B (2:51)

Yeah, fair. I'm gonna get back to vitamin D thing in a minute. I want to get your and Gonza's opinion on this. So. People call this so many different things. I tell patients I can think of at least six different names. So I call it insertional Achilles tendinitis, Insertion Achilles tendinopathy, Insertion Achilles enthesopathy. Haglan syndrome, Calcaneal bursitis. You said calcific hyperplasia. Ar there other terms I can't think of? And are those all the same thing? Donzo, you start with that?

C (3:15)

Yeah, I don't think all of them are the same thing. I think wrong.

B (3:20)

That's okay.

C (3:21)

I think you, you bring up a good point because I think we lump them all the same. But I think that's where maybe we have to be a little more specific because I think, for example, I think there are some people who may just have what some people. The one thing you for got in there or didn't include is like, right, the pump bump. People talk about that where they just simply have an enlarged hag lens with no insertional disease or it's just pain back there, the runner's bump. And I think sometimes those patients may benefit from just. Sometimes people just do a minimally invasive haglin resection or just remove that and don't do anything like a zadig or an open haglin's resection or an endoscopic calcaneoplasty. Right. So I think understanding if the tendon is involved is really important because I think when you, if the tendon's involved, I think that directs Us to a minimally invasive zadig, an open haglins or minimally invasive hagglens resection with Achilles repair. So I think understanding what the pathology and where it actually is can help guide us in these different treatment options.

B (4:29)

Kaplan, you got any other names you can think of? They call this. And do you think they're all the same thing?

D (4:33)

Yeah, I mean, I think most of them are very similar. I do agree with Tyler that I do think there's a subset of patients that really just have irritation of their posterior superior prominence. And there is no tendon changes, no tendinopathy. But I think the vast majority of patients that we see have this conglomerate, I like to say, cornucopia of names that are all the same. Right. So I think a lot of them overlap. Other than these subtle little nuances.

B (4:57)

I think that's true. I think the patient that, like you and Gans are describing to me, I've only seen that somebody who's ballpark 35 or younger, I mean, they just haven't had the time to develop the rest of the disease process. It's sort of starting, but they don't have bad tendon yet because they just haven't had enough years to beat it up. Is that what you guys see?

C (5:14)

Yeah, I agree.

D (5:15)

Yeah. I think for the most part, I agree.

B (5:17)

The other fascinating thing is it almost always starts posterior lateral. What do you think that is?

D (5:24)

Well, I mean, I think. I think you see it in the corners. Like, I do agree with you. It seems more often that it's on the lateral edge than the medial edge. But on occasion, you'll have the patient who it's on the medial edge. And I think. I don't know. I mean, maybe it's because, remember, the Achilles fibers do rotate as they come down on the insertion. And maybe there's something about that rotation and maybe there's something about the tension that gets distributed more laterally than medially in certain patients. I think obviously it's important to look at the alignment because I think that can contribute to some of these patients, because a lot of these patients do have some level of cavus. I mean, it can happen in people in flat feet, neutral and cavis. And obviously as a whole, we've looked at that as far as ZX go. But I think that maybe it's that rotational anatomy of the Achilles that we learn about in medical school and residency that we kind of just ignore when we're in practice.

C (6:09)

Yeah, I. The one thing Ben, I do think Ken K. Brought up, I think the Ones that hurt medialy or have more of a pain medially. You know, it always is a little bit of an outlier, but they exist. And, you know, you work them up the same. And I think. And I don't know if you guys have treated them any differently. I haven't, but I haven't had any different results. Right. Like, I think it's just kind of like a variant. Right. I think the most common is that posterior lateral, but I think it can exist centrally and medially too.

B (6:37)

Yeah, for the most part, I agree with you. I've seen it be more medial, but that's rare. I'd say 90, 95, start lateral and then progress to central and medial to where this whole thing hurts as sort of time goes on. But I think probably the vast majority are lateral for reasons I don't understand, because we always talk about it's really the medial head of the gastrocnemius. It's tight, but maybe it's that rotation of the Achilles tendon fibers that end up. Maybe the medial fibers of the gastroc end up being more in the lateral side. Lateral side of the calcaneus, possibly. Yeah. All right. So basically everybody's a candidate for a zetic in Kaplan's mind. Gonzo, same zealot.

C (7:10)

Yeah, yeah. I mean, I think we, all three of us together, I mean, we've looked at this pretty extensively and over the last almost three years, we all three of us together have, you know, looked at this. Trying to answer this question, right? Because I. I think the real answer is we don't know fully. I think right now, based on what we've looked at, the majority of people who are candidates for an open hag lens, who I think all of us would consider the majority, what we all done historically are candidates for Xadix and they tend to do well. I think there may be some patients who are better candidates for it than others. And I think we've looked at the basic stuffs, MRI differences, radiographic parameters. We've looked at insertional calcifications. There's been some studies out looking at insertional like degree of calcification with anthesophytes or without, and all the data is coming out. There's not much of a difference. So I do agree with Kaplan at this point. I think, you know, I think most patients who you would consider for an open hazardous section could be considered for a zadic osteotomy with, obviously, I think the exclusion of some poor bone quality that you may be worried about healing of your osteotomy Other than that, I, you know, I. As of now, what the three of us have shown others, I don't see a reason not to do it.

D (8:27)

I mean, I guess speak on that, too.

C (8:29)

One.

D (8:29)

One patient, I guess, would say contraindication, too, is if they've had an Achilles debridement with an FHL tendon transfer. I mean, I'm weary of doing an osteotomy and putting a screw or doing the osteotomy through the transfer. And then those patients, it becomes even harder, you know, because I'm really. What do you do? But I think, you know, aside from those unique situations, the only other patient that I'm not doing is Datacon. I mean, I think it's important to have the conversation with the patient. And there's some patients that. It just doesn't make sense to them. And I don't try to sell them on something they don't want to do. But I think all things could equal. Most patients are candidates.

B (9:02)

I think the reason why I'm still doing majority open is because I'm just still struggling to not get rid of the enthesia fight and not get rid of the bad tendon. And obviously, I think we're doing a study through the AFAS to try and look at that. We're biopsying people's tendons at the time of surgery. We're going to biopsy them again a year later to see if there are truly cellular structural changes of the tendon. That's just my tough part is just I believe that when I go in there, it looks like crab meat, and I want to get rid of that and sew down some good tendons, some good bone, and people do well. And I think the real issue, I think, you know, and guys, you get into this some. But to me, I think we publish around about three papers now or so. They were reasonably significant. One he mentioned MRI thing that basically showed it didn't really matter how much insertional disease you had based on MRI scans did not affect outcome. I think that was important. The other thing, we have a gait study that basically said the gates are, I would say, equal. I think we measured.

C (9:50)

They're clinically equal.

B (9:52)

Clinically not significantly different. There was one measurement that was better in Zadig, but, you know, in small groups, I think it was probably not significant. And so I think they're of equal gait pattern at one year. And I think the thing that we're going to be publishing soon is the complication rate, wound healing complication is Higher with the open. The caveat, I would say about that, I think that's absolutely true. And again, many of those study were my patients. The wound healing complication rate issue is this. I think the important difference is it very few of those who want to go back to the operating room, we're talking a gap of a few millimeters of their wound. I said, hey, let's stay off an extra week or two. Let's leave your stitches in, let's bring you back, you know, three weeks, four weeks, get the stitches out, let's start weight bearing. So it slowed them down a little bit, but did not really, I don't think, impact their long term outcome. But there are more wounded healing complications with the open approach. Is that, did that summarize that gonzo from your standpoint?

C (10:40)

Yeah, and I hit the nail on the head because I've talked to people. I mean, I talked to Holly Johnson about this a couple weeks ago. We were at dinner and she was like, because, because some of those opens were mine as well. And she's like, that's a high wound complication. I'm like, holly, Ben and I looked at every single wound. This is not going back to the or. Like for an ind. This could be a small little wound that we slowed them down for. Like you said, we. Maybe for me, I maybe got a little slower. I recasted them or, you know, put them on oral antibiotics. But most of them were not major complications having to go back to the or. But they were things that affected the recovery period and slowed them down a little bit. And, and again, I would agree it's not like three months, four months, it was a few weeks. But I think for some people that's important. I think that's important to recognize. And I think we do a good job of documenting all these things. So we were able to get accurate measurements of these. But I do think that is real. I mean, that incision kind of does. It's not in a great place. And if you have a small wound and you have to slow them down. And for some people that really matters. If it's their right foot. They can't drive for a couple weeks kids. So I don't think it's. It's that terrible, but I think it's a real thing. And I think, yeah, with the minimally invasive Zadic, you know, that the wound complications low, I mean, as it should be. So. But I think those are. That. That's a fairly good summary of it.

B (12:00)

Yeah. And I think we try and be very accurate Reporters of our data. And so if the wound didn't heal exactly like you would expect, at least in my case, take out the stitches at two weeks and then that's not a routine pathway. I will say also though it doesn't mean there aren't complications in the zeta group. One of the early zadigs I did, I think it's one of the few times I've. I think I probably had three or four patients between Ms. Bunions and zachs where I just burnt the crap out of somebody's skin. And there was a young woman who was a military Service member, like 33. I did a zadig, you know, she's like rocking. Her bone was unbelievable. She was a black woman, very strong bone. And I think I burnt the crap out of her skin and she ended up with about a 1/2 centimeter round ulcer that was like a burn. And I mean I didn't put up Silverdine on it. So you get wounded complications with the zadig as well. I do think there's more heat generation with that. So things important to irrigate, take your time and things like that with it. I often pull the bur out and then irrigate into the hole and put the burr back in. But you can get windling complications with the zadig too. Have you guys had some of those as well?

D (12:59)

Yeah. I mean I think there's a learning curve and there's a learning curve both with the zadig itself but with using a bur in general. And that's something that I've seen in different procedures with the bur early in my career is learning how to know avoid burning the skin. I've had a patient who very similarly had now the zadig but different mis procedure very early in my career. And I had to use S and things like that because it's a burn and that's what happens. So yeah, that can happen, I think. But when you look at the wound healing rates, no, it does happen with osteotomies, with calcane osteomies, but not nearly the same capacity. And I think that's important. Right. And yeah, you guys did that study looking versus MIS wounds, but. And again, they're not changing long term outcomes, but they are changing short term things. And I think that matters. So it's still, even though it's not changing the rate of surgery, I do think it affects their outcomes. Right. It affects how quickly they get back to life like Tyler said. So I think that's still something that

C (13:53)

I favor And I would say for the people listening, I think all of us, you know, here we do a lot of mis every week and I think obviously we all know that more and more people are starting this. And I think Ben, you bring up a great point about the burr because I think this is an area and I'm not going to digress to a whole burr thing because we could have a whole panel on that. But I do think two things you mentioned were important. I think at least for me, if I burn the skin in the or sometimes darker skinned individuals may be hard to see, but sometimes you can see it. I'll just cut it out right there because, you know, I know it's not going to do well. And it's such a small incision. I'll just remove the burnt skin and then close because the incision is already so small one. So I think that way you can avoid future potential problems by just sitting on it because you already know it's burned. The second thing I think Ben mentioned which is really important is irrigating in the osteotomy. We actually, you know, Ben, we looked at this where the heat bones insulated. So the heat actually rises after you burn. Right. So irrigating after, like I still irrigate during the burring. Ben doesn't do that really. I know Kaplan does it. I think. I don't know if that really helps, but you can do it. I think it can cool the skin and the outer bur. But I think definitely irrigating inside, especially with the calcaneus which we saw generated a lot of heat after burying, can really cool the burn. And I fortunately haven't had a non union in the zadic in the primary zadic. So I think some people starting early on say they get a lot of non unions. And I think some of that has to do with the burrowing technique and the irrigating. So I think it's important technique when you jump onto this to consider those factors too.

B (15:32)

So I think it's out there that I have truly no experience with. Have you guys done the sort of minimally invasive or percutaneous Achilles tendon debridement option? And there are companies out there that since you do a suture anchor thing where you sort of do an haggling section a little bit, I guess think endoscopically or with a burr and then you percutaneously put, you know, a suture configuration down there on the Achilles. Have you guys done any of that, seen any of that or what are your thoughts on it? Kaplan, you seen it?

D (16:01)

I did one today, actually. Yeah. And I think it's important. So I. I do it for a few reasons. One, I think it's important to try different procedures so that you can understand what works and what doesn't, and so you can try to see if there's outliers, if there's things better for certain patients. So I started doing this a while back, actually, because it was your indication

B (16:19)

to do that instead of a zc.

D (16:20)

Yeah. So, actually, to be honest, it goes to that discussion I have with a patient, and if I have a patient who feels like the Zadic doesn't make sense to them, or they're really worried about the spur and the presence of the spur, and even if I tell them that the spurs and change outcomes and all these things, and it still matters to that patient. And I think there's a human element component to success with surgery. Right. Like, I think when patients do a surgery that logically makes sense to them, that they feel like their choosing is in line with them, I think they're probably going to do better because they have a better open mind about the surgery. And, look, we can convince our patients to do a certain procedure, but if they have a doubt in the back of their mind throughout their recovery, they're constantly going to think, I'm not doing as well. I should have taken this spur off. Or, like, think about patients who are symptomatic at two months. We know that's normal for any sort of surgery, but they're saying, I wish I didn't do this. And you have to tell them it's still already in recovery. You're still going to do fine. So what I've learned over the years is there's those patients who just, you can explain all the data, you can explain all the science, you can explain why the spur doesn't matter and how that ZIC works and all these things. But there's some patients that it just doesn't make sense, and they just don't like the idea of it. And those are the patients that I'll do the minimally invasive debridement and Achilles reinforcement. And I think it works well. I mean, I'll be honest, I think it works well. And I think you'll see data come out that shows it works well. And I think it kind of going back to what you brought up, too, where you said, I like to do the open procedure because I like to remove the spur, but I also like to debride the tendon. So this minimally invasive procedure, it does not debride the tendon. Right. You're not really doing anything to the tendon, but you're debulking the under surface of it. So you're debriding the hagland, you're debulking or taking away that pressure, and you're getting rid of the spur. And I don't. Again, it's not the spur that's the pain, but I think you're debulking the under surface. And so I think it works well for that.

C (18:07)

Yeah.

D (18:07)

And the nice thing is, real quick, sorry, Tyler, it's. It also, it blends both things, which is it's smaller incisions, so you lower your risk of wound issues, but then you can at least address those other things. So go ahead, Tyler.

C (18:20)

No, so I was going to say, I want to go back to Ben's. That exact comment, the crab me comment, because I was just going to say I. And Ben, you. This is a great segue because I was going to say that I don't do that minimally invasive hag lens with the Achilles reinforcement, but a lot of people do, and everyone has said they do very well. And I think there's more data coming out that they do well. And so when you have that procedure that does well but doesn't really remove the tendon, you have the zeta that does well, that doesn't touch the tendon, then you have an open procedure that does, but does well. And why we're doing the study, Ben, is I don't know if the tendon is a problem because then I don't know how the zadic and the minimally invasive would work if you're not debriding the tendon. Right. And that's where to me, the whole this is such an interesting. I don't even want to call debate science figuring this out, because you have three good surgeries that we know work very well, and two of them don't even touch the tendon. Right. So. But I think all three do the same thing. They decompress the area, they clear out the retrocalcaneal bursa, and they all move the Achilles tendon more anterior. They all three of those do. Right. And so they all biomechanically change the environment back there. And I think we all know that there's different recoveries. But at the end, at least at one year, all of these patients do very well. So I think the biomechanics is what is probably going to be the similarity between all these three. And that's probably the etiology of the pathology in my mind. But we'll know more after our study. But I don't know what you guys think about that. But that's always what's rattled my brain.

B (19:57)

I agree. I don't understand either. That's why I'm excited about our study and hopefully we get some answers to that, right? I mean, obviously we can't take huge chunks of people's Achilles tendon like you used to do. But that's some of the question I want to answer to figure out what is maybe the optimal best or you know, trying to figure out who's best for what procedure as well. Because like I said, they all work pretty well. I mean, all of us have, I think overall good success rates. I mean, that's what our studies have shown so far with one year outcome, with gait, with pain, physical function promise scores, like people are doing well. So then we're sort of on second order things like wound healing complications, infection, non unions, those kind of things.

C (20:31)

Yeah. So I mean, I think anyone listening, I think it's, I think you can just pick your poison, right? I don't think any of these, I think they all have their little nuances. I think there's probably, as we continue down this rabbit hole, probably find some better indications or better patients for each procedure. But I think what we're going to find out, it's going to be the biomechanics that we change is all three of these. That is why they all work. And it's probably what's best in your hands or what you're most comfortable with. But I do think, you know, on, on some patients, like especially maybe our athletes, right? Or our military personnel or people are at high risk, maybe one of the two minimally invasive might be better suited for some of those higher risk patients where we might find the open procedure might be better with certain people with some type of tendon pathology that, that we might better identify better. But I don't know, I think we just, we're on the right path. We just need more answers.

D (21:24)

I mean, look, if you look at these procedures though, I mean, they all for the most part have a 90 to 95% success rate, right. And I think that means they work in most people. Now the question we have to ask ourselves is how do we identify those 5 to 10% for each of them, right. Like for the zadig, is there 5% of people where the tendon is the problem? And maybe those are the patients who are older patients or any patient, but have a really Significantly tendinotic tendon and yet happens to be at the insertion. But it's really the tendon is so thickened and hardened and nodular that maybe those are patients that need a debriefing or they need a full reconstruction, whether it's an allograft or an FHR or anything like that. And then the patients who you attrition, open debridement and they fail. Is it they their tendons too gone and it can't heal itself and they needed either an FHL or a zadig is enough to take tension off that tendon and then both of them. When do you do mis where you can just debride the bone and not have to touch either? Right. And I think that's where we have to find those 5 to 10% outliers.

B (22:24)

Yeah. But you can find that prospectively.

C (22:26)

Right.

B (22:26)

Like identify this beforehand. Here are the risk factors for failure of this thing or wound healing complications or whatever it is. Right. So I think that's what really trying to kind of narrow down and we have I think proven, you know, this term gets used a lot. They're all safe and effective, relatively speaking. Right. Any surgery has complications, but when we look at our long term outcomes, people are doing pretty well. We're trying to get the right surgery to the right patient, the right time.

D (22:48)

Exactly.

B (22:49)

Classic surgeon problem.

D (22:50)

Yeah, but the patients want it too, because if you can tell them which one's the best for them, I think that makes it easier for them too.

B (22:57)

Absolutely. Absolutely. No question about it. Well guys, I appreciate the talk about this. I think there's been a decent number of questions answered around this topic, but there's still a lot of things to try and sort out, I believe with these and trying against like the right surgery for the right patients. I appreciate Yalls time and being here for this and discussing it. And even though you're zealots, you at least let me talk about some open treatment and didn't really shame me too much. That's. It's good.

C (23:22)

I appreciate you. We care about you and we just care.

B (23:26)

Thank you. Thank you. I appreciate it. Any final closing words you guys have?

D (23:31)

No. I think you're a zealot as well. You're just an open zealot and I'm flexible.

C (23:36)

He's coming around. I'm coming around on any given day.

B (23:40)

Slowly turning the Titanic here.

D (23:43)

Yeah, there you go.

C (23:44)

You'll get there one day. But no, thanks for organizing, Ben. This is great.

B (23:48)

Yeah, thanks for your time, guys.

A (23:51)

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