use a 6,000 rpm burr with copious chilled saline to avoid thermal damage ([19:55]).
  • Emphasizes adequate wedge size and correct screw placement; “goal is to have it be, you know, around three and a half bur widths… that’s how I know I’m getting enough.” ([25:17])
  • Satisfactory outcomes driven by taking a sufficiently large wedge (“biggest mistake is not taking enough wedge”) and placing two screws for stability.
  • Tips on patient positioning and tools (beanbag lateral, mini C-arm, 10-cm burr) ([28:35]).

Memorable Clinical Story:

• “I had a severe rheumatoid arthritis patient … she did great. ... Type 2 diabetic, some of the biggest plantar calcaneal enthesophytes you’ve ever seen … they did great. ... I could never go back to doing open as my primary option.” ([29:18])

---

5. Comparisons with Other Procedures

• Gastrocnemius Recession:
  • Zadek provides mechanical “de-tensioning” and increased dorsiflexion (approx. 8°)—but Dr. Schipper notes isolated gastroc recession hasn’t been a home run, especially for insertional disease ([31:17]).
  • “The Zadek must work… because of that mechanical irritation of that posterior superior corner on the tendon.” ([20:28])
• FHL Transfer:
  • Now reserved for revisions, not as a first-line adjunct in primary cases by all three surgeons ([37:02–37:45]).
  • Recent literature does not show additional primary benefit; used for large re-tears or failed primary repairs.

---

6. MIS Bunion Analogy and Technique Maturation

[43:16–44:47]

• The group compares the evolving learning curve and technique development for MIS calcaneal surgery to the “generational” improvements seen in MIS bunion surgery.
• Dr. Jackson: “For MIS bunions, we're on the fourth generation—because we got better after one, two, and three… I think we’re somewhere in between generation two and three [for Zadek’s].”

---

7. Post-op Protocols

[39:01–42:46]

• Dr. Jackson (Open)

  • 2 weeks non-weight-bearing in plantarflexion splint, then progressive weight-bearing with heel lifts, typically back in laced shoe around 10 weeks.

• Dr. Schipper (Zadek)

  • 6 weeks in a boot; weight-bearing resumes at 2 weeks; PT starts at 6 weeks; uses no heel lifts as dorsiflexion is protective ([40:10]).
  • “Dorsiflexion is protective for the Zadek… so it’s a little counterintuitive…” ([40:31])
  • Stresses importance of patient compliance and the advantage of two screws for early stability.

---

Notable Quotes

• “It's really that tenderness across the Achilles insertional sleeve. That's what I'm really referring to as Achilles insertional tendinosis.”
  — Dr. Oliver Schipper ([02:44])

• “I have had wound healing complications [with open], those stink a lot. I think those patients tend to hurt for longer.”
  — Dr. Ben Jackson ([14:16])

• “When you do an open Achilles insertional reconstruction…sometimes, people [have] residual pain at the insertion… those were some of the challenges.”
  — Dr. Oliver Schipper ([06:06])

• “These patients, oftentimes, their pain was gone at like their two-week appointment, their six-week appointment… just kind of wild.”
  — Dr. Oliver Schipper ([08:18])

• “I feel like my ZCs just don’t get to that hundred percent range that an open does.”
  — Dr. Ben Jackson ([16:48])

• “The biggest mistakes surgeons make is they don’t take enough wedge. … My wedge hasn't changed. If anything, it's, it's been maybe slightly bigger than when I first did it.”
  — Dr. Oliver Schipper ([28:57])

• “I could never go back to doing open as my primary option. I just really think it's changed my practice for the better.”
  — Dr. Oliver Schipper ([29:18])

• “I think that we’re definitely progressing in a way that people are going to be doing less and less open. … I think, like a lot of techniques, the more people are doing it and giving good, honest reporting of their results, the better we're going to get at it.”
  — Dr. Ben Jackson ([42:57])

---

Timestamps for Important Segments

• [01:51] — Dr. Schipper defines insertional Achilles tendinosis.
• [05:12] — Start of operative approach discussion; Dr. Schipper’s practice evolution.
• [07:14] — Zadek osteotomy defined and explained.
• [13:44] — Dr. Jackson discusses his mixed experience and technical challenges with Zadek.
• [19:55] — Dr. Schipper shares MIS technical pearls.
• [25:17] — “Three and a half bur widths” rule for Zadek wedge size.
• [29:18] — Dr. Schipper: “I could never go back to doing open as my primary option.”
• [31:17] — Comparison of Zadek to gastrocnemius recession.
• [37:02] — FHL transfer reserved for revision; literature insights.
• [39:01] — Post-op rehab protocols compared.
• [42:57] — Technique evolution and future of open vs. MIS.

---

Takeaways and Conclusions

• Open vs. MIS: Both open and minimally invasive options (specifically the Zadek osteotomy) have a role, but technique, surgeon experience, and patient selection determine outcomes. MIS approaches offer promisingly quicker recoveries and lower complication rates “in the right hands.”
• Learning Curve: MIS (Zadek) outcomes are operator-dependent and the field is still “second or third generation,” with technique refinements ongoing.
• Future Direction: Expect further technical maturation, more publications, and continued evolution away from open toward minimally invasive strategies, mirroring the trajectory of MIS bunion surgery.
• Patient Communication: Surgeons must understand all available techniques, as patients often inquire about specific procedures.
• Collaboration & Honesty: The episode underscores the importance of honest reporting, shared experience, and collective progress in foot and ankle surgery.

---

Hosts and contributors:

• Dr. Nick Strasser (Host)
• Dr. Oliver Schipper (DC, Anderson Orthopedic Clinic)
• Dr. Ben Jackson (Columbia, SC, PRISMA & South Carolina University)

---

For further learning: Check the AOFAS video library, LinkedIn pages with technique videos, and the minimally invasive foot and ankle surgery textbook for more on the Zadek osteotomy and related techniques ([23:43]).

Transcript

[A]

Welcome to AOFAS Ortho Podcast, where leaders in foot and ankle orthopedic surgery discuss the issues that affect you and your practice.

[B]

Please note that the views expressed on.

[A]

This podcast do not necessarily represent the views of the AOFAS or its members.

[B]

Welcome to the AOFAS orthopodcast. My name is Nick Strasser and we are recording today with two of who I'm honored to call close friends, Oliver Schipper and Ben Jackson. And we're continuing on with our series on how I treat things. And tonight we're talking about insertional Achilles tendinosis. And I think we have three different viewpoints and advantages that we look at this pathology with, and just super excited to talk about some of these, the different approaches that we take to treating this pathology. So we have Oliver Shipper joining us from the D.C. area out of the Anderson Orthopedic Clinic, and Ben Jackson from Columbia, South Carolina, from PRISMA and South Carolina University, and then myself from Middle Tennessee. So welcome to the podcast, gentlemen.

[A]

Welcome.

[C]

Thanks, Nick. Thanks for having us.

[B]

Yeah, so we're, like I said, we're continuing the series. We're talking about how we treat things, and tonight we're going to talk about insertional Achilles. First off that I want to kind of get out of the way though, is how do you define insertional Achilles pathology? What kind of terminology do you use? Do you refer to it as insertional and non insertional? Or do you get more nuance and talking about haglins? And if so, how do you define that? Oliver, why don't you start?

[A]

No problem. So for me, when I talk about insertional Achilles tendinosis, and again, I differentiate from non insertional being really over the mid substance. Often you can have palpable thickening of the mid substance there, but again, that's really tenderness over the mid substance. So we'll leave that aside because really we're going to focus on insertional tendinosis here. For me, it's tenderness across that broad Achilles insertional sleeve often associated with edema. They really have to have that on exam. Right. If they've got, they may have associated symptoms of, you know, retrocalcaneal bursitis, pain, tenderness just anterior to the, to the Achilles insertion. Right, right over the retrocalcaneal bursa, they may have palpable bony prominence. If they've got a hagwon deformity, or if they've got basically calcific metaplasia, the Achilles insertion, again, I think a lot of people use hyglund Deformity to describe that calcific metaplasia, the Achilles insertion, along with the bony prominence. But again, it's really that tenderness across the Achilles insertional sleeve. That's what I'm really referring to as Achilles insertional tendinosis. Along with that can come Haglan deformity, retrocalcaneal bursitis, bony edema, tendinosis of the insertion seen on mri. It's really that kind of constellation of symptoms.

[B]

Yeah. Even getting to the point where you get some of that almost a delamination type appearance of the tendon at that insertion. And then when you talk about the metaplasia, you're. You're. That would be the same as the enthesophyte.

[A]

Is that retrocalcaneal exostoses and these calcaneal and thesophytes at the insertion. Exactly. I'm differentiating that from, you know, a true Haglund deformity where you get that posterior superior calcaneal bony prominence or seen on radiographs.

[B]

Ben, how about you? Anything to add to that?

[C]

Not a lot for me. I call it typically insertional Achilles enthesopathy. When there is that calcified enthesis of the tendon for patients, they use a lot of different terminology. I say, for the most part, for patients, insertional Achilles tendonitis, insertion, Achilles enthesopathy, retrocalchaneal bursitis. Those are really, for the most part, most of the time, the same thing. I think there are some people, particularly young patients, that may have an isolated retrocalcaneal bursitis or an isolated Haglin's deformity without some of those other changes. But I think to me, that's really almost exclusively younger patients. So I typically call it insertional Achilles. Enthesiopathy is a term that I use.

[B]

Okay, so you kind of referenced this already, but a lot of times this is going to occur in the patient that's in there. 40s, 50s, 60s, oftentimes female patient. And. And we're talking about insertional tendinosis. We're talking about this metaplasia or in the. So fight that's present degenerative changes of the tendon and oftentimes inflammatory changes either to the bursa or to the bone or both. So let's take this patient. How are you guys approaching this current currently in your practice? Let's just say they've gone through the non operative treatment. They're coming to the point of wanting to pursue operative treatment. Oliver, talk to us about how you're approaching these.

[A]

Are you.

[B]

Are you open Approach, insertional approach. Are you doing an osteotomy of some sort? What's your approach to these?

[A]

Yeah, so I'll take a quick step back and just talk about my evolution. You know, I trained ortho. Carolina had some of the best mentors in the world. They're really incredible surgeons and came out doing an open Achilles insertional secondary reconstruction plus minus gastrocnemius recession. If they had a gastrocnemius contracture and really reserved FHL transfer for revision situations, that wasn't part of my primary treatment algorithm. You know, and I'd say patients with open Achilles social reconstruction, they, they do well most of the time, but wound problems are definitely real. That area at the Achilles insertion is a very slow healing area. You know, it's a little challenging sometimes to get the right angle of your saw blade to take out the posterior super corner of the calcina tuberosity where the haglin would often be. So, you know, the question is always, how much do you take, right? Is that enough bone? Is it too much bone? You know, number three, my other issue with it was, you know, it's like, how much tissue do you remove? It often all looks like, you know, we just talk about disease tending. Kind of looking like crab meat, right? You know, how much do you remove? Right. You have an idea on MRI where maybe the more diseased areas, but sometimes it all looks bad. So again, how much is enough, Right? Because it's very hard to tell, you know, in trop, okay, am I removing all of the disease pain generating area or, you know, am I removing too much or again, not enough? And I always thought that was kind of interesting, you know, for you feel like you kind of do a similar job on most people or do it the same way. And yet sometimes, you know, people with some residual pain at the insertion, you know, again. So those were, those were some of the challenges. And then finally I felt like these cases, you know, oftentimes they could be 6 to 12 months to recover. Especially if you include a gastrocnemius recession. There's just a long recovery. And for these patients, right, when they go through this and say it's in that small percent that again, don't get better, it's kind of a tough pill to swallow when you tell them, hey, we got to try and do it again. And they got to go through this whole process again. And so I thought again, as I started my journey in mis percutaneous foot and ankle surgery, started to really get fat. Saw with the burning, you know, I Was talking to my buddy et ray Volcano. And you know, he, he'd been doing, he'd seen ZX done open with, with Mark Myerson, his fellowship, you know, in Europe. They'd been doing open ZX for a while, you know, but the thought was, hey, could we try doing that, you know, minimally invasive percutaneous. And so, you know, we started to both do this and do a lot of it. And you know, it really been kind of a wild ride in terms of great journey. You know, I just found like this, this became kind of my first line option, right, for a couple reasons. So I'll take a step back again and just say, you know, define Zadig osteotomy. So this osteotomy has actually been around for a while. It was developed by Dr. Isador Zadek, who kind of was right on in the early 1900s, right. Described this osteotomy for patients who had a mechanical irritation of that posterior superior corner on the Achilles insertion. Never really took off in the US had been done in Europe. I think part of that was very industry motivated. You know, you could do a single row, a double row repair. And obviously that got pushed by industry, you know. But again, I started, you know, started doing the Zadig and to define it, sorry, it was, it's a dorsal closing wedge calcaneal osteotomy. So you're basically taking out a wedge with the apex plantar. And, and these days my goal is to remove the posterior superior corner. So the area where the Haglan deformity is along with that wedge. And then you close that wedge down and it does two, there is two, two kind of biomechanical changes to the Achilles insertion. Number one, it removes that area of biomechanic of mechanical irritation at the posterior superior corner. And the Achilles insertion, that's often where the most diseased area of the tendon is on MRI. And then number two, it, it detentions the Achilles, they gain about 8 degrees of dorsiflexion without doing a gastrocnemius recession. So those are just two very significant biomechanical changes. And again, you're not even touching the Achilles tendon here. It's really just changing the biomechanics there. So again, now that we define Zadic osteotomy, right, I started doing this and you know, noticing these patients oftentimes really like their pain was gone, their Achilles insertional pain was gone at like their two week appointment, their six week appointment. I mean really just kind of wild change in their pain complaints Right. And that Achilles insertion pain was gone. Whereas when you do an open Achilles insertional reconstruction, right, you know, as they start to recondition their Achilles, you know, when they start pt, whether it's four weeks, six weeks, you know, up through three months, even three to six months, they're often having waxing, waning Achilles insertional pain and swelling. As they recondition that tendon, they get the collagen to mature and then, you know, align, align with the forces that the Achilles is seeing. You know. So I thought, again, there's got to be a better way to do this. And so I started doing the Z X. Right. You know what? We learned early on a couple things. One is these patients, I always counsel them, they can have six weeks to three months of plantar heel pain. And the thought was it really almost mimics plantar fasciitis. It's right. Again, it's right down where you'd expect chronic plantar fasciitis to be. There may be a component of that because when you do close down the wedge, our apex is kind of just anterior at the level of the plantar fascia origin. So that will increase tension on the plantar fascia and as you close that down, but also, that's also where the apex is, right? So if you get an MRI kind of, you know, in the three to six month range, you'll still see some edema down there. So it could just be kind of calcaneal bone edema. But again, I found that that was one kind of aspect of Zadic that was different from open Achilles insertional reconstruction that I noticed. But then I found these patients were just recovering so much faster overall. I mean, I tell patients this is like a, you know, three to five month recovery, right. And, and sometimes I have people back on the golf course by two months. It's just a very different recovery. I feel like I've cut the recovery in half, number one, and then number two. My other, or kind of the other big advantage of the Zadac is, you know, I felt like this was a great first line option, right. I tell patients, hey, look, there's a high chance you're going to improve clinically with this procedure. But, you know, God forbid you don't get better with this. I can still do that open Achilles insertion or reconstruction as a veil. And as we all know as surgeons, you're always thinking about what do I do if this patient doesn't get better. Whereas if I do an open Achilles insertional reconstruction, I'm not sure you have the same biomechanical benefits of then doing a Zach osteotomy to revise that. Obviously talk is good and all, but ultimately you got to have literature to back you up eventually. Otherwise it's just completely anecdotal. We have our two year paper minimum two year follow up average. I think four year follow up was accepted. FAI and that should be. We just got the proof for it, but it should be out relatively soon, if not already. But again, showed high satisfaction rate, 98% complication rate of around 4%, significant improvement patient outcomes, functional outcomes, but really kind of added some validity to what we've been seeing. That being said, this is my first line procedure for all patients with Achilles insertional tendinosis, whether or not they've got significant calcific metaplasia, if they've got partial tearing. You know, my buddy Etre doesn't even get MRIs on these patients. I still get an MRI just to make sure they don't have any significant Achilles mid substance disease, you know, and then just if they do see that on mri, I'm going to examine them, really check the mid substance, make sure they've got no mid substance pain before I say, hey, we're just going to do a Zadic on them. But again, this has really changed my practice immensely, you know, for the better and I think really changed how I approach Achilles insertional tendinosis. You know, the, the one thing I would just add quick is just as I've kind of been teaching this, right? The goal is to, how do you, how do you generalize this to everyone? And I've got some buddies who are, who are great surgeons, you know, who don't do a ton of mis, but somebody's who are great surgeons where they, you know, they've, they've done some, some have done well, but some have not done well. Right. And so it's like, how do you get everyone on the same page, you know, as you are in the results you're seeing along with your buddies who are doing a lot of MIS surgery And that, that's kind of been the goal and the challenge for me, you know, as we started to do more and more of these minimally invasive or percutaneous zeta gasteatomies.

[B]

Ben, what's your approach? I know you got a partner who's on the zeta train as well, and so you've kind of seen it from your institution. Are you open? Are you on, are you zadic? What's your approach?

[C]

Somewhere in the middle. So I would say my evolution has been. I also did my residency at North Carolina, then a fellowship in Utah. And so I had traditionally done the complete open split, the Achilles tendon, take it off big saw cut, take off the, the back of the calc. I would start the saw blade very inferior, below the most inferior portion of the enthesified and angle it up and take off a big portion of the calc and then also use a suture anchor type of device to, to attach it. You know, I agree with Oliver. I think he's a very level headed guy with all this. I have had wound healing complications. Those stink a lot. I think those patients tend to hurt for longer. I have to slow them down a lot in folks that have that. And I think there have been some technical challenges where I think I've had, I would say some just surgeon error where I would leave a little bit of bone because I didn't see it on the far medial or far lateral side where I couldn't see it. So now I make sure I kind of sweep my edges to feel that. And I do agree with Oliver as well. I think it's a longer recovery. I tell people it's roughly before. So my definition of recovery is I tell folks it's like 8 o', clock, 9 o' clock at night and you're like, wow, I didn't think about my heel all day. And that's when you're recovered. And so I think for an open resection, I think that is, as he said, six months to a year. I tell people probably average of 9 months. Most patients feel better than they did before surgery between six and 10 weeks. But most patients aren't really feeling happy that they did it until, you know, five, six months. So I agree it's a much longer recovery with it. I've definitely done, done some of the Zix and I, I would say that I've had very mixed results. I think some of it's probably technical. So to me I wish there was a little bit more and this, this is evolving. So I, I wish there was a little bit more kind of definition about exactly where you do your V cut. If there was some way to have a better algorithm of how much you take, I, is it 6 millimeters dorsally? Is it 12 millimeters? Oliver mentioned he starts at really where the Haglin's deformity is. I typically do it more towards the forefoot than that and take my wedge out so I actually leave that hag lens so that I can basically attach my screws to it and then like where do you put the screws? Exactly so and I think that some of it could be. I think there's definitely a learning curve to me much more so for the zadig. I do all my bunions minimally invasive now like 100% and I've had great results of that. Been incredibly happy. That is absolutely my go to unless there's a clear contraindication. So I feel like I've used the burr fairly extensively but just AICs have not had as good outcomes. I've had one that had some thermal necrosis that a really long time to heal her wound in a completely healthy like 28 year old. So that was a tough complication. I've had one, I've broken the plantar calcaneus ultimately didn't matter but I think they hurt for longer. I had one where the screw was kind of in the enthesiophyte and about two to three months out from the surgery they broke the enthesiophyte off again. It didn't really lead to any long term things but an acute worsening of their pain at two to three months. I've had to remove hardware in a couple of them. One was probably at least technical. You know, you put them in a little bit medial and lateral. So on the direct lateral view it looked like I was in with the screw but really I was probably out a few millimeters that caused somebody pain. I've got one a patient, I've gotten their MRI scan. I'm seeing it back literally on Wednesday that I'm probably gonna have to revise because they have some residual indiesopathy and and some partial tearing of the insertion calcaneus that I didn't address at the time of surgery. So I think I've definitely had some zetic complications. Could be just learning curves. So I would say I've gone from complete open to probably 50, 50 zadic and open. And now I'd say I'm trending back more towards open because of the complications I've had. My other concern, I agree with Oliver completely. I think the ZX do get better more quickly. My concern is I saw a patient today, actually had a zig on one side. She's six to nine months out and I would think she would tell you she's about 95% better. But I feel like my ZCs just don't get. Some of them at least don't get to that hundred percent range that an open does. So I. I'd be curious to ask Oliver in a moment. So you mentioned like you don't know how much you kind of Achilles tendon to. To debride, which is a fair question. I would say I don't know that. It's very subjective how much I debride when I do it open. But we do it zadig you to breed none. And so I feel like even if I get that wrong, I'm probably gonna get it less wrong because I debrided some of it than debriding none of it right. And so that's where my concern has been. So I. When I have done Xadix for the most part, I'd say 75% of them, to me the indication was because I was early in trying to get the best patient for the surgery was you did not have much enthesiopathy at all if you had a lot or big bone spur. I tended to do the open. So I tried to pick people that I thought were going to be good candidates. But I just feel like at least in my hands thus far, we are not. I was not all the way there with his. With the outcomes. I feel like my complication rate was higher. The other thing I'd mention it in kind of closing before I get all of our thoughts about how much Achilles tendon take down was I agree that we need more research on this. So we're actually looking to do a study right now where we're looking to look at push off strength and probably hopefully a minimum of six months to a year or more out from Zadic versus open to see if there's a difference in strength. So it's interesting. I. I don't know that I've ever done a gastroc recession with an open hag lens. And I would say most of my patients, and maybe just because I take a large piece of bone, most of my patients have at least 10, if not 20 degrees of dorsiflexion. And many of them were. They were all above neutral, but I would. I would say they averaged 10 plus degrees more dorsiflexion after my open haglin. So maybe it's just how much bone I'm taking, I don't know. So I'd be curious. Nick, your thoughts and Oliver, your thoughts about the fact just not taking any. Any Achilles tendon. And also if they have the enthesia fight, I've done this on one or two patients. I've taken the mis spur and just shaved the enthesia down just blind. Um, because I kind of want to make that thing go away because a lot of people complain about the Bump in the back and shoe wear. So what are yalls thoughts on that?

[A]

Yeah, Nick, let me just go through kind of some technical pearls, I think, because Ben. I think that they'll all kind of, you know, and respond to Ben and hopefully help surgeons out there who are maybe considering this as part of opportunity. So, first of all, right, anytime you're doing calcane mis with a burger, a couple things. So we run this on 6000rpms, and for everyone, it depends on the handpiece you're using. But if you're not doing it, you know, copious irrigation is so important. It's a bulb syringe. And then even I have one paper out on this, but an fao, but just using chilled saline, right? It. It. You have your. Your staff put the saline in the fridge, right? They just know after you tell them this a couple times, right? It's. It's just in the fridge and you pull it out right before you start. So just. You cannot. I cannot emphasize enough for anyone using the burr out there or especially if they're new or not like Ben, where it's been doing it for a while, but, you know, it just. There's no greater way to have trouble with mis surgery if you don't keep the burr cool. And then the other parts are pause as you're, you know, pause every couple seconds. Clean the burr flutes, because if they get filled, the Shannon burr gets filled with. With bone, you know, it'll generate more heat because there's less. Less flutes actually cutting, and you're kind of pushing and it's not advancing. So that just creates more heat. So that's. That's number one. Number two. So the zadig, as it was described, like Ben was describing, right, that your. Your wedge is, you know, somewhere between the posterior superior corner and the subtalar joint kind of midway, typically, you know, still within the safe zone, ideally, right. But that's where the zadig was traditionally, you know, described. And so, you know, at the same time, you know, the reason Zadac must work right, in patients is because of that mechanical irritation of that posterior superior corner on the tend, right? You. You remove the wedge, you kick that posterior superior corner forward, you anteriorize the Achilles tension, which also, as we mentioned before, detentions it. But, you know, that's. That's the. That's the biomechanical benefit, right? That's the change you're. You're doing, right? Because we're not, as Ben said, we're not touching the tendon at all, right? So it's like, why does this work? Right? That's the only possible rationale of why this works, right? And so then I thought, well, you know, in. In patients who have a hagland, right? Or have prominence back there, well, you know, I was kind of creating a separate portal and removing, you know, that. That true hagland, right? Because I didn't want to leave that maybe over time, that would continue to kind of build up, you know, that could be a reason for recurrence of Achilles insertional pain in the long term. And so I thought, well, why don't I just move my wedge posterior, right? It's the same, you know, same size wedge. I'm doing as I would be straight up, right? I'm just tilting it posterior. And we know the Achilles insertion comes down right well beyond that posterior super corner. So I don't feel like I'm gonna detach the Achilles. I mean, I'll never forget. And fellowship Bob Anderson, you know, we've got the whole Achilles insertion peeled off. And he'd show you, hey, do a Thompson test. And they still have a normal Thompson test, right?

[C]

So I show the residents that all the time. It shocks like, I know, because, like, my cow.

[A]

My point is.

[B]

And.

[A]

And ironically, right, I told. I told your partner, Tyler, this, right? I said, hey, I'm doing all my ZX posterior. He goes. He goes, dude, that's crazy. The Achilles is going to rupture. Like, I'm like, no, man, it does not do that. And I had to tell him the same thing again, Ben. I told him the same thing. So anyway, I've been doing that for probably going on two years now, and I think that's really helped. Now we talk about. So the screws and screw places.

[C]

A few questions, Oliver. So I think what. I'm looking forward to reading your paper because I think it'll be an honest assessment of a couple folks with a lot of experience. I hope that in there, you guys have some pictures where you show how much you're wet. Do you have any intraoperative floors? Because that's what I'd love to see, because there's just. I. And maybe I'm missing it. I don't see a lot out there. So I would try and mimic what yourself and other experts are doing. I just don't feel like it's out there for me to. To mimic it right now.

[A]

Yes. You know, I'd say a couple resources. There are pictures in there. Again, the. The posterior wedge is more. I describe it as an optional kind of alternative. And a surgical technique because really when we were collecting data, it was the traditional wedge in this paper. But a couple things. So there's a, done an aofas, you know, video on Zadac, which is, which is on the site. Number two, I've got a, I've published a whole tech a recent technique video on LinkedIn. Number three, we've published our minimally invasive foot and ankle surgery textbook, which goes through the technique pretty nicely. That was written by my, my colleague Etore and has got ample pictures. Those are just three different resources. And obviously I can send you my most recent technique video privately. So I'll continue just in terms of screw placement, right. Also super important, do you go just like you said, it's like, do you go through, you know, dorsal start, dorsal go through the calcific metaplasia if it's there, right. And again, I think to your point, right, we know that's the kind of diseased area of the tendon. You know, from a purist standpoint, it's just like we don't ideally want to fire a wire through a joint. It's like my, my view is my first screw is going, is starting just below that Achilles insertional ridge, right. So just below the area of calcific metaplasia. And I'm angling toward the, the more dorsal portion of the posterior facet because we know that subchondral bone is the best bone, right. We want to grab that bone to compress with again, a headless screw. I'm not using headed screws for the very point you mentioned. Obviously they can be symptomatic over those. And then my second screw, right. So some, you know, some guys do a lot of safe to say, oh, you should put a raft screw, right. Like raft it just like you do with a, with a intra articular calcaneus fracture. The problem with a rap screw is they don't have the same bite, right. And this is, you don't need to wrap this osteotomy, right? You again, your goal is to close it down and compress it. And so I use a second screw and that one's just plantar to the other one. And with this screw I'm trying to catch the angle of gasane, the subchondral bone at the angle of gasane. And so I used to be a one screw guy. I'm in a surgery center private practice trying to save money, but I felt like they had a higher amount of plantar heel pain. Then when I again then when I switched to Two screws. I felt like that really reduced the amount of plantar heel pain. You know, I saw in the longevity of the plantar heel pain. I think that made a big difference me. So I think screw placement does matter. And then probably the most important question he asked a couple of times was, you know, what about the size of the wedge? The way I tell people is, you know, we use a 3 millimeter burr, right. So 3 millimeters, because you can't measure on the screen. Right. Obviously, it's all eyeballing. And the other key I would tell people doing this is, you know, not every company's got a 10 centimeter, 3 millimeter Shannon. Right. So it's 10 centimeters long. Some companies it's a 3 by 20, meaning or 3 by 30. And that 20 or 30 is describing the actual cutting length. But some companies just have a 7 centimeter calcaneal bur. And the problem is because you're starting so plantar to kind of. It's a very ergonomic motion. You're dropping your hand as you do this osteotomy. But it. It's sometimes just not long enough. So then surgeons kind of have to struggle to complete the osteotomy. They're having to push harder. Make sure you're using a 10 centimeter bur and really letting the bur do the work. So it's three millimeter. Three millimeter bur. Right. So my goal is to have it be, you know, around three and a half bur widths. Three to three and a half bur widths dot right. And that's how I know I'm getting enough. Right. So I make my one cut just posterior to the posterior superior corner, right where the haglan would be. I make my. My second cut. Then I run the bur to change my position and make my second cut just anterior to that posterior superior corner. And then I've got this. What you end with is this kind of wedge of bone in between. And I just pull that out. I just fish that out with a pituitary and hemostat until that's out. Then I again, my assistant maximally dorsiflexes the ankle to close the enemy down. And I just tee up my wire so I can just advance them. And this is a very. This procedure is definitely most easily performed in lateral position with the whole foot resting on the mini C arm. And even easier be on a big CRM. I just reduce radiation by using the mini, but I do them beanbag lateral. Their whole foot's resting on the CRM so it's very kind of easy to do and, and very ergonomic to just drop my hand as I'm completing the osteotomy back toward myself. But I think the biggest mistakes surgeons make is they don't take enough wedge. And it doesn't change for me. You know, I can just tell you, like, in my experience, I've been doing this, this osteotomy now for probably going on five years now, four or five years. You know, my wedge hasn't changed. If anything, it's, it's been maybe slightly bigger than when I first did it. My first one, I felt like I took out like it was the exact patient you described, really mild Achilles insertional disease, younger patient, runner. You know, I might have taken like 7 millimeters out maybe, you know, and I thought that he honestly ended up doing pretty well. But maybe just like you said, maybe a little bit of residual pain. And then I said, you know what, I'm going to take a bigger wedge. And that's really, I just haven't looked back since I started doing that. And I think that's super important. And again, I, you know, whenever you do something like you do a new technique, you kind of do it on, or I do it on mild and I, and then if it's working on mild, I do it on severe. And then I kind of just take a break and give it kind of three to six months and see how they do. And you know, I did it on that, you know, that mild runner. Right. Did pretty well. Did it on another couple. Then I had a severe rheumatoid arthritis patient, 50, partial tearing, big calcific metaplasia, golf ball at the insertion. And she did great. And she was a rheumatoid arthritis patient. Right. This is like the last patient you want to put, you know, I think she was on, she was certainly on methotrexate plaquenil, but I think she was on some other immunologic as well. And it's about the last person you want to do an open Achilles recon on. So in a way it was ideal. But she did great. She did great. I had a type 2 diabetic, some of the biggest plantar calcanel, visa fighting, Achilles insertional and visa fights you've ever seen, you know, and again, they, they did great. So I think there's definitely something to this. I think the technique does matter. And that's what, you know, I've been working to refine and, and to get to be where it's Very generalizable because, I mean, I couldn't, you know, I still will do open recons rarely, maybe in my practice now it's like 2% of the time. And that's because there's so much heterotopic ossification going up into the Achilles mid substance. You know, I just think, hey, this is probably someone I should open to remove just to do the severity disease. But, you know, really, this has changed my practice. It's my, it's my first line option. And, and again, as we've just like we did with MIS bunions, it's like we've really tried to kind of refine the technique and then make, you know, teach consistent teaching points. And that's what's allowed MIS bunions to kind of keep growing. And obviously Zadec is earlier in that, in that kind of trajectory. But again, I, I could never go back to doing open as my primary option. I just really think it's changed my practice for, for the better.

[C]

Do you do operative leg up or down? And then where do you stand?

[A]

So operative leg is up. So I'm, I've got the lateral calc resting on the, on the CRM. The other, the non operative leg is down and that's butterflied out of the field. And I've got the whole foot off the bed. Right. This, this operative leg is off the bed. I'm standing then just distal to the bottom of the foot.

[B]

So how. So I got a question about something you said, is, you know, you're changing the trajectory of the, the tendon. But how do you differentiate this from, say, those who are proponents of like a gastroc recession? I don't know if any of you all use gastroc recession as a, as a primary means for treating insertional Achilles, but how, how would you say the zadig is different from like a gastro?

[A]

Yep. So you do, I mean, you do gain around 8 degrees of range or dorsiflexion, I should say, with the knee straight. So it does detention it. But, you know, again, I, I've done some gastros for Achilles disease, more for me for mid substance. And like, they just take a long time to get better. In the ones I've done. It's not a home run, you know, and. And again, I just felt like it just wasn't enough in my practice. I can tell you personally, I mean, I would, I would use it as an adjunct for Achilles insertional open reconstruction, but I'm not one who can speak on doing isolated gastroc for the insertion. I mean, I think, again, it does have a component of that. Right? Because you do. Detention. The Achilles, they do gain dorsiflexion by anteriorizing the tendon insertion. And to Ben's point, that's why you don't have to take out the calcification metaplasia, the anthesophyte, because that kicks anterior by, you know, about a centimeter. So it's much less prominent in the back. And I've had patients tell me that, they say, you know, hey, it's not nearly so prominent in the back anymore in my shoes. Like, I don't feel like it, you know, I don't feel it back there like I used to. But again, I. I think, you know, it does have a detentioning effect. I just, I wasn't really impressed with gastroc alone for mid substance. So, you know, it wasn't something I was doing isolated for insertional.

[B]

So you think that open surgery is dead? I mean, I imagine that it's. This is something that is.

[A]

There's nothing that's 100% right. I mean, you should run from something that's 100%. I don't think it's dead. I think there'll always be a role for it. But I mean, like the rest of orthopedics, you know, it's gone minimally invasive, right? So I think if we can achieve our same goals, which is ultimately get the patient out of pain and improve their function. Right, through minimally invasive means. I mean, I think we're going to do that. Right? But just because, you know, just because you have a way to do it, MIS doesn't mean everything's better. With mis, there's certainly things I've tried where I thought, hey, this just isn't as good as doing it open. Like, for me, kylectomy is one of those. And that's part partly because I can't be bothered to scope the first MTP joint. Personally, it's just not something I enjoy doing. It's not something I love my practice. But again, this. That's. That's where it's going to go. And so I think whether, you know, whether you're doing an OPE or, sorry, a minimally invasive or endoscopic Achilles insertional reconstruction or a, you know, percutaneous zeta osteotomy, I mean, ultimately that's where it's going to go because that's how the rest of orthopedics has evolved. You know, I'd be interested to hear what your, what your algorithm is Nick.

[B]

So I was an open guy and central. Central split. I did a few Zadix. I think, you know, you helped me through. Through some. The. The. The easiest one for me to decide to do was one that had actually an open ZC on the other side relatively recently, which was. Which was kind of like my introduction to it, if, if you will. But. But I was predominantly an open central split, and I've used all sorts of approaches, whether it's lateral, medial, dual, central. I had never. I think in. Maybe in fellowship was the last time I did the hockey stick or the L type incision, but predominantly open. But I've kind of trended towards the more minimally invasive. But the minimally invasive bur. Resect the hag lens and then end up basically detaching the tendon scope, the posterior ankle scope, the under surface of the tendon and debride it and then use the mis. The double row construct for repairing those. That's. That's been my kind of evolution. I'm probably nine months in and done pretty much all of them now. And I feel I've. It's been fun to see the improvement in terms of pain, kind of like you were describing with the Zadig, where they come back at three months and they're, you know, basically out of their boot. And some. One of my favorites is asked if she could play pickleball. And I said, yeah, it's probably fine. And she said, okay, good. I've been out playing already, you know, kind of deal. So. So it's been fun to see. And it makes you think a little bit about that. That incision, we've talked about that before. You know how that can cause. Even if it heals fine, it can still cause some shoe wear, irritation.

[A]

I mean, you're also still. You're also still splitting the tendon. I mean, like literally splitting the entire tendon, which you don't have to do. Right. When you do this minimally invasive. Right. Or endoscopically.

[B]

Yeah.

[A]

So, I mean, that. That may be a big negative for the patient and, you know, probably doing a lot more soft tissue stripping. Right?

[B]

Yeah.

[A]

But I mean, the other question is, well, is it because you're. You're again, removing that area of mechanical irritation. Like, could you be doing maybe a really aggressive endoscopic haglins alone? And maybe that would be enough.

[B]

Right. Well, and that's the, you know, that's the question of, you know, kind of going to back what Ben was saying. And Ben, I think you talked about this on another podcast. You recorded on insertional Achilles where you just took, you took. Talk about it. You just take a big wedge when you do it open, and that basically decompresses the tendon. And a little bit of the question is do you have to do anything to the tendon at that point? You know, how much do you remove? And obviously we remove some so we get down to healthy appearing tendon. But once you decompress that area, is that enough to. To be able to allow that to heal? And, and, and there's obviously some regeneration of tissue in that area. What about fhl? I mean, it seems like with some of the more modern techniques, we've kind of trended away towards fhl, at least in our primary. In our primary reconstructions. Are, Are any of you doing an fhl, Ben? Are you adding that to your open surgery at all?

[C]

No, I would say it would be only limited to revision situation. And typically that's in the rare instance when somebody essentially falls down within the first couple weeks after an open hag lens and just ruptures their whole thing off. I've had that happen a couple of times over 10 years. And those folks. I will transfer an FHL tending because I feel like they often just need more collagen than kind of what's pulled through. So I've done it for that. But I, it is probably been a couple of years since I've done FHL tenant transfer. I think the literature out of Charlotte for primary.

[B]

For primary.

[C]

Yeah, for primary. I think literature Charlotte shows there's not a lot of functional benefit to it.

[B]

Oliver, I'm assuming the same with the, with the Zadig that then you're probably not doing an fhl.

[A]

Well, I'm never doing it with it with that, but I mean, for the revisions, like I had a guy come in seven months out from an open recon done locally and by a great surgeon, but the guy just had a retear, partial retear off the insertion. Just still in a ton of pain. And, and just the insertion looks severely diseased. So that was a guy I revised open and did an FHL transfer on again. For me, it's really for revisions. Yeah.

[B]

Yeah. And I think what I, what I like about it, you know, the, the. What you said, Oliver, was that we're definitely looking at different ways to approach these through lesser invasive issues or lesser, lesser invasive techniques because there are some skin healing, wound healing, skin irritations that happen with these. And I think you're going to see that become more popular, whether it's with an Osteotomy, whether it's with an mis bur, you know, directly at the tendon and reconstruction, I think that's going to become more popular as, you know, as over the next couple of years. One question I think that's important to talk about, but can you talk a little bit about your rehab protocols? Are you, are you putting them in a boot right away? Do you split them for a couple weeks or do you put them in a cast? What, how do you all approach your rehab with these?

[A]

You go first, I'll let the professor go first.

[C]

Yeah, right. So I, for my open, it is 2 weeks non weight bearing in a resting plantar flexion splint. I see it back in two weeks. I would say probably 90 of the people I take the sutures out. And if, if I've concerned about the wound, I've learned to understand I've concerns about the wound and wait longer because I think if they have a dehiscence of their wound, even it's very small, just a few millimeters, one, it can take weeks to a month or more before it heals, number one. Number two is I find that those people, if they have any type of wound dehiscence, they end up having a lot more incisional pain for months, like six months or more. Just their incision hurts. And so if I've learned my lesson with trying, it looks pretty good. Let's go ahead and let them start weight bearing. Um, so anyway, two weeks, 90% of people stitches out at progressively weight bearing, so no weight to fold over. Two weeks they have four heel lifts and then I have them in four heel lifts until six weeks. I take one out at six, another out, seven, eight and so by nine they're flat and 10 weeks they're out of the boot into a lace up brace.

[B]

Oliver, how about for you?

[A]

So for Zadac it's I do six weeks in a short boot, they're weight bearing after two weeks. At six weeks I let them resume driving and low impact exercise.

[B]

Do you send them pt?

[A]

I do, yeah. I send a PT starting at, at six weeks.

[C]

Do you do any lifts or is it just a flat boot?

[A]

Flat, because actually dorsiflexion is protective for the zadic. Right. Cause you dorsiflex to close the osteotomy down. So it's a little counterintuitive to like, you know, say an Achilles insertional recon where you don't want too much tension there just so they don't rupture, you know, say one of their Anchors. But yeah, I do the, the boot for six weeks and just two weeks off it let it cool down. But nice thing is like I said, I don't have to do a splint. So it kind of improves my flow, decreases my or time my and my flow. I'm talking about clinic flow. Yeah, for sure.

[B]

I'll typically do a splint for two weeks and then like you said Ben and resting plant reflection and then they get a boot and I'll let em start progressive weight bearing at, at that two week mark and, and kind of gradually increase from there. I'll send them to physical therapy starting after a couple weeks. As long as everything looks, looks good.

[C]

Hey Oliver, how many people walk on it? So that's what I'm definitely afraid of. I've got a bunch of patients that don't listen and so already telling them not to walk on things. They walk on it anyway. I feel like then they're definitely walking on it.

[A]

You know, if you give a mouse a cookie, they're going to take it, right? So you always got. That's why you always tell them not wait bearing the first two weeks because I mean that's the other thing with MIS and like MIS bunions, right. Sometimes these people just don't have pain the same way they would with an open procedure. So they kind of just. It's hard to, it's hard to read that pre op. Like, you know, sometimes you've seen these patients once, right. And they just come in, they're like I really want surgery. You know, tried all this, right. So it's hard to read that pre op. I think it's always good to just trial in two weeks. No wait. But I would say that's why I use, I mean that's even a bigger benefit of using two screws and getting that good subchondral bone purchase. You know, my buddy, the answer, he weight bears them right away in a short boot, you know. So like I said, I haven't done that personally. I still do the two weeks off it just to let it cool down because I don't, you know, I don't want to see any shift in the osteotomy or say, you know, the plantar hinge does break. I don't want to stress it too much too, too early and then they get significant inflammation there. But I mean that's the benefit of using two seven zero screws and getting that good subchondral bone. I mean it's a pretty solid osteotomy number one and number Two, again, if they're in the. In the boot, you know, they're dorsiflexed. Right. That's protecting. That's keeping the osteotomy closed. Right.

[B]

So it's not, in theory, weight bearing would actually protect you a little bit. Because it would.

[A]

I mean, as long as you're in the boot. Yeah, exactly right. As long as you're in the boot at 90 degrees, like that ought to be, that's a relatively stable position for that osteotomy.

[B]

Yeah.

[C]

And, Nick, you know, I just had a comment on one of your previous questions about, you know, is open surgery dead? I think that we're definitely progressing in a way that people are going to be doing less and less open. I think, for me right now at this point, which my opinion may change on this next year, I think it likely will, maybe with some of the research that Oliver is putting out and others. I think, sir, the folks out there, like Oliver and Etra and many others that are kind of developing the technique and refining it. So, like, for mis. Bunions, we're on the quote, unquote, like, fourth generation, Right? Well, the reason why we're on generation four is because we got better after one, two, and three, and I think the fourth generation works great. And I think we're somewhere in. In Oliver, I'd love your thoughts. We're somewhere in between generation two and three, because, I mean, for me, like, when I was putting the screws in, I was putting at least one of them, like, top down because I wanted to actually close the. Close the wedge. And then I put a one below.

[A]

That and be perpendicular and right. Be perpendicular to it. If you go. If you go up high, right? Like, yeah.

[C]

And then to hear that you're doing it lower and going up, I mean, that may be better. I mean, you know, I. I could see that. And then. And then I had people with the plantar heel pain, and I talked to Tyler Gonzalez, my partner. He's like, yeah, man, if you should put more of a planar screw and you kind of protect that plantar hinge, so maybe once you parallel the bottom part of the calc. So I just think. I think that there. There's a lot of different ways to do this. And I think, like, a lot of techniques, the more people are doing it and giving good, honest reporting of their results, the better we're going to get at it. And I think they're. I think that the things that I'm doing are probably minor, technical things that are not the exact same way Oliver's doing it. I think it's probably why I'm not, and get, not getting the same results that others are quite yet. And I think as we're refining that, I'm looking forward to seeing people continue to publish that so we can hopefully mirror their, I mean a 4% revision rate with 2 year follow up is pretty outstanding. I don't care what your surgery is. You can be taken off a toenail. That's pretty good.

[A]

Yeah. I mean, like I told you though, I, I totally agree with you. I mean we're probably in like the, you know, I don't know, second generation maybe. And, and, but we, we really, I mean, I really feel like we've made a bunch of advances, you know, relative to doing open ZX is very different. But again, I would agree with you. I mean, honestly, like I've, I've shown this to a lot of people, talked to a lot of people about it. And like I said, I know some great surgeons who've had mixed results, just like you said. And it's. So my goal has been how do I generalize this so everyone's seeing the same results that, you know, a group of us who do a ton of mis kind of are seeing. And it's like, what are we doing different that we're not maybe making clear to others when we're teaching this, you know, and how do we get everyone to the point where kind of we are, that's kind of, that is the goal, right? How do you make it generalizable so everyone can do it? Because that's ultimately what happened with open recon, right? I mean everyone was able to do an open recon, so it happened. Right? I mean, that's what, you know, PSI kind of was for total ankle. It made it easier for kind of everyone to do total ankles relative to just using the jigsaw, you know, mis. Then we started developing MIS bunions. We got jigs to do it now, right. The goal is to make it as generalized as possible and reduce problems. But I mean, I think the great part about orthopedic foot and ankle is a lot of really smart surgeons out there and, you know, no one. Everyone hates complications, everyone has them. And so we always want to avoid that and minimize that. So we're always trying to make it better.

[B]

Well, that's been a pretty good discussion. I think. We've covered three different types of surgeries really, from open to an osteotomy to insertional MIS approaches. And you know, we've three different approaches from different, different parts of the country. So it's been fun to have that, have the discussion and hear how everybody approaches things. I think, you know, we, we have to be comfortable almost with all, all approaches and understand what's happening because you're going to see those patients in, in the office, they're coming in more educated. They're going to ask for particular, particular techniques or particular surgeries. We just have to be, be familiar with them whether or not, you know, it's, it's something that you use in your own practice. So. Oliver, Ben, thanks so much for joining us today. This has been really fun conversation to have. It's always very thought provoking hearing both of you talk.

[A]

Awesome, Nick, we appreciate the opportunity, man. Yeah, thanks a lot. Thank you for listening to the AI AOFAS Ortho podcast, a Convey Med production. To learn more about joining our dynamic.

[B]

Community of highly skilled orthopedic specialists, visit aofas.org.