I'm gonna get started. Good evening, everybody. Thank you all for joining us amidst, especially those in the Midwest and Central, on the Central part of the U.S. with the winter storm. Today is a special guest that we have on board. Introducing him, Dr. McGarvey, graduated magna cum laude from Thomas Jefferson in Philadelphia, Pennsylvania. He was inducted into the AOA Honor Medical Society, completed his internship in general surgery and residency in orthopedic surgery at Union Memorial Hospital in Baltimore, Maryland, and then completed a fellowship in foot and ankle surgery at Baylor College of Medicine, Houston. He was then appointed and continued to escalate and is currently associate professor at McGovern Medical School at the University of Texas Health Science Center. He is the orthopedic residency program director. And I can understand if you're working with orthopedic residents and fellows, then you go from here to there. I'm on my way. I guess most of us in academic institutions are on that path. But thankfully, I think it's a rewarding path. Dr. McGarvey was the immediate past president of the AOAS. He gave a tremendous push to all the committees. This here is a picture with Dr. Chris Cozia in our last pre-COVID meeting. So in the COVID era, this wouldn't have been the picture. This is from the Resident Scholar Program. And it was actually the very first time, I think, in the history of our society's meetings that both presidents, so president and president-elect or past and present presidents of the society were there to give a brief talk to the Resident Scholar Program. And I think it gave a tremendous boost to the event that year. He is currently the board liaison for the Young Physician Committee. And for those of you who have not had the chance to listen to the first Orthopodcast series of the AOAS, Dr. McGarvey was the inaugural guest for that with Joe Park and Anish Kadakia. And if you haven't listened to this podcast, it was an excellent podcast. And again, I'll have to personally thank Dr. McGarvey for the initial boost he gave the YPC as he commended our work and said that we were one of the most lively committees within the society with a lot of efforts. I mean, of course, needless to say, if you look his name up in PubMed, you're gonna find his publications covering all aspects of foot and ankle surgery, a few of here to mention. So I think a very well-rounded experience that we're all gonna benefit from tonight. Some testimonies. I sat on the Resident Applicant Review Committee and Selection Committee this year. And whenever I met medical students from UT of Houston, this is what they had to say. He's all over Houston. He works out of three or maybe four hospitals. He does everything perfectly. His practice is so unique and an amazing surgeon mentor. He continues to serve, of course, as mentor for a number of fellows, both national and international. One of whom was a very close friend of mine who told me simply he's a giant surgeon and a human being. And Joe Park, quote unquote, said that he is a giant of the society, which I totally agree upon. Don't freak out if we lose him tonight. There are outages on my side. So we'll keep our fingers crossed that we have him throughout the whole hour and a half. And without further ado, I'll welcome Dr. McGarvey on today. And we have a little bit of an echo. So I think your speaker might be working right now, Dr. McGarvey. I'm gonna hand it over to Cesar. He's gonna go through a few housekeeping items before we start. And then him and- Hello? Dr. McGarvey, we can hear you, sir. Can you hear us? Okay. Well, why we figured it out was for housekeeping. I think there's a lot of the names that are very frequent names here. So people are starting to get used. But just the idea here is just to discuss the cases that were posted in the AOFS Connect website. So unfortunately, you cannot share cases here on a live basis. So if you want to discuss the specific case, please go. There's still time to go to the AOFS Connect and post the case. We should behave the same way we would behave on a discussion with colleagues. We usually say, let's do like in the grand round. So not providing any information. They can identify patients and treat colleagues in a proper way. And I think there's no problem with that if anyone is here, but that's what we usually do. Well, I'm not sure, Dr. McGarvey, can you hear us? Let's see if we can hear you. Go ahead. Cesar, Sarah, I think for the sake of time, we're gonna start going through the case. I believe Dr. McGarvey reviewed it. So if you can present it to all of us and then we'll have Dr. McGarvey's input by the time he's logged back in. Great, thank you so much for letting me present this case. This is the nurse and clinic manager of one of my colleagues here in New Orleans. And she came to see me for a second opinion for great toe pain. She had seen a previous surgeon who'd recommended a chiolectomy. My concern when I examined her was her history didn't line up with just that classic bump pain that we think of that responds well to a chiolectomy. She had mid range pain. She had pain with running and any activities. It wasn't just pain over the bump. So I got an MRI and I included as a video attachment some of those slices from her MRI, which does show primarily metatarsal head, but also some accompanying phalangeal base, articular changes, particularly along the lateral aspects of the joint. And so the question that she and I have been having was originally I was hoping she would be a candidate for a minimally invasive chiolectomy type procedure, especially given her young age, the fact that she has goals of running and doesn't wanna limit her shoe wear. But given that there is articular defects, my concern was that that was gonna be one, that she has articular defects and two, it seems she's having symptoms from those articular defects that I felt like a chiolectomy may be under treating her or not really helping her problem. And so my question for Dr. McGarvey is there's so many choices out there for how to manage this grade two hallux rigidus, but it's not really bump pain, it's more articular pain and how he would tackle this, whether chiolectomy alone is still the solution for this girl, whether she needs osteotomies, whether she needs some cartilage restoration procedures. And I was hoping for his advice on how to counsel a 31-year-old runner and busy nurse and mom. When you measured it on the- Who I also happen to see. When you measured it on the MRI, did you have any dimensions on it? I didn't measure it, but it looked to me to be somewhere, it's less, it's probably around five millimeters was about what I gauged, but I didn't measure it out. And did you get a CT scan, Sarah, or just an MRI? Just MRI. Okay. So while- Dr. McGarvey there. Let me see. Can you hear us, Dr. McGarvey? And I guess the other thing pertinent to her history is she really wants to limit downtime. So that was also kind of part of how I've been having this conversation with her too that we've been weighing as well. And she wants something done sooner rather than later. She's tried all the other stuff. I think we could run through other attendees while we wait for Dr. McGarvey, then he can give the expert opinion. So I think Daniel Gus, you're just upgraded to an expert. So- Hi, Dr. Gus. Of course you are an expert. I guess, I think you've aged me by a couple of decades. I think that's the amount of time. It takes wine to become an expert wine. Yeah. Yeah, and I think this is a tough one. And if you've exhausted all of the sort of non-operative means, then I would probably do something that's not sort of permanently destructive to the joint. I would lean towards first trying kind of a joint protecting even a debridement and biocartilage, realizing that that doesn't feel as good as completely replacing the defect. And then I would even toy if that doesn't work with something like an osteochondral type graft before I would act a, ask, you know what I mean? An artificial replacement to sort of function in that manner. Because we really don't know what the longevity. And then, and superimpose on all of this is goals and patient demand. Someone's hoping to return to high level athletics, the likelihood of success starts dropping relative to other means. And in that sense, when you add that perspective in, I think that also implicates the timeline of what you do and when you do it. Paul, what are your, Talusin, let's hear Talusin's thoughts. Yeah, well, I'm curious. Did you say that she had an injection already? She had one injection by the podiatrist. He didn't do it under fluoroscopy, but she did have a couple days of relief and then it came back pretty quickly. Yeah, well, I think, I think number one, and probably the most important thing and interested in what other people have to say. I mean, I think managing her expectations is probably the most important thing out of all of this. It sounds like she kind of wants to be 18 again more than anything. 100% agree. The MRI actually helped with that conversation and being able to see her, the MRI actually helped with that conversation and being able to show her that you have arthritis of your joint. Our last conversation was a lot more productive in terms of conveying some of that reality to her because yes, she wants to still be able to run and lose her COVID weight and be a mom, a nurse and all of it at the same level as she did 10 years ago. Let's open it to the floor. Dr. McGarvey is still here and I think we're gonna hear his voice shortly, but please unmute yourself and give us your opinion and let's see what the floor attendees are gonna think of. And the only thing I would add as background, cause I'm curious what people think is when everything else fails, you know, the beautiful thing about the first MTP is that it does well with the fusion and obviously nobody's jumping to that in this person. It sounds extreme, but I'm just curious what people would think as far as where that would fall on the spectrum. Mio, Mio is mine. What would you do? It's funny you called on me because I did a case very similar to this about six weeks ago. She was a little older. I think she's 42, 43, but she had dorsal degenerative changes with a central osteochondral lesion in the metatarsal head. I did a hybrid of chylectomy, but still left a rim and then did a biocartilage fill of the central lesion. It's still too early. It's still too early to find out to see if it works, but that's what I did. I did a chylectomy with a biocartilage and hopefully it works out. My only concern with biocartilage here is the depth of the lesion. And that's why I asked for a CT. Usually if I see the cystic change, I would like to assess it more accurately with a CT. And if it's deep, going all the way to maybe five or six millimeters, I've had a limited case series that I'm looking into publishing on an OATS, an autologous osteochondral transplant from the knee to the hallux. Some of them have been really highly active younger or middle-aged patients, just like yours, Sarah, avid basketball players and avid runner. And in my small case series, all of them returned to their competitive level. One out of these had a knee discomfort that actually stopped him from the donor site, that stopped him from playing basketball. But the others did well and returned to their previous level. So I am all for biocartilage, but make sure that the defect is not deep to hinder putting in the biocartilage, or you can build it up with some cancellous bone. Dr. McGarvey, are you here, sir? We can see you, but we can't hear you yet. All right, can you hear me now? Yes, sir. Yes. Okay, well, that was a load of fun. That was really probably the best thing I've done in the last two days. All right, well, I'm really sorry about that. Right now, my laptop is not connecting to any wifi. The desktop is telling me that I'm not the user that I think I am, and my phone won't connect me. I think we're just out of internet usage here in Houston. Honestly, it's just been a fiasco. All right, so you can hear me? Yes, sir. Okay, so, and my internet connection's unstable because it keeps bouncing me back and forth, but I did see some of the pictures, and I saw this case. Sarah, are you still there? I am, yes, sir. Yes, sir. All right, so what I thought about this, and I've heard some of the comments. I didn't hear them all because I've been trying to just bounce back and forth, and for anybody tonight, if you would like to call me individually about these cases, you can do that. You can get, I'll give you my cell phone number, and you can call me later, but I'll just tell you what I think about this going forward. So give me the profile again. It was a young nurse, I think. 31-year-old nurse. She's the clinic manager of one of my partners in vascular surgery. She is back up running, is trying to lose her COVID and post-baby weight, and as she started running, started having a lot of articular-type pain in the joint, not classic bump pain, came to me for second opinion because pilectomy had been recommended. It just didn't sound like bump pain, so that prompted the MRI, and so the conversation was kind of what options in the spectrum of kind of cartilage restoration versus not burning a bridge procedures would, should, or would I consider at this point for someone? We talked about setting realistic expectations, obviously, but would love to hear your thoughts on kind of where you think a 31-year-old female falls when she has basically great toe arthritis, what your algorithm is for these. Yeah, and so it's an expanding algorithm. You had thrown a couple of options at me in your question when you sent the case, and I saw a couple of the answers. I will tell you, in this patient population, it's a challenge, and I'll date myself a little bit just from the standpoint that I was around when there were basically two options for these, maybe three, and beyond stiff sole or changing lifestyle, which nobody wants to do, particularly in this patient population. She's a runner, and she's high. She's gearing herself up. I think, and so those options were basically colectomy, MTP fusion, or just sit it out you know and don't do anything anymore and she's not going to do that. But I do think that you have some options that as we've kind of learned from our colleagues sports we we can start to go down that road. Her osteochondral lesions appear to be on both sides of the joint which is a little bit problematic and and so you know your intra-articular stuff. Do you do any small joint arthroscopy? I mean really small tiny joint arthroscopy. Do you scopescope the great toe? I have no experience with small joint arthroscopy no. Okay and I only bring it up because if you do I think it's an interesting thing. I don't think it's necessary but I think it could give you it could give you a little bit of perspective that you're probably going to get anyway through a small arthrotic. Right. Is it do small joint arthroscopy? I mean I've tackled a few great toes and and I'm not thrilled with it. No it requires a lot of setup. You have to have distraction. You have to use a tiny scope. You fiddle with it a lot. The inflow doesn't work. If you use a shaver it's a nuisance. So you can hear from my the tone of my voice I'm not excited about it. But if you have that skill set or or if you just want to try it I think this is a great case to try it off. Having said that I think that your options here for me she's not gonna want a fusion. She's not gonna like fusion. I think a fusion would be great here. But I think at 31 she's not gonna love it and she's gonna feel like hey why didn't why didn't I have some other options and I think you have some. The the the traditionalists would say chylexia works well but you're gonna get in there and likely find Caesar I don't know if you can scroll that. What I'm seeing is the coronal shots. I see two sesamoids. I don't know if you can scroll that a little bit on one or the other so that people can see it. But that's a that's a good one right there. So what you're seeing is you know there's there's some articular surface probably loss. So I'm going to rephrase that. There's some articular surface loss for sure on the distal metatarsal head in the central portion and there's probably some on the proximal phalanx. Now in my hands for runners I'm going to go through the negatives first. You had asked about cartiva and we can have a conversation about cartiva but this would be a bad patient to cartiva I think. I don't think it would hold up under the duress that she's going to put it under. I think she'd be unhappy with it and then you've actually created a fairly large defect metatarsal head. So I think for those of you thinking some sort of artificial arthroplasty I think that that's not a great choice for her. Maybe if she's 50 something and thinking about okay I'll try something but if it doesn't work I won't run anymore that's probably a little better. That last sagittal that you had up which was I think a G2 or fat sac showed that there was some proximal phalanx articular surface damage. That one shows it a little bit. There's flattening in the head but there's also flattening on that proximal phalanx side and as you scroll through it you'll see some more. She's got a little bit of dorsal osteophyte but it's not much. It's not much at all. So I heard some of the discussion. I heard Alim talking about you know possibly some OATs. I think that's a challenge as a primary procedure but it's not wrong. In my hands I have had some experience with arthrotomy. The chylectomy part of it actually probably would do better if you took some off the proximal phalanx. I think that that works better. It's called a valentate and it's probably called a couple other things but if you took a little bit off the proximal phalanx it's kind of hinging and an added image it does actually show a distal metatarsal osteophyte. So you could get better motion with that by doing a small and I emphasize small chylectomy off the metatarsal side and off the proximal phalangeal side and then assess your joint and here's the options for the joint. I think you it depends on what you have available and where you're doing the case. If you're at a surgery center you may not have some of these things available. I have lately been using some articular substitutes and I'll name some names but I don't necessarily have any relationship with these companies. Arthrex has an IOBP which you can do hip aspiration for stem cells and mix it with their cartilage and cartilage product and you can actually put it in there you can put it with their bio cartilage but Stryker has some and other companies have some everybody has some so I don't necessarily feel obliged to tell you that it's one company that you need to use but you could consider a cartilage substitute and a fibrin glue. I think that that would not be unreasonable. You probably might want to even do a little microfracture underneath. I have done purely microfracture. Stu Miller wrote up some of those. Again I think that pure microfracture might not be enough here because the articular surface lesion is fairly large and it may be bipolar one on each side and so you may have to have something on both sides. The other thing that I have done and have been and grow an increasing fan of again a little bit older but still kind of has a role in my big role in my practice I've used it in similar similarly active patient population would be an interpositional arthroplasty with a dermal matrix allograft. I don't know if you've done that before Sarah have you tried that before? I've done it in a lab I haven't done it in a patient yet it's just in the lab to try it out and get more comfortable with that in my hand. What is the durability of the allograft this dermal allograft sir in these patients long-term? So there's very little published. Brulette and Tom Lee did their series back I want to say 2008 and wasn't it wasn't very many maybe it was 2012 and there were eight patients maybe that's where the eight comes from but it was not too many patients and it was you know they did reasonably well but those guys stopped doing it for whatever reason I just don't think that they had enough to really base it on and and I think other things came up as you go you know I mean I think Cartiva thing came up but I again I just this patient's not the right patient for that for me. I think if I were going to do something for her I would be I would have some biologics and a some sort of either you know some sort of dermal matrix available and go that route or if you were really you know sort of a poor person's game and just felt like okay I'm gonna go bare-bones I don't think it's unreasonable to do colectomy on proximal phalanx distal metatarsal and then do with it like the smallest finest wire you could find like a 2.25 you could drill some holes and and ask for some fiber cartilage to fill that gap. I don't think that that's unreasonable it's a little older school but it has worked and again Stu Miller has written some of that up some other folks have with some good results. I would probably add to that just based on what's happening in the talus and quite frankly what's happening in the knee. One of my partners is a high-end sports guy and he basically says he doesn't do microfracture alone in anybody anymore. The evolution is there. I still think it works. I think it works in the talus. I think it works in the metatarsals and I think it's not unreasonable but I think you know she's going to be unhappy with some of those she's going to be unhappy with the fusion she's going to be unhappy with the cardiva and I think that a colectomy alone is probably not enough. I think you're going to have to address the articular surface lesion. Like I said I'd probably keep some of that my back pocket for in case it fails and so if you want to sprinkle some pixie dust in there you could definitely try the whatever articular surface substitute. Have you had much experience with that either in talus or anywhere else? A little bit in talus doing a couple cases with my sports partners because I've been trying to get more comfortable with that in my practice. I've done a couple combo cases with my sports partners using one of the like you know the synthetics that you place and then put some fibrin glue over the top. Yeah not at all bad and to fill that up I think this is a great case to try it. I have a couple navicular lesions in my practice that I'm kind of looking to do that for similar problems. So just don't see this kind of thing in a younger patient who wants to continue to be active as much but we're starting to see it more and more and so you know if I'm if I'm sort of you know extrapolating I have two patients one's just 40 the other guy is like an 18 year old basketball player and they have navicular lesions similar type situation to what you have where they're kind of central and you could take off some bone but it's not going to fix the problem. Right. So having something biologic in your in your room when you're in there and then yeah if it doesn't work you can bail out. Not even that. You can do that and just tell her hey look we're gonna see how this goes we're gonna fix you we're gonna close you we're gonna do early range of motion no weight-bearing for four weeks then start weight-bearing no push-off for three months see how that goes and then okay see how you get back to activities and if it doesn't work we can do an air position we can do an OAT we can do other things we have not sold anything. Don't want to take off too much like a traditional chiolectomy. This is where you kind of have to start looking at tradition versus current. If you do a traditional chiolectomy you're taking off a lot of bone off the dorsum of that metatarsal and then you know a solution like Helene just offered you with his OATs procedure you may compromise the the area around it which you can then get good impaction on something like that if you were to go back and that creates problem it also creates a little bit of problems for the interpositional arthroplasty because you've taken off a portion of the joint and so when I'm doing those procedures with something else in the joint I'll take off enough so that my mechanics are still okay but I've decompressed whatever potential impingement is there so it's less than the third of the joint that's been traditionally recommended by Ken Johnson's of the world you know the traditional literature it's maybe like less than 25% but just enough to make sure that you know that the first the proximal phalanx can get around the corner on it and still have good dorsiflexion but not more than that. Does that help you? Yes and can you at my can you restate your post-op protocol if you do a cartilage substitute procedure? I do four weeks four weeks no weight-bearing but I start range of motion pretty quickly like we did the first week I'll let the incision heal to a point even with stitches in I start range of motion and I oftentimes send him to therapy but she sounds like she's pretty motivated and since she's got healthcare background you can probably just show her some things so four weeks of that with non weight-bearing and you know active and passive range of motion that she can do reach down grab her toe pull on it and then at four weeks let her start weight-bearing you can do it in a surgical shoe but at that point you've already instituted range of motion so as long as her wound is healed well just put her in a tennis shoe or something and let her walk but not run and then no running until about three months no push-off activities because you want to let that whatever cartilage bed you have settle in there and work well. Got it and is your protocol the same as you do? I didn't get her into a physical therapy with an altergy. Okay. Is there ever a role for a Moberg here? I can hear you. Would you ever would you ever throw in a Moberg osteotomy in addition to the all the things you discussed? That's a big Charlotte thing. Bob Anderson's talking about the Moberg. I've just not seen the need to do it. I will say that when I'm doing these cases I spend a little time on the bottom of the joint to try and loose up any adhesions and if you look at that imaging there again there there does appear to be maybe a little bit of arthritic change at the sesamoidal metatarsal joint but I'll slip like a blunt elevator like a Joseph or a Freer something that can push down there and try and free up that that the sesamoids a little bit not necessarily breaking up the plantar plate off of its attachment although sometimes I wonder about that but then what I do is I have a C-arm in the room I'm seeing how much range of motion I can get after I do my little colectomy and I really want to get 90 degrees on the table if I can do that then there's no need for a Moberg. A Moberg just fools the foot at the thinking that's dorsiflexing but you know at the same time if she's going to be in flat shoes when she's working as a nurse and that toe sits up it's gonna bug her I think you know that's not that's I've not heard the results of that it's just been a lot of anecdotal stuff they consider throwing in a Moberg and I think that that assumes that you're not going to get range of motion through your joint which is problematic in this patient population you really want to get it through your joint sometimes that requires that you do a little release medial and lateral you know you kind of get those collateral ligaments eased up a little bit spend some time just getting the joint to move and if you can get 80 or 90 on the table even down to 70 I think that that's plenty without having to add dorsal osteotomy. I'll turn that question around have you done it? Me? No. I haven't done a Moberg in practice. Like I said I think you know with people that have the experience with it I think it's great it just it never really made sense to me because like I said just kind of you're you're robbing Peter to pay Paul you're taking some of the dorsal bone out to reposition the toe and make it look like it's dorsiflexing but if it's not dorsiflexing it's not dorsiflexing and so you're not necessarily gaining anything from the joint. Does that make sense? Yep. Okay, let's move to the next next case. Sarah just one regarding the literature I think the longest follow-up for interposition is Dr. Miller's and Dr. Shawn's publication maybe about two years ago three years ago I think Einardi is the first author and I think it was eight years average follow-up 92% of the patients were happy and didn't didn't go to a fusion but I agree with Dr. McGarvey I wouldn't go for interposition in this patient I do a lot of interposition I love the procedure but for this patient with her profile would not do it. Yeah I would say I would I would definitely keep it in my armamentarium if it doesn't if something doesn't work I do think I've done it in distance runners and I've been actually fairly pleased with it but I think there's some other things that you can do but what I would say is that the also is that if I'm and you know Cesar because you were there loose interposition uses the extensor hallux prevalence and the planar capsule right he doesn't use in a dermal matrix allograft mm-hmm yeah they combine the okay it's a mix of dr. Sean's with the in and dr. Miller's with the with the a seller dermal matrix I think it's the longest okay next one so I think the next case is Ziad my thanks Sarah thank you sir do we have Ziad with us I saw him earlier I hope he's still on yeah he is Ziad do you want unmute yourself and take us through your case hi good morning well it's morning up here in Johannesburg so I hope you guys are having a good time there with the weather and it's not too bad thanks for being here. It's interesting. What I can tell you is the south does not tolerate cold and wet and icy at all yeah no so well anyway yeah I hope you get safer and warmer up there let's talk about your case what do you got okay so I've got a 48 year old guy who comes in pain in both ankles he's been a soccer player since his youth lots of twists in between he treated them as sprains never really had any proper treatment for them and he's gone through his years he's kind of now 48 years old still wants to keep playing soccer if he can kind of pain and discomfort here and there but nothing much to write home about and he he kind of just wants to look into things and see that he hasn't done too much damage to his ankle maybe treat things before things get any worse his ankle does have full range of motion with no pain but there is crepitus mainly in the lateral gutter the rest of the ankle is fairly okay I just wanted to open this up for thoughts on this I think that's all we have here, Dr. McGarvey. Okay, so if I can summarize what I think I just heard, you said he's 48? That's right, yes. Okay, and his pain is predominantly lateral gutter. Well, he's got crepitus in the lateral gutter, doesn't really have pain or tenderness anywhere in the ankle, but I think he's a tough guy. There probably should be a lot more pain than he's actually showing me. It's actually stopped him from being on the soccer field, so it's reasonable. So now I'm a little bit confused. When he came to see you, what was his complaint at that time? Yeah, well, I think he's underplaying the amount of pain he's got more than anything else. Like I said, it stopped him from getting back on the field, and he's kind of more worried about doing things, you know, of hurting the ankle any further for the future. So kind of doing something now rather than later. Okay. Let's take a look as these pictures go by again. So this is his, is this his contralateral side? His right side or his injured side, correct? Well, he's injured both, but it's, yeah, it's more on the right side that his problem is. He's more painful on that. And to your exam, where does he seem to react? Again, he didn't react to anything really in the exam. It's just that lateral side, he's got that swelling, he's got the herpetus on the lateral side. But if you look at the x-rays, the arthritis is a lot more advanced than he's showing us clinically. So in that picture, is that a standing radiograph? Yes. And that's, so his natural tendency is, or what I'm seeing there, I think is just a various wear pattern. Is that correct? That's not his. So it's interesting. I'm going to wait for the, or Cesar, do you, if you have control over it, can we see that coronal MRI cut again? So before you go anywhere I mean there's if you look let's look at that that's fair. There's a couple things on that and then we could go back to the sagittal. I mean these are just cuts but there's I mean there's there's some subtleties and then there's some obvious things. The subtle or the the obvious things to me are that he does have some joint space narrowing on plane radiograph and MRI particularly on the medial joint but he also has some subtalar uptake in the posterior portion of his posterior facet on that tailor side. I'm not sure what to make of that whether that's like a little trigonal fragment or not a fragment but a trigonal irritation because it looks like the back of his tibia has got some increased uptake as well like he's got some wear at the back. So I'd be interested what his exam was in full plantar flexion or forced plantar flexion particularly with the sport that he's doing. His stress test is not terribly impressive to me in terms of either in the AP or the lateral. Go back to that coronal that that one. So and then he's got a little bit of subfibular uptake as well. He's got that whatever you want to call that that increased area of uptake at most medial aspect of his distal fibula that could be consistent with it. It's a little increased uptake which we didn't see previously. So I'm just taking these at each individual cut. The other thing that you may also be experiencing here is that that and again it's a single slice that area of syndesmosis is is fairly bright. So I wonder if there's some syndesmotic instability as well. Where is the swelling mostly? Subfibular? Sorry subfibular and lateral gutter mainly. Have you done any injections? No haven't tried any. So I think I might consider that. I mean you definitely have some medial joint space wear on this joint right. I don't think anybody's going to look away from that. You have a weight-bearing radiograph and MRI that confirms that if you look at this picture that we're looking at right now the area over that corner which a lot of people would just say well he's got an osteochondral lesion. Well he does in that he doesn't have any cartilage on that most medial portion of his talus and probably the kissing lesion on the tibia. So that presents itself with a significant problem in an individual who wants to continue to play a running or cutting sport. At this point it's difficult to say that there's any great operation for that. I do think it's certainly reasonable to consider a treatment plan. CT scan is something that I do and I saw your notes that there were some insurance financial issues with that which I get. But I suspect it's probably not going to show a significant bony defect there. It would be nice to see if that were cystic but I think if the MRI is accurate and if you have more slices that show similar appearance then I think what you're going to see is just breakdown of cartilage and intact bone. So what you can do if his foot is you know the clinical picture that you sent actually shows a fairly neutral to maybe even slightly plano valgus foot. And one of the things that always makes me worry about is global instability. You know does he have his deltoid looks intact by the MRI but you don't have a valgus stress test or a dorsiflexion external rotation stress to see if the syndesmosis is okay and also to see if his medial joint is okay. I suspect the medial joint is fine. The way I would probably approach this patient if he's active and wants to continue to be active is you know you can try some differential injections. I think that would be helpful just to eliminate his subtalar joint as a potential source of pain because I do think that there is some subtalar pathology but he's got essentially an athletic ankle that's been run around on for a long time. Second thing that I would do assuming ligamentous stability because we don't have a coronal shot of his anterior talofid or syndesmosis is I'd want to see what those look like both on the on the MRI but also clinically. And so I would probably lean toward an arthroscopic procedure to assess his joint surface to also assess his syndesmosis see if you can get a shaver or a probe in there and see if it opens up. See if you can you know I think you already have some suspicion that he might have some you said that he was unstable in your exam like I said I'm not sure if I should express that but you know that is what it is. And then based on that I would consider similar discussion and I hate to have these back to back to back but similar discussion what we just talked about with Sarah you know considering some level of biologics. Now there are going to be a patient or I'm sorry a small population of surgeons that are going to say well hey it's a unilateral isolated lesion what about doing a redirectional osteotomy what about a valgus producing osteotomy of the tibia which I think is on the table but I don't think he's got an alignment problem and what you're going to do when you do that is you're going to actually alter his what appears to be reasonable mechanical alignment into a distorted mechanical alignment and so I'm not a big fan of that but it's on the table it's not unreasonable. I do think that you know you have a medial osteophyte there as well and that is something that could also be addressed at this time in the scope and then maybe some you know some flexible fixation for the syndesmosis not unreasonable and then consider addressing his lateral ligament instability however you would like to do that. But I think in general it's hard to it's hard to say what's going to take this guy from 48 to 60 reliably whether we're talking about biologic procedures intraarticular or osteotomy is extraarticular. I think that there's equal support to do both and maybe even do both on the same patient but again I'm not a big fan of the osteotomy and somebody that's got normal alignment. If this guy had distal tibia varus or if you had a full length standing view top to bottom that showed some varus I might change my argument but I don't see that in this patient. What I also see and I will say this if you look at that that weight-bearing view and this just caught my eye it looks like his posterolateral subcalar joint looks a little narrow there and there may be a cyst there and I'm not getting that on the on the MRI cuts that we have. So that's where that's where I think the injection becomes helpful because this guy looks like he has two levels of joint arthropathy. I think he's got a medial tailor tibial tailor joint space narrowing basically arthritis and I think if you were to look critically at his at his subtalar joint through the MRI he's going to have posterior facet arthritis as well and I would I think an injection is very helpful in delineating what's what is potentially going to make him happier and then you know I wouldn't necessarily not address the other but subtalar joint's going to be more difficult to address in a joint preserving procedure and probably less problematic to allow him to get back to some of the things he wants to do if you do a subtalar fusion and an ankle arthroscopic procedure not even necessarily at the same time but as part of a treatment armamentarium and sequence it out but I'd be in there with with my needles or you know if you have an interventionalist or if you do a hundred ultrasound I'd want to make sure that I got the needle in the right place that's the critical thing you don't want to necessarily blindly inject and not come up with anything and then it doesn't work and you don't really know you want to be in the subtalar joint inject him see how he feels I walk around on that for a week or two have him come back do his ankle anyway and see if he gets the same or similar relief or if it's there's there's a night and day reaction with one versus the other and then I would focus my efforts on that joint and in the way that we just talked about yeah thank you would you consider doing sort of a calcaneal osteotomy I know that's that's also reaching for something but just to offload that lateral side a little bit but I will tell you that I have done it and I didn't bring it up because I think it is a little bit of a stretch but I think it's probably under the circumstances not unreasonable at all to try and redirect his weight-bearing load with the expectation that he may need at some point an ankle replacement or an ankle procedure and so with that in mind I think it's not unreasonable to do a calcaneal osteotomy here valgus producing and and see if that might offload it and you know your subtalar fusion you could do that too if it became I guess in the in the instance if it became obvious that his subtalar joint was the culprit for his pain production and he felt substantially better you could do a little bit of a valgus producing subtalar arthrodesis as a as opposed to a osteotomy but I would only do that if the subtalar joint was clearly 100 percent or you know at least 80 plus of his pain if his pain was 50 50 or less from subtalar then I would probably say do something at the ankle consider a valgus producing osteotomy I will say that the ones I and I get again I only have a handful of these but they've lasted probably five or six years if I'm thinking back correctly so it's not it's not terrible thank you dr mcgarvey could ask a question sir you can do whatever you'd like any uh any role for a subtalar arthroscopy with your ankle arthroscopy so yeah we brought that up with the last patient as well last uh series I think it's not unreasonable to and I do I think if I'm worried about ankle arthroscopy I kind of I guess I globalized that term and assume that the ankle and subtalar joint are kind of one in the same I don't always subtalar scope but I think under the circumstances it's very reasonable and you may find that there's enough laxity that you can actually get something done maybe a little debridement maybe a little microfracture maybe even squirt a little um biologic in there to get something done just like we were talking about sarah's case with some uh orthobiologic and some fiber glue type situation okay excellent shall we move to the next next case sure let you run the show I'm happy to do however you'd like to do it but I think are there any further questions about this one again if it's not clear I know we're running through this stuff fairly quickly but you know the algorithm that I would have and I'll take a breath here so that we can just do that would be to do differential injections because there are two joints involved and maybe three you know if you consider the subtabular area a joint the um I would do it differential injections decide what I felt was the most uh contributory to the pain and then proceed with some sort of uh uh addressment of that problem if it's the ankle joint then I would consider arthroscopic debridement and some form of a biologic and then with or without a calcaneal osteotomy or for those of you that are tibial osteotomy fans you could do that as well um the if it's a subtalar joint I think you scope the subtalar joint along with the ankle and you can consider debridement joint preparation of some viola or marrow stimulation and then if it's wide enough that you can get something in there you could potentially slip in some orthobiologic and some vibrant glue and see if you could do that ultimately you may need a subtalar fusion ultimately you may need an ankle arthroplasty so you have to keep those things in mind and don't forget the ligamentous stability here this may be appropriate that that single view makes me suspicious about the syndesmosis so I would test that at the time of arthroscopy and I think that the disadvantages are outweighed especially with flexible fixation that you could do relatively percutaneously to stabilize that syndesmosis and provide a little bit of extra power to that repair All right, the next one's from Dr. Haggie from South Dakota. Looks like you got an interesting case involving a total ankle. Can you hear me okay? I can hear you just fine. Yeah this is I just saw this lady today she's 78 lives alone 15 years out from an agility. She's very healthy and she just and she just came in and said you know I've had some ankle pain for the past couple years bilaterally the left one's worse and I got these x-rays and knew I was going to be doing this session today and I was keen to see how you might respond. I don't know if you can end up seeing the lateral but obviously subsidence of the tailor component with erosion valgus to the tibial side on the lateral I don't know if that came through but there's a lot of there's been some significant destruction to the talus and the talonevicular joint appears to be involved but that's yet to be elucidated with the CT scan that I hope to order. There's no evidence of infection this is just a long-term issue for due diligence she will be getting a sed rate and CRP but that doesn't that's not really on the table but I wanted to know your thoughts there we go about whether you would one stage this two stage it try to bring it out to length with cement if you did say okay we're not going to go to an inbone construct and there's something there to do with the talus are you thinking plus minus 3d reconstruction of a talus you think you can get some screws into that subtalar joint for a fusion or would you single stage it and go with a nail I talked with her and she lives independent and so whatever you do with her that's of paramount importance so with that I'll look forward to your input. Yeah this is uh you know this is not an uncommon failure pattern for these agilities and that's not necessarily a great thing can you hear me okay I sure can okay so um you know I think that the short version of this is going to be that your CT scan is going to give us much more information and so um that's going to be helpful it looks let's can we go back to the can we go back to the AP before you go it does look like she's got a reasonable amount of talus despite the fact that this thing is sunk down deep it does look like there may be a reasonable amount of bone now the question becomes is there is it fractured bone or is it viable bone as it as a unit because it looks let's go back to that AP and keep it up there for a second Caesar if you can you're doing a great job with this by the way I did I've gone nuts with this already but you're you're able to bounce back and forth very nicely so it looks like that component or that whole implant may be placed a little bit lateral failed and valgus is there foot in valgus or is it a neutral actually her foot is a new so we don't know if the implant was maybe put in a little valgus to start with it's decided or if it was maybe even just placed that way and and so at this point it doesn't matter but if you look critically right if you look it looks like that that lateral side is actually positioned without any lytic changes it looks like kind of that's where it was originally placed so I don't know do you have the original she doesn't have I guess it's 15 years old right you didn't do this that's correct yeah so it's going to be a little more challenging but it's interesting and I wouldn't be surprised quite frankly if it was placed in that position now that may work to your advantage because if that's the case that tailors is subsided and the remaining tailors is actually intact then I think that this gives you an opportunity to explant this now there may be the need to go staged you've got to get the screws out as well and that's depending on what you have I think the CT will be helpful to see if there's an intact one big talus or if it's going to be in fragments if it's in fragments it becomes more challenging but let's just let's take scenarios let's say it's intact and this is what you have you have a valgus aligned ankle with a talus that subsided to or maybe even through this part of the subtalar joint I think what you can do is explant and then maybe put in a cement spacer yep excellent and hardware removal and then consider doing a subtalar fusion at the time and again that is going to be a little bit challenging to figure out exactly how to do that but I think if you can get that bone stock to heal then you're coming back on something that has good bit of bone stock now if she's got enough talus to accept a component right the tibial side you know and I'm always a little nervous about mentioning brand names and I will so I'll make a disclosure and I probably should have done this in the beginning I'm a right medical consultant I am a design consultant for the Envision prosthesis which I'm about to talk to you about so I just want to just be full disclosure here but but I think that a stem implant is probably the way that you need to go if you take that out to a non-stem implant I just don't think it's gonna work out well because you're still gonna have to cut up to the top of the skin you're still gonna have holes from your screws above she's 78 I may have poor bone quality anyway with all that and you're gonna need to get some lengths on this thing too because she's short she's subsided down fair amount so then and that's where quite frankly the cement spacer comes in handy I think here you take all that out and then try and maybe put a laminar spreader in maybe do some soft tissue releases and and try and get some length there and then put your cement spacer in and let her just stretch out a little bit now I make no assumptions about what people do what I have done with this in the past for myself is I've actually used a thin wire frame and actually pulled it apart that way and give myself some distraction either before this part or after this part where we explant the joint and so it's you know it's multiple procedures for 78 year old who wants to be independent she's gonna want to come in and say hey look fix me I need one operation and the truth to that and you might be able to get her that with a single try at an implant not a big fan of the TTC but it's it's on the table and I think it's not unreasonable but I think that you can revise this fairly fairly reasonably on the Taylor side the tibial side it's not going to be that bad because whether you use the stuff where you use the jig for the stem implant you are going to still have to cut out more medial than lateral you gotta square that joint but you're gonna have enough there and you're gonna get a three or four component stem up there it's the Taylor side where that component subsided leaves you with a void that you're gonna have to contend with if there's reasonable amount of tailors left it's just that it's just that that we're seeing right there you may be able to make a flat cut on the tailors and then just fill that lateral side either with cement or some rebar you could shoot a screw for you know from front to back horizontal and just use it as support and then fill it with cement I would not try bone graft I don't think that's going to work particularly at this age group I've used some off-label products with some metal and there are a lot of 3d print companies out there you could potentially look at your CT and maybe come up with some metallic fill-ins for that to which you could rest your Taylor component on and then get that to fix in there or cement it and have like like I say some rebar so you could have like a concrete and the rebar in it could take like a cage type thing and put it in there and put cement fill the cage or you just put some screws and fill the cage or fill that gap with that I think that's not unreasonable as well I it looks interesting that there very well may be enough tailors that you could probably think about fusing that joint and then coming back and doing that whole thing as a second stage and that's probably how we probably approach this with her telling her that she has to stay off it anyway because subtalar fusion but this event will actually allow her to wear weight through it so that's not going to be a big deal if you have to cement the joint or the space where the joint came out so again I'm kind of bouncing around to ideas because I'm just seeing this but I would probably you know again without the benefit of a CT I would take I would tell her it's probably going to be staged just so she has that expectation and then I would think about taking the joint out and and doing a subtalar fusion and coming back and doing and stem implant on tibial side and then I mentioned the InVision because you don't have to actually I think it gives you more opportunity to sit a component on top of a residual tailors as opposed to having to drill that hole from the in bone and you know that sort of thing and it's also you don't have as much surface area on the in bone tibia as you do on the InVision tibia you get that whole big tray. Correct. If it's fragmented then it becomes more of a challenge you can still do the exact same thing that I just mentioned with the pieces you can try and get a fusion or at least stabilization with the pieces. I've done that I actually have a case that I've done that and tried to fuse the back piece to the posterior facet the front piece to the anterior facet and see if that'll work but it's a little more challenging and then you start getting into some really weird stuff and I have no experience with this so I'm going to I'm going to conditionalize it first that you could consider again 3d 3d print companies some form of a tailor replacement product that takes up the body of the tailors that's not there anymore take out that back piece that's fragmented and have something that actually has screws through it that you can bolt to the calcaneus and will give you a representative tailors that would sit underneath a stemmed tibial component total ankle. I'm kind of looking for the right patient for that this might be one but if she had an intact tailors I would not do it. So devil's advocate here Dr. McGarvey you mentioned that you like the idea of a TTC fusion here but I'm guessing her ankle doesn't move very much and so what do you hate about it is it that she won't have motion there or is it the fact that you take out the total ankle and there's a huge bone void yeah so I would I guess I would ask you what are you going to fuse to? I mean TTC nail is fine but what are you going to fuse to what? It's really going to be a TC I think. Right. I think that the biology of that tailors is is reasonably suitable for an ankle replacement because it's not even if you don't get in growth if you get some on growth you're you're reasonable. If you're trying to get a true TTC fusion by shortening and trying to fuse to that tailors I don't know that you're going to get much success so what what would you use? So I have just one other little variable question I mean she obviously most of her pain is actually subfibular and she does have very limited motion and I'm not going to debate that she has subtalar issues but at 78 would you leave that alone because I mean you're gonna have to put hardware up into that limited tailors anyway that you're likely may have to take out if it does even fuse so is there a role to would you just fuse that because if she had pain you'd kick yourself in the you'd kick yourself in the head or whatever as opposed to just doing the cement distraction technique that you described about originally? If it fused you have more bone stock to play with and that's an advantage for you and it may not just based on the previous question and I'm sorry I didn't see who asked the question because it's just that's not well my phone is working right now so as far as the TTC you know you may get one joint to fuse it's hard to say you get both but I think if you do a posterior facet prep you can get that that back of that tailors to fuse a little bit I'm not married to the concept if you have enough tailors you think you can just do a single ankle arthroplasty I think that's very reasonable and I think it's appropriate to do that without having to worry so much about it and quite frankly you can always expect a sub-tailor to fuse her later if she has that problem or just inject her joint and see I mean you could do that up front see if she has some sub-tailor pain that gets relieved with an injection up front I'm a pretty liberal user we have an interventional radiologist in the office and so I used to do all these myself I used to do them under fluoro very time-consuming now we have an interventionalist who actually likes to do them they get to bill for it I get to just send a patient down the hall and I get my results and it's really helpful but I think an injection the sub-tailor joint here is very helpful and of course as you mentioned you know the whole thing about the infection whether that's appropriate or not but I actually it was a rhetorical question I asked if you're going to fuse that with a TTC nail what are you going to use to fill that gap well yeah my series has just been doing femoral head allograft you know soaked in stem cell but I've only and I've had that work before but I've also had it fail I mean my plan my plan is that I wanted to do the stem implant I was just concerned about the defect and I wanted to do it to stage but if it was fragmented that was what I also wanted to hear what you had to say so I'm thankful for your input I mean the thing is that if it's fragmented it just it creates a whole bunch of other problems that I don't think either a nail or even you know I mean I've gone that route again and you just kind of have to have a strong stomach because it's it's one of those challenges that you're gonna you're gonna put some metal on a dead bone and hope that it all holds together and most the time you get lucky but again I think I would not toss out that that 3d print concept and maybe take out that Taylor body and put in a you know a custom device that you can screw into the tail into the calcaneus and articulate with your with your tibial component you know that's big with some of the Duke guys I think they're doing quite a few of those and not just those guys I've had a couple partners who have done those things I do think that we tend to pull the trigger very quickly now on getting rid of a list trying to get a whole implant in there and I think that you have to be really careful about that because it takes takes a lot of options out of your hands this is a different set this is a different type of case this is just a very difficult situation but I think you're gonna find once you get that PT maybe wrong but it may be in one piece and if it is I think there's a good chance that you can just saw across that and place something on top of it and fill the gap with some cement if you want to stay like I said if you want to stay very simple use some like 3035 screws across the gap where the tail is currently is and use that as rebar or just cement by itself and just just have something to hold it in place maybe even K wires for rebar but something to hold it so that the cement doesn't slip out and then just lay something on top of it that's something being the Taylor component and and you got yourself a total ankle very much dr. McGarvey question when would you be that CT at some point afterwards send it to me and either send it through the big group chat or you can send it to me by email I'm happy to look at it I'll call you back talk about it dr. McGarvey no I think we're gonna go for a while sir it's okay but I have one final question here when would you do horizontal rebar in versus vertical rebars like on the technique for the rebar when would you do horizontal rebars versus vertical bars yeah so vertical is only going to work if the subtalar joint is either stiff or fused so it's and it's okay you know I hate to I hate to pass along you know these bastardized principles because we like to think that we all do things the right way but in this case there's not really a right way and you look at this and this is a challenge this is a 70 year old woman who wants to maintain her independence and let's just let's just take for the sake of argument that you said okay how about if we just went in there got this thing out cleaned it out did a primary ankle replacement with your choice again stemmed on the tibial side for me flat tray with three prongs on the bottom vision tray on that but what if then you didn't fuse the subtalar joint or you prepped a portion of it to fuse it through a small lateral incision and then just ran a bunch of screws like 4o size fully threaded from the heel all the way up to underneath that that tibial tray and then just fill that with cement you know that's not unreasonable at all that's technique that I've used a couple of times on patients that have had a vascular talus's after I've actually done the envisioned tray and they start to subside I'll go in there underneath the tray fill it with cement prep the remainder of the joint that looks viable take out all the cartilage and then just start running screws from the calcaneus up right up against the bottom of the tray and they're used they have to be you know similar metal typically but that's another consideration if you want to just you know you're kind of doing a little bit of everything you're doing a subtalar fusion she's already got an ankle replacement so it's not like you're violating that principle I typically don't do a subtalar fusion at the same setting the only bit the issue with the stage procedure frankly was just that you know there you may encounter something that you're not prepared for so I'd leave that on the table but if you want to go with at one stage that's a great way to do it so I would add that to the procedure and I think that that's a outstanding consideration We're going to move to the next case, Cesar. Yes. That was it. Did that, did that get, did that get your question, Aleem and Dr. A? Yes, sir. Sure did. Thank you. Yeah, I think that technique works pretty well. And like I say, the more I think about it, I think that that's a very reasonable approach based on age and infirmity and this whole thing. I think you can start shooting some, and I've gotten like four or five screws from the bottom of the heel or percutaneously, just kind of sitting up against that implant on the underside and through the cement. So the screws won't back out, cement won't leach out. I think that's a great technique. And that's, I'm sorry, that's, you know, horizontal rebar is if you're not fusing the sub-tailor joint or don't want to do anything. If you want to do something to the sub-tailor joint, I guess I didn't express it very clearly. But that's the approach that I would use. And I think that you could do that at a single stage if you wanted to. Well, next is Daniel Guzquez. Daniel, do you want to take the lead? Sure. We're going to tone down the degree of difficulty. No quadruple axles on this one. This is a 44-year-old healthy male, has a history of a remote sprain, seven years prior playing basketball, and thereafter developed anterior lateral ankle pain that he describes as deep. It's worsened over the years. He feels it's especially during impact activity, but is trying to, starting to limit himself, even during activities such as walking. And I included below the radiograph that shows the cystic lesion and the lateral tailor border. And then we also have an MRI that I uploaded the video. And there's a sagittal one as well. Okay. In case it's helpful. And I thought it'd be interesting, because I always love benefiting from people's expertise about how they deal. You know, as osteochondral defects become more cystic, et cetera, they become very different animals, no matter where they are. And I think this always leads to a very robust discussion. I don't disagree with your consideration, because I don't think that anybody has the answer to this. You know, that's the difficulty, and especially when it looks like, you know, the cysts are metastasizing, so to speak. Can you go back that, does this just play through, or can you hold it on one image? It can be paused, yeah. Okay, so let's get the sagittal, and if we can, it's just spinning for a second. Let's give it some time. So this guy, let's get that sagittal up. When you get, let me just kind of make a few general comments on how I just, just that one right there, if you can hold that, that's great. If we can just analyze what I, I'm a, what's the word I'm looking for? I don't think abuser, but I'm a heavy user of imaging for these lesions. I get an MRI and a CT scan. I think the CT helps me with the bony lesion part of it, and what I'm gonna have to do. This is fairly large, and it's obviously cystic, but it has collapse as well. And it's challenging. It's got some reactivity at the base of the lesion, in addition to some cartilage loss on the articular side. And there's also what appears to be the beginnings of a separate lesion in the lateral process, just in the anterior most part of the posterior facet. But I'm gonna, I mean, that is kind of a separate issue, although I wonder if there's not some subtalar arthritis forming, because he's got a little calcaneal lesion down there as well. But, you know, with respect to the ankle, this is challenging because, and this is where the CT comes in handy. If those cysts are real, which I have no reason to believe that they're not, there's articular surface defect. This is one that probably for me, I would look to scope and to consider some level of curatage and articular surface reconstruction. Curatage and bone graft, sorry. I think that location may require an osteotomy to get to it. And, you know, then it becomes dealer's choice as to what you use. I typically am an autograft user. I think it's too irregularly shaped. If we go down the differential, let's go down the differential, because I think it's helpful to do that before, I've already kind of let the cat out of the bag as to what I choose, but I think differential treatment options would include sure, microfracture. And in the old days, that would have been a very reasonable consideration. Go in, read the lesion. I think you're going to find that there's not going to be much cartilage left over it, or at least there's going to be a hole. Breathe out the remaining cartilage that's not mechanical symptoms, and then just punch some holes in it and see if it works. And, you know, quite frankly, if you look at the old literature, that was like an 80 plus percent success rate. Now, I'm not sure that that's going to hold up in a guy that's 44 and he wants to continue to be athletic active, if that's his intention. But I would put that as a consideration. Number two, and these are in no particular order. Number two, start thinking about, what about osteoarticular transplant surgery, like an OATs specifically? Well, it's a shoulder lesion. I think it's contained if we go back. Cesar, can you go back to the coronals now? Let me just see. So as we, as we wait for that to come coronal, if it's a big, if it erodes into the shoulder, then that comes off the table. I think there's enough medial or lateral wall that you could do an OATs there. So that's a consideration. OATs, either, you know, autologous or allograft, whichever you want to call it, allograft, whichever you feel more comfortable with. I think that's not unreasonable at all. Then joint reconstruction, putting in something to reestablish the articular surface, which is going to necessitate that you have something underneath that to support whatever it is that you put in there. So whether you prefer, you know, whichever company they have, you know, Biocartilage and, you know, Cardiforms and DeNovos and all these company products, they're a little different, you know? And so whichever you have your preference on, I'm not sure that any one of them works any better than any of the other ones, quite frankly. But biologics, I think, are reasonable here. And then lastly, you could certainly make an argument based on the size of it to do an osteoarticular transplant graft, you know, just to actually go in and carve that whole thing out, take it out, and put in a big block piece. I think that's it for those things. I would not take fusion and replacement off the table, but he's young for replacement. He's probably not gonna be happy with fusion for his activity and lifestyle. And I think that's pretty aggressive for this lesion without trying anything else. So after we boiled down those things that I just went through and itemized, I would say for me, some form of either, if he wants a minimalist approach, you could go in, debride, and microfracture, and leave it alone and see what happens. I think that's not unreasonable at all. See if he gets better, see if you buy him some years, and then think about coming back. I would probably image him on the order of once a year just to make sure that he was doing okay. But if that did not work, or if he wanted to kind of swing a little harder, then I think a debridement with a curatage, bone graft, and then some sort of biologic on top with fiber and glue would probably be the way I'd do it. I'd scope it first, see what it looks like. On the odd chance, I guess I'll throw this in there, on the very odd chance that the articular surface was intact over top of it, the other thing you could do is consider a retrograde drilling and filling. Go from the medial side, because you're not going to get the angle on the lateral side. You'd have to go medial, obliquely across the tailor body, drill into it. You can try and curatage it out, but then fill it with a demineralized bone matrix or bone graft substitute or autologous bone graft, whichever you prefer, that would support the articular surface that he's likely not to have, but you may find something different. No, I think it's interesting. Those are all amazing and very summarial points. To your point about the imaging, he does have a CT, I have a very low threshold as well for getting a CT scan. I feel, especially when you get a lot of T2 signal, that especially can hide a lot of the cystic component and the CT shows that better. He wasn't ready, and so we raised the osteochondral graft, and so the hybrid that we did was, we went in and scoped him. And we just treated him last week. I'm just always curious to learn in hindsight what would other people have done. He had very, very significantly loose kind of bodies and elevated cartilage, not at all a smooth surface. And then we curetted into the cyst and actually got rushes of fluid. And then we took a dowel of bone from the calcaneus, morselized it, and then through the scope, just painstakingly packed it all. And it actually took up that whole dowel and just mashed it down with a freer, and then put the cartilage product with fiber and grew over it, sort of as a middle ground before considering something like an osteochondral graft, which require an osteotomy, et cetera. And I also tend to harvest from the knee. And so it was sort of like an in-between, and I'm always curious what others would do. When you use these biocartilage products, by the way, all the instructions say either PRP or mix it with stem cells. But I feel like you go through all this trouble and then you literally end up using maybe half to 0.7 cc's of it. Like you use very, very, very little. Have you ever considered just mixing with whole blood or do you feel like that tiny amount makes a huge difference? Interesting thought. I guess the question is, is the concentration of the factors and cells worth the cost of doing all that or just take some peripheral or even just aspirating from the crest and taking what you get as an aspirate and injecting it in there? I think, I guess the corporate world would lead you to believe that the dilution of what you aspirate is not helpful enough. Because typically if you're gonna do some of these things, it's 60 cc's of blood out of the pelvis and you get something that's about six or eight cc's, you get about 10% of that back in the form of cells and product. So then the question becomes, is there enough? I don't know that we have enough answers on how many stem cells or biologic factors we need in a concentrated area and what's the concentration to do that. So I guess based on that, I kind of default to what most people do, which is concentrate it down in a centrifuge. But I don't know if it's the right answer or not. And I have done it the other way. I've taken just some whole blood, just squirted it in things. I have not looked at that scientifically though. If I may interject here, Gus, I wrote my answer in the comment in the chat box. So usually I try and use whatever aspirate concentrate I get. So besides mixing what I have with the biologic, if I'm using fibrin blue, I tend to mix, take out half of my thrombin or prothrombin out and mix and put in the remainder of BMAC in that vial. And then as I inject the thrombin mixed with the stem cells in one vial with the fibrinogen in the other, it clots and makes a quote unquote, a rich stem cell fibrin clot. And I've had some success using that. So, yeah, I think, so Daniel, I think we were, we were probably saying very similar things. The osteotomy, I had this, I kind of looked at this backwards. I was kind of thinking it was a medial lesion. I'm not a big fan of doing a fibular osteotomy if I don't have to for this. And I think that the access is probably a little bit easier. And I have done that, you know, for the arthroscopic purists. I have done what you've done. And I think your word painstaking probably undersells the amount of aggravation that goes into trying to jam even morselized pieces down into that hole, but it does work and you can do it. I think a couple of things that may be helpful are a preoperative plantar flexion view of that ankle to see how far that lesion will come forward. I don't know if that necessarily does anything to make it, make your job easier. It just gives you an idea before you get in there, where that lesion is going to be. You can use your scope and shaver to debride out some of the anterolateral tibia so you can get in there a little bit easier and your working portal has a little bit more room. And again, similarly with the distractor, if you want to put something in there to open it up a little bit, invasive distraction, this may be the one indication I would think about that, but usually plantar flex and, you know, just kind of work back and forth. I can do these through dry scope. So I'll use my medial port as a visualization scope, dry, and then just work everything with the instruments that you have. You know, you can pack it in, or you could use some syringes. There's some proprietary things that you could use that allow you to inject some of the morselized graft or you could just put it in there with, you know, put an arthroscopy cannula in and then just use the blunt obturator and push the bone graft through. And then you got to get the freer curette or whatever you're going to use to pack it down. But, and you could go through the detail if you want to tell us how you did it, because I think sometimes we gloss over that because we just assume that everybody knows, oh yeah, you just do it this, you just pack the bone in. And it's kind of like, well, how do you do that? You know, if you've not done it before, you haven't done it, you know, well in the past. And so to your point, yeah, once you start filling, it has to be dry and I'll go so far as to disconnect all the suction and the inflow from the camera because I don't want someone to accidentally turn it on and flush away your hard work. And then there is no good device. I've used, if I'm going to use a cannula, I use a knee cannula for the inserting of the bone graft because it's wider. The problem is it's also really long. And so what I've settled on that again is very makeshift is if you take a 3.5 millimeter drill guide, it's short and blunt, that will fit the trocar of a standard ankle scope, but it's shorter. And so you put the trocar just through the tip of the drill guide, push that in and then remove it. So now it's a much shorter distance and then use that, you fill it, fill it all with the mortalized bone and then reinsert the trocar and shove it all in in a controlled fashion. But it is painstaking. There is not a great device to do it. I was impressed by how much bone he took. Like we really got that whole giant dowel more sliced and in there. These are real cysts, but there isn't a great device to do it beyond sheer will. Oh, you're right. You're absolutely right. And so, you know, I mean, it does, if you can come at it from the top, it does make it a lot easier to do that step, but to get it from the top, it's going to be quite a challenge to get, even with a fibular osteotomy, quite frankly, because you still have to get past the portion of the tibia. You do take away the ligaments. Yeah, we were able to do this all through a scope. Yeah, and you gotta go fix the fibula and it's a big incision and blah, blah, blah, blah. So this is a good choice. Now, I also wonder sometimes with these, whether it wouldn't be a bad idea to do your fill from underneath, you know, do your retrograde drill, even though you know you're going to do something to the articular surface, come underneath, drill it, get it from the bottom, and then do exactly what you're talking about until your bone graft, kind of like loading the musket, so to speak, right? You put your, you do use your arthroscopy cannula at this time because you need the length and then put the bone graft up from underneath and hold it, you know, with something on top so it doesn't spew out at the joint. I've done that maybe once or twice. I don't know that it's any better. It's, none of it is easy. None of it is simple. You just gotta just accept the fact that it's going to take some time. I would like to add one, I would like to add one trick that I've learned with these lesions, and that's using a otolaryngology, ENT speculum, because they're long, there's a variety of them, and you can usually find them in your core. And you can do a little mini, you can extend your lateral portal, open up that soft tissue, and then you can get that cannula in there better. And then you actually can reach in there with some long pickups. It's still tedious, but it does help a little bit more than doing it completely arthroscopically with just a small extension of your incision. Just a little tool that I've utilized. This is why I love these forums. That's brilliant too. Thanks for raising that. These are the practical tips that you can't read in a textbook. Ha ha. Great. I think we have time for one more case, and we're going to finish with Paul Toulousan's case. Fire away. Yeah, so my guy is 30 years old. He had a subtalar coalition. So at an outside hospital, they did a subtalar fusion and a talonavicular fusion. Immediately following surgery, he had severe ankle pain and basically trucked along for about two years and then just came to see me. So on the x-rays, he had a good solid fusion of his talonavicular joint and subtalar joints, but then look at his AP ankle. And they said that his surgeon never ever got an ankle view. So what we see is this. So the subtalar screw is sticking out of the talus and into the ankle joint and looked like he had some fragmenting of his talar dome as well. So I got a CT, confirmed the fragmentation of the talus. I'm pretty concerned that this talus is dead. And so in this 300-pound young guy, what are you going to do next? I mean, it's going to involve ankle fusion for me, but how do you go about it? Do you do flat cuts of the talus and tibia? Curious what you think. Let me just see all the imaging here. Do we have... I think we saw, let's see, that looks good. I think we saw a coronal cut a little earlier. The CAT scans I uploaded, I think are just sagittals. Okay. But there was at least a crescent of... Was it the sagittal? Keep going through that, Cesar, if you would. Just kind of give me a rundown again. Sorry. Can you guys still hear me? Yes, sir, we can. Okay. Somehow, I'm not sure exactly what happened. I just, I'm seeing myself. I'm not seeing those images anymore. Let me see this. I think we're coming back. Shh. Sorry about this. I think my screen, I don't know if my internet's just kind of wavering or what. All right, there we go. Let's see. All right, if you can just kind of give me a couple of these pictures. So Paul this is not something that you feel like an ankle replacement would be worthwhile? Well he's 30 years old, 300 pounds. Yeah so I think a fusion is certainly reasonable. You've got some central defect in that in that lesion and see if this works for a second. I'm not sure what I just did there. All right you can still hear me though you still have the audio? Yeah. All right so I would probably you know it depends on how much of the of the dome of the talus is missing but I think that you can do joint preparation so you don't have to shorten them and so you could save it because quite frankly and I you know I used to used to drive me nuts when people would say this at their meetings you know you might want an ankle replacement sometime in the future but he might and he might be a candidate for it for a takedown at some point down the road. Probably not I mean I think in the guy that you're describing at his age his size and with his previous infirmities it's probably going to be whatever you get for him. Now his talus like you say is potentially dead but I think if you even when they look that way radiographically I'm always impressed by you go in there and you kind of debride it thoroughly you may have a defect where that crescent is but it doesn't look like it's too big. Do you typically bone graft ankle fusions? I'll tuck some bone graft into the gutters and a little bit into the posterior joint with allograft and some biologic stuff for that that would be for a sort of your normal ankle fusion without all of this stuff going on just sort of your regular arthritis. You're going to have to take the sub-tailor screws out so you can have an opportunity for some more robust fixation and I think that that will that will get you a little bit better opportunity there. And then you can bone graft from the heel or that may be a little challenging to come now I have Cesar's pictures back still trying to see can you just bounce between the CT images? I got the plain films at the idea of the plain films there's one more CT image that I think was interesting so that one starts to show that that crescent piece on top that's starting to collapse. There it is in better profile so that thing you may need to bone graft a little bit. I'm not a big fan of the flat cut I mean I do it when I have big enough deformities and I do think that there's some merit to it but I it'd be nice to see the coronal cuts because if he's not malaligned now if we can go back to the AP ankle we just have the plain radiographs he doesn't look malaligned. He looks like he's still in a lot of valgus. That's kind of what he was born with because he had a sub-tailor coalition but so that's not really bugging him that much. It was sort of his. It may be a mechanical issue. As I look at that image by itself right you take that screw out that's potentially penetrating the joint and maybe take another one take the other one out what was gonna be your fixation choice? So I was probably thinking of doing flat cuts in this situation and then I usually do an anterior ankle plate then a leg one or two leg screws. So you know that's flat cuts are not wrong don't get me wrong with this but I think you could take these take these screws out and you have probably two-thirds of the joint there that looks potentially viable again I don't it's hard to tell I'm just a plain radiograph but that that fragment that loose fragment looks predominantly lateral and you could just pack that with some graft and then use your fixation with your plate anterior approach just prep the joint you could always start out that way and just didn't like what you're getting out of it make your flat cuts as you would but you have to go down fairly low on that talus because that piece actually has some height to it so you have to take out about a centimeter centimeter and a half bone to get down something and then you know there's a reasonable curve on that tibia so you have to take that out as well and you'll wind up shortening probably by about three quarters of an inch or more but you know that's okay and under the circumstances if you get it to heal that's probably great. I don't have a preference I typically don't flat cut unless I'm going it's something that I need to you know what's this guy's ankle was at 40 degrees of valgus incongruent and you needed to get it corrected that's where I start doing flat cuts because I know I'm gonna have to take a fair amount of bone out to get soft tissue correction out of that in this case where he's lined up reasonably and he's okay with foot position I usually just prep the joint maintain height that way and then you know if he's got that much viable joint then I think it would not be unreasonable to allow that to heal again it's hard for me to tell I'm trying to blow this up on my phone but that dead bone may be more than I'm what I'm appreciating do you think it on your view does that dead bone and that sort of crescent sign extend past the screw medially no I think it's right through the screws yeah so you know you take that piece out need to turn around and use it but look at that image right there get below it you're gonna be flush with the top of the calcaneus and then you're gonna have to take out a reasonable amount even if you stay distal to the pisceal scar and the tibia because of the amount of curvature there so you're gonna lose some height not terrible in a TTC fusion which is what he's gonna wind up having to be a little short so I think if you feel comfortable doing the flat cuts I'm not gonna steer you against it I probably would just try and prep the joint bone grafted and then use some some form of orthobiologic stimulation because of the potential for dead bone but I would drill the talus a little bit to stimulate some bleeding in there and I've gotten I've had some pretty good luck I've actually just you thought of that to fill in that defect in the past you know from the hip and and done pretty well in a younger patient or in younger patients same same approach anterior approach curatize the lesion see what you're dealing with and then decide either okay I'm gonna flat cut it or I'll go to crest bone graft it prep the joint on the medial side and just get my fixation that way with cup and cones fit or male and female fit whichever you like describe it yeah and you know I think the thing I worry about the most about executing this is getting the foot in the perfect position because he's not gonna he has no tail navicular motion at all and so I mean would you put someone like this in a little more dorsiflexion than you normally would in an ankle fusion I might because if you leave them in plantar flexion I mean you can always adjust that through his heel but it is a nuisance he may adjust through it but a little bit but I think I would I would make sure that I'm at least getting 90 out of it and I might just reach back and take you know he's got that anterior osteophyte so you're gonna have to do some joint work to try and get him steered back up again but I oftentimes these with most ankle fusions actually I'll just oftentimes cut the Achilles you know I go percutaneously and I'll just cut the entire Achilles so it is not a deforming force for me because I do find that sometimes you're just working against yourself especially if he's got a flat foot configuration but that's one of the first steps cut that Achilles get it out of the way you know do your hardware removal and then come from the front of the joint and then like I say either either just to breed it and oppose it and bone graft it or you can flat cut it but you know the flat cuts like you say it's very exacting and you know if you don't get it right you wind up shaving bone shaving bone shaving bone becomes a little bit of nuisance. Cool, thanks. Absolutely. Well that was very insightful. The concept here would be what if you went from the back and did an on leg graft in addition to the plate wouldn't be an anterior plate it would be a posterior plate now but you could plate and get fixation down into the calcaneus, talus and the tibia you could do sort of an on leg graft. back if you're avascular then you don't have to worry about you know you still get apposition but you could you know you make a trough in the distal tibia and the back of the talus and back the calcaneus use a bunch of bone graft down there and then put your plate over top of that. I've done that a few times if I'm clear that there's avascularity but you could always save that for another day and put that in the back pocket and save it if the anterior approach doesn't work. Yeah, that's interesting. That was great. I guess we're coming on to 10pm Central Time. We've made up an extra 30 minutes for the first 30 minutes we've had. I'd like to thank all of those who sent us cases and participated. Dr. McGarvey, this was an eye opening experience as usual and a lot of insights that we definitely needed. I thank the AOFS staff that have stayed with us that late and I thank my co-chair of the session Cesar and my moderator, Dr. Toulousan and a final word for you Dr. McGarvey. I had a lot of fun and I'm really disappointed with the state of affairs in the southern part of our country. We're just struggling with internet and everything else but I appreciate everybody's time and attention. I don't know how many people are still on but these are great forums. Some of us get a hold of a microphone or get in front of a camera and we just can't stop talking but I think this is a great opportunity to share ideas. I don't have all the right answers for any of these cases by any means but I think just the dialogue and sharing and an opportunity to just meet some other people is really a nice feature that you get to talk to people that you wouldn't otherwise have gotten a chance to talk to. I appreciate everybody's time and certainly I'd like to give a round of applause, virtual applause to Shelly Entscher not only for her routine diligence but her stick-to-itiveness tonight to get me to be able to actually participate in this in a way I wasn't really sure was going to happen based on the fact that lines are down and things are not working. So thank you Shelly very much for today and all the things you do. Happy to help. You guys are awesome. Great job with this. Really appreciate it and the work that you guys do with the YPC. We talked about it the other day at the board level and it's just so nice to see the enthusiasm coming from young surgeons and leaders of the future. You guys are definitely carrying and bearing the flag very well and I just want to encourage you to keep going. This is outstanding work and the amount of work that your committee, I know this is a little off topic but since I have you here, I think it's appropriate. The amount of work that comes out of your committee is unbelievable and that's a credit to everybody that's involved. It's a large group of young people with clearly a lot of energy and a lot of enthusiasm. We want to see that keep going. We want this. We want to see all you folks on the podiums and in the meetings and at some point in these sessions as the experts. So keep up the good work. Keep driving. Thank you so much, sir. Well, just one thing before we go, we need the picture. No one that is here at the end can leave without us doing the print screens. So we have to turn our cameras on. Dr. McGarvey, you have to be on. You're the guest. Here we go. I can see a bunch of cameras. Cesar, don't forget to quit sharing your screen. Oh yeah, that's a good one. You always remind me of that. Let me do this. Okay, let me. Should I go to gallery? Yeah, that's it. Found it. I'm back. Okay, let's do the picture. Where's Dr. McGarvey? Don't see him. Hang on for a second. I just lost you. Yeah, I just saw you. Here it is. I think it is. Am I back on? I see myself. Yep. I don't see him. Do you guys see him? Let's do the picture. Before the power outage takes you away again. I'm back. And just so you know, Dr. McGarvey, if you were not here, we were ready. I have my super mask here. We will be covered. That's a better looking shot. Thanks for being here. That was really fun. Thanks for being here. Zayad, I'm not sure what time it is there, but you're still with us. It's been really fun. All over the world. This has been really fun. Have a great night. Have a great day. Great afternoon, whatever it is. Thank you. You all stay safe. Thank you so much. Great session. Thanks again. Take care.

78-year-old woman

total ankle replacement

ankle pain

subsidance

taylor component

erosion

valgus

CT scan

two-stage procedure

cement spacer

subtalar joint

InVision prosthesis

pain relief

stability