Good afternoon, everybody can take their seats, thank you so much. If you've been here all day, thank you for your attendance and we appreciate you coming back. If you just got to town, welcome to Charlotte. I know we're not in Vancouver, but we think you're going to really enjoy your week with us here in the Queen City, so welcome. This symposium looks ridiculously fantastic, I really mean this. Every topic is fascinating, every faculty member is one of the best in the business, so Mark, no one can better handle these big personalities than you can. A quick shout out to John Kwan and Ken Ellington for the content today, they really were the ones that set up the whole pre-meeting, so if you see them, give them a hand. If you've registered for today, which should be everybody in the room, you do have access to all nine ICLs online after the meeting's over, so you don't have to move from one room to the other to avoid missing something, you'll have access to everything. So you can sit tight right here and be comfortable. When this is over, and I'll let Mark close things out, at four, the welcome reception is in the exhibit hall right downstairs, and that's from four to six. And it opens tonight, and then it closes Friday around noon. So we'd love for all of you to spend as much time as you can in the exhibit hall, because these sponsors are a huge part of making this meeting happen from a revenue standpoint. And there'll be cocktails down there to encourage all of you to further go down there. With that, Mark, I will turn it over to you, enjoy this, which should be an awesome session. Thanks, Carol, this should be, oh my god, can we get, is there any way we can get more chairs in here, is it possible? Can you see? How about doing that would be great, it's amazing. Can we take this wall down? Make a little more room. Anyway, well this should be great, we've got great speakers, and so we'll have didactic teaching going through the whole session, thanks to Bill, no, I'm just kidding, no. We did try, I wanted to make it interactive, and I got shot down, but we will make it interactive anyway. So we'll have Steve go first, you've got the schedule here, we'll follow this schedule, and if time permits, we'll go over some, all of your questions, and then I have some cases in the event we have time for that, so, Steve? Should Steve stage, or should he go? Thank you. Thanks, Mark. It's always, this is a great audience, we just gave a lecture at the Academy where we had six people in the audience, which is a little bit different, so I'm going to give a talk here on staging ankle arthroplasty, and I will tell you that it's a little heavy at times, but I hope you can kind of follow me, I'm going to try to speak slower than I normally do to make some sense here. I do have some disclosures, I do work on design of ankle arthroplasty, and the ones in this talk are those that I've been involved with, but I will tell you that I'm teaching principles here, not implants, and so look at it that way. So here are the issues at hand. The failure of total ankle arthroplasty can occur acutely, acutely, under a variety of circumstances, and not many when you think about it. First being, component subsidence or loosening due to some type of compromise in the bone itself, and that may occur in circumstances like this where you have a subtalar fusion and beneath you've got some loosening of your tail or implant because of compromised bone. Secondary factors might be progressive deformity, something either unrecognized or ignored as a part of the pre-existing conditions that cause secondary tilt and failure. And third is infection, but for the purpose of this talk, since we're looking at staging ankle arthroplasty, we're going to ignore infection and talk about the first two. So this really in the end isn't rocket science. What causes compromised bone? Well, think about it. Your surgery can certainly have an influence on that. It may be something major, like a vascular insult that you occur at the time of your operation, but more commonly, it's you operating on bone that's pre-compromised before you start it, and that may be due to some extensive surgery that you've done here, like this triple causing a vascular necrosis to the bone, to the talus. If you just think you can go in and put in an implant and make up for this, you're fraught with disaster as part of the future. You can have some pre-existing poor quality bone in your post-traumatic cases that you don't realize, where a low-profile implant may actually cause secondary compromise here because it's not engaging good natural bone architecture, a very important point. What causes progressive deformity? Well, ignoring ligament balance in the end does make a difference with it. These are issues that you should think about as a part of the process when you're thinking about staging your implants to make up for these deficits. So if you ignore that balance of the foot beneath a perfectly balanced ankle, you can certainly get into trouble. So what does the literature say about staging? Nothing. In fact, what's amazing about it is that we don't have any comparative studies on staging total ankle arthroplasty with ankle or hindfoot pathology in the literature as a direct compromise. So instead, we do have studies that look at hindfoot fusion and total ankle arthroplasty, but not with respect to staging simultaneous or staged reconstruction. So this, unfortunately, leaves us in the world of the anecdotal. So let's dive a little bit deeper. Let's try to see how everything does relate to staging, and there's very basic concepts here. If you think you're going to insult the blood supply on some level to a critical support structure such as the talus, this gives you a chance if you stage it to learn about your compromised bone before you put an implant in place. Then you don't wind up having secondary failure of a tailor component overcompromised bone because you can make up for it by adjusting whatever your implant choice is to span defects and add cement into the poorly compromised bone equally to make up for that problem. So think about that in advance. Literature does have some value here. This study by Federico Uccelli, it's pretty much the only study out there that looks at simultaneous subtalar fusion and total ankle arthroplasty. Federico did this on 25 patients using both a U.S. implant and a European implant, and his results showed a subtalar fusion rate of 92% when the subtalar fusion was done simultaneous with the ankle arthroplasty, and he rated this by CT scans done at one year post-surgical. So this has a pro in this study, the fact that the follow-up was at one year with CT scans with three independent reviewers. But simultaneous, it has a con. Not only did they use a little bit compromised scoring systems and the range of motion was done not radiographically, so there's a little bit of leeway there, but really the biggest problem that he didn't do, he had advantages here of looking at the subtalar joint and the ankle prosthesis at the time to see if there was implant loosening or subsidence, and that is not even mentioned as a part of this paper, a missed opportunity. Another study by our friends at Duke looked at a larger series, 404 patients with hindfoot fusion and access to look for compromise in results. So they looked at those patients with hindfoot fusions done either before the ankle arthroplasty, during the ankle arthroplasty, or after the ankle arthroplasty to see if it did compromise their results. They did show that gait and scoring significantly improved after ankle arthroplasty, but of course the gait was slower in those that had prior hindfoot fusion. They had a controlled population to compare with without hindfoot fusion, which I thought was also valuable. They did find, however, the failure rate in the implants in the hindfoot fusion group was 10% versus the controls only 2.4. They did also assess tailor component subsidence, finding that it was pretty much the same in the fusions or the controls, very valuable. So this looks to be a pro study for that region, it's a large database, they had controls without hindfoot fusion, but again, the one thing they did not do in this paper is separate the timing of the subtalar fusion with respect to the ankle arthroplasty. Some were done prior, some were done at the same time, and some were done after. So we don't have that stratified data to know that if it matters at the same time or done as a staged procedure, and that really is, again, the one problem with using this as a comparative study of what we're looking for. So is there a common sense answer on staging? Well, I think so. I think that if you're unsure whether you as a surgeon can adequately, completely correct the deformity in a single stage, then stage it. The caveat is if you're doing extensive corrective surgery at the same time as an arthroplasty, give some thought about the compromise of the supportive bone, then stage it. Or if you think you have to do a massive ligament reconstruction with allograft, in this case, you might end up causing stretch or compromise of that allograft as you work on early range of motion of the ankle. It's a compromise in protocol, and that's what causes the problem. So in that case, stage it. So sometimes you need some help to decide. And then in that case, don't simply use your three-rated graphic views of your ankle to make your decision on how you should do the ankle arthroplasty. Add some data. It will help you in the end to give a better functional outcome in your implant. You can't simply just get ankle x-rays and look at it and say, should I put the alignment Preoperatively, even if you don't think you need it, you should get full in alignment views on these patients because you will better understand the mechanical axis and know if something might be done better to give you a better longevity of your implant because of it. In addition, think about, in those that have deformity, should I get stress and reverse stress x-rays before cutting the skin? We can then look at the rigidity of the deformity, if it's passively correctable or not. We might have an idea whether this should be a staged procedure because we know we're going to struggle getting it corrected and neutral in the operating room. And there's more. CT scans should also be done, in my opinion, before ankle arthroplasty. Looking at the quality of the bone, looking at pre-existing sclerosis and cysts to get an idea, in this case, as to whether you might be putting a low-profile implant in the bone that is poor, setting yourself up for a single-stage failure. And if you can get a weight-bearing CT, you'll have even better data on bone impingement and even ligament instability and alignment to help you to make an educated decision. So what's better than MRI, a diagnostic ultrasound? It will not only give you an idea here of presurgical on the magnitude of your instability, it will also tell you what the quality of the ligament tissue you have to repair is at the same time. So you will know if you have to do a primary repair, which would be a single-stage procedure, or an allograft reconstruction, which may be better done as a staged idea. So now you've got your data to make your decision by those principles as to whether you should stage it. So the question is, how do we prevent this kind of thing from happening? And I will tell you that the one thing that I've learned to do this avoidance over time is to develop more of a vision, a vision into what everything that you do will lead to consequences. Every procedure that you do has a consequence. You have to be able to see every move you're going to make in the operating room before you make it and see in the end how that's going to influence the end result of your arthroplasty overall. You can see some people may not have an ability to have that vision. I'm hoping that you can develop that vision so you know what each move you're going to make does, because in the end, this really is a chess game that we're playing as we do each procedure, and we want to make the ultimate move to win the event. So let's look at an example. Let's just take an example in flatfoot. So this is something you might think looks pretty easy, the congruent valgus deformity, passively correctable in this case. We want to check that with our stress X-ray. We think we can probably just stuff an implant in that, go home. If you work up to free the gutters, if it's rigid, you should also be able to do it. But then take a step back and look at the patient. The patient not only has a valgus ankle deformity which we recognize, but look at the foot in combination with it. The foot is essentially plantigrade or slightly supinated beneath a valgus malaligned ankle. And so when you think about that, you start to break it down and think about what's going to happen when you do your correction. You know your deltoid's stable because you have a congruent deformity here, but when you sit there in the end and in your head, look at this plantigrade foot and you think about your adjustment to bring it into play, the neutral, you're going to start to think about the distortion you're creating in your foot at the time after you do your ankle replacement. That's evident from the front and the back where you can see it almost looks like an adducted deformity. So if this can be done through osteotomies and you've got a stable ligament complex, the single stage procedure. Dive deeper. Look at the foot. It's actually abducted, not abducted which you would expect in a flat foot condition or valgus deformity. So we know here we've got something more going on too on top of this. And again, think about a valgus ankle. That fifth ray should be offloaded because the ankle's in valgus, but in this case, the fifth ray is still loading. So you know you've got more issues here in your foot than you bargained for and you have to dissect that out in your head and your mind because you know that when you correct that valgus deformity, you're going to create even more lateral column overload. Look at the calcaneus, the weight-bearing axial view. It is actually not in valgus, it's in varus and you're going to put it in further varus when you go ahead and correct the deformity. This isn't a problem with the mechanical alignment. You get your preoperative full alignment view. That is actually neutral. So you're putting this all together and you can see so far, these are all probably osteotomies. This is a single-stage procedure because of it because I can correct and realign upon a stable ligament complex. And then you add your crusher. You get your weight-bearing CT imaging here and you recognize that you've got a shift of the subtalar joint and significant cystic change and this suddenly becomes a two-stage operation because cutting the subtalar joint using it at the same time as a matter of opinion can cause secondary compromise in already a diseased talus bone. So am I just crazy? Is all this really necessary to dissect this out in this kind of a position? Well let's look what happens if you ignore the rules. This is a varus incongruent ankle. Again, one that some surgeon prior to the surgeon who did this case had done some ligament reconstructions, an old metal anchor you can see, in an attempt to try to bring stability in this case. In addition, there was no erosion in the medial tibial plafon. So you as a surgeon with your vision recognize there really still is significant ligament instability as a part of this implant, a part of this ankle. Also this patient has an adapted plantigrade foot on top of a varus ankle deformity. Think about what happens when you change that biomechanics. And if you look at the fifth ray, it's overloaded. Not unexpected when you have this varus deformity at the ankle, but is unexpected when you see a foot that looks neutral. So start to think this through. Start to think what's happening. Use your newfound vision. Because your vision tells you that if I correct the talus to neutral, I'm going to have to go ahead and plantarflex the first ray, because that's going to happen when I rotate and elevate the lateral column of the foot. In addition, I look at the anatomy. I don't see any medial shift of the calcaneus upon the talus, often seen in cavo varus with rigid deformities. So so far I'm not thinking I have to do a subtalar fusion in this case because of it. And then I want to look at the sagittal plane imaging. Look at the apex of deformity at the ankle where the varus is. And note, is there any adjacent joint arthritis that might need to be fused at the same time as a part of that procedure? And finally, look at the stability. We know we have bladder ligament as compromised, because of course we have an unstable varus, particularly on that left side. So did the surgeon that do this case use your vision that you just learned about? Well, this is the result that I saw when they came in the office. You can see here that. You might look at that and say, wow, that's a good job. But when you dissect it out carefully, you'll see the problems. The first is, this is an artificially straight ankle, because this weight-bearing image shows the talus was actually just sort of cut in situ, with the varus deformity that was already present, just to stuff the implant in there to make up for that deficit. So now when you start to think about the fact that talus was left in situ in varus and the saw cut made upon it, think about the consequences of that problem. The surgeon had trouble with the tibial stem and actually left it in varus, even though you thought it was neutral. If you really draw out and map the tibia, you'll see it is in varus. And look what happened here. The surgeon tried to make up for the varus deformity by doing a closing wedge calcaneal osteotomy. But the surgeon couldn't get enough firepower to correct that, because all of the other fundamental principles we talked about were not addressed. There's minimal rotational change of the foot. You still have less lateral column overload a little bit, but you have that foot that's neutral. And you know it shouldn't be neutral in the medial column with Mary's angle, because when you designed it pre-surgical, you knew that rotation was going to create increased pronation of that first ray. So if this was really going to be corrected, somewhere along the line there should have been dorsiflexion osteotomy or dorsiflexion arthrodesis as the first way to make up for it. So how would I look at what's going on? Am I in trouble? I'll take care of it, Steve. Okay. Good out there. Should I speak or should I go? Good man. So is somebody coming back through the door here? I'm almost done. Don't worry. So what's my laundry list for this case? The first is I'm going to open this up, and I'm going to remove all the lateral impingement that's blocking my reduction, and I'm going to free up some of the medial soft tissue structure so I can bring my talus to neutral and pin it in place. So now I know that I've got an ankle that I can study my foot carefully and correct all deformity beneath. And in this case, I know the subtalar joint is neutral or anatomic. It's not shifted medial calcaneus upon the talus. So I know I don't have to do a subtalar fusion, and I'm still in the world of the single stage in this case because of that. In addition, if I did have gross instability, I'd have to do something more aggressive, like one of these crits and snooks with an allograft. That's going to default to a 2-2 stage procedure in my hands because I want to move that ankle early. I don't want to disrupt that allograft ligament complex as a part of that process. I'm going to look at the fifth ray when I do my surgery as well. If it is still overloaded, as I expect when I correct this deformity, I'll consider a vertical slide calcaneo-cuboid joint arthrodesis to derotate the foot, to offload that lateral column using the talon-avicular joint as a fulcrum, again, part of a single stage procedure to make up for that deficit. And of course, because I expect that first ray to be plantarflexed, I will add on top of that a dorsiflexion osteotomy of the first metatarsal versus a dorsiflexion arthrodesis of the first tarsometatarsal joint, depending on where that apex of deformity is. And then, when all that's done, I'll finally take a minute and take a look at my heel, and if it's necessary, I'll correct that varus deformity. It might not even be necessary, given all that I've just taught you. That's the last step. It's not the first step or the middle step as a part of that. So, to answer my question, should we stage or not stage, well, back to the anecdotal. In this case, we can go ahead and fight about this all day with all you guys in the audience, but here's my philosophy. A two-stage ankle becomes those that require a simultaneous subtalar arthrodesis for arthritis or secondary deformity, because I believe that that can compromise the talus significantly due to both sides. Two-stage in my hands, those that require a more aggressive deltoid reconstruction with allograft, and sometimes even with Pritzman-Snook with allograft, because early range of motion can stretch the graft out and cause secondary failure of that construct. And a two-stage also are those that have significant mid-foot pathology that require naviculoconeiform arthrodesis, because again, I'm going to work aggressively on that range of motion of that ankle early, and I don't want to compromise that more tenuous fusion to make up for that deficit. But there are roles for single-stage, as you would guess. You can certainly fuse showparts joints without compromise of the talus, and in that case, fair game. They can be single-stage procedures requiring ligament reconstructions with primary tissue. Those that don't require allograft, single-stage procedures. And finally, those that require osteotomies are safe bets, because osteotomies do a better job of healing than arthrodesis and are not compromised by early range of motion in ankle arthroplasty. So, that's my summary. That's what I think. On to the next topic. How are we doing on the chairs? Any luck? Nothing? Well, Hodges, you have a standing-room-only crowd. Carol, how about the beers? Who's talking? What's that? Four chairs? Yeah, but I see you have an aisle seat. Nobody wants to sit in the middle seat. That's not a chair. And while we're waiting, are there any questions for Steve? He was starting to get a little too comfortable checking texts. So, but Hodges, don't worry, it's not a failure. It's not a failure. An opportunity. All right, so we'll go to Bill, who's gonna talk to us about conversion between arthrodesis and ankle replacement. All right, good. So this is all about failure. Failure of one, failure of the other. What I'm gonna try and do, this is really two talks that I had to try and cull down into one. And so I'm gonna try and get through it fairly quickly so that everybody else can speak. And I also want to try and get through it without forming that little spit that Steve had in the corner of his mouth when he was so passionate about. Was I not supposed to say that out loud? I think it's just dried skin. Well, it's the masking. It's the masking, but so we're not supposed to see that. If you'd worn your mask, you wouldn't have had that problem. Maybe you could learn to preach like me and everybody. I know, people don't want to hear this. Do you think if he had a little, like a goatee beard, it would disguise it better? It catches a lot of extra stuff. All right, that's probably way more than we need to. Going down the wrong road here. All right, so thank you, actually. Just thank you for showing up. This is great. It's just nice to see everybody face-to-face again. And it's really nice to see the enthusiasm that everybody has for total ankle arthroplasty. So I'll see if I can shoot that down in about the next 15 minutes. So we're gonna talk about conversions in both directions, to and fro. These are my disclosures. Like Steve, I have some royalty-bearing potential conflicts, but they really don't enter into the principal portion of the cases. So let's get right into it. Why are we converting fusion to total ankle replacement? Well, the answer is pain. And these are dysfunctional people because they hurt, they have a fusion that they hate, and it hurts, and they don't like it, and so they want to get it done. So why is it really hurting? Why is it causing the problems that it does, and what can you do about it? And that's what we're gonna look at in the next few minutes and then we'll go the other way. The actual reasons are basically secondary arthritis is adjacent joints, and those could be not just subtalar joint, but salenovicular, and even tarsometatarsal. Any contiguous joint or related joint on down the foot that is increasing in its pain due to stiffness at the level of the ankle can be a reason, a relative reason to consider the possibility of taking down an ankle fusion and providing more motion across the joint. Malunions, nonunions of both the ankle and subtalar joints, consideration of the stress fracture, and then the relative ones are pain with residual motion, and the last one is patient hates the fusion. And we'll talk about that specifically. So the concerns are basically the technical difficulty, the length of the surgery, risk of infection, persistent stiffness, pain, bony collapse, which is a real concern, and then the unsatisfactory patient-reported outcomes, which we are more and more concerned with, all the way to the level of our board examinations now. So technical difficulty, we're gonna get into each one of these briefly, but when you have to do these types of procedures, when you take a perfectly good ankle fusion and you take it down to do an ankle replacement, you have to consider all these things, just like Steve, there's a lot of considerations, and you have to have that vision about what is going to happen stepwise, sequentially in your surgery, and what you need to do to address that. So prior incisions, really important. Soft tissue adhesions, which generally you think in a fusion, are gonna be stuck to the bone, stuck to the tendons, the tendons aren't gonna glide, and the neurovascular bundles may actually be adherent to all those tissues. Existing hardware enters into it, and how to get it out, how to get it out of your way. Dense and sclerotic bone, which may be a result of prior trauma, or the fusion itself, because these patients may have had multiple surgeries. Gutter overgrowth, which occurs as a result of long-time fusion. Posterior capsular tightness, which you have to combat, along with tight Achilles, and then complex wound closures, which can add like an hour to your case, just by having to close up what you've done. This adds to the length of surgery, and that parlays into the risk of infection. The longer the case is open, the longer, the higher the risk of infection. Greater dissection is oftentimes necessary to get around and into the spaces that you need to cut and make your saw cuts. Thermal injury, because a saw blade may take a little bit more time to get where it needs to, or to do what it needs to do, and get where it needs to get. And then, what if there was some level of prior contamination? Is that gonna be reactivated by stirring up the milieu inside that the stability of the fusion had already taken care of? Limb ischemia that may have been under-recognized, and devitalized tissue envelopes are things that you have to worry about. Persistent stiffness is clearly a paramount worry. Soft tissue sleeve, which is circumferentially adherent, or at least perceived to be. The tendons that are adherent, because they haven't moved in potentially a decade. Capsule contracture, and then gutter overgrowth, as we've already mentioned. Persistent pain is a concern, because one of the things that you're doing is you're taking down a perfectly good operation. They may not like it, but if it's perfectly fused, if it's solid, and it's working, then you're taking a risk, you're taking a gamble, because you're actually taking down an operation that you would actually do, and we'll talk about that in the second half, for a failed total ankle replacement. So you have a failed fusion, you take it down. What if the replacement doesn't relieve their pain? Well, what are you left with? Basically, fusion, which you just took down, or amputation, or leave them alone and let them live with their pain. Bony collapse. Well, bone at the distal tibia is the hardest. As you move up the metabasis, it gets softer. But the interesting part is that when you do a fusion, you get a remodeling potential, where you get this circumferential support, and the cortex actually thins out at the level of the fusion. So when you take it down, when you take that bone out, it's actually softer bone, not harder, and that's kind of counterintuitive, but it's true, it's actually a much softer bone that you have to take into account. And then the patient's perceptions of what they're gonna have. A lot of these people figure, I'm gonna have a replacement, it's gonna be much better. And that may or may not be true. So let's see what that actually bears out in some of the literature that's reported. So Justin Greisberg and the group in Seattle actually took the first look at this back in 2004 at CORE, and they had conversions to agility, so they looked at 18 patients, 19 ankles. What they found was, first and foremost, if you have a fibulectomy, they don't work. These patients drift into valgus, so no fibula, no conversion. That's a rule that you can just write down, take home with you, because you're gonna see that in all the literature that I quote on this particular topic. But what they looked at, and they divided up, is that if there's a clear source of pain, the AOFAS high input score went up precipitously. When not, it didn't. And so saying that again, if you look at this, if there's a reason for pain, if there's a malunion that's identified, a nonunion that's identified, or if you can identify by injection that there is a specific area of pain in a contiguous joint, then those patients in conversion actually did much better, more predictably. If they did not have a specific source of pain, if it was just, I hate my fusion, it hurts when I walk, those patients did not significantly improve, and it was much less predictable to get a good outcome. Look at Hinterman's study, and he looked at 30 painful ankles, and similarly found a fairly significant improvement from those patients that were dissatisfied with their fusion from pre to post-op after conversion. But he found some specific things that he found were problematic. Conversion with patients that had more than four surgeries overall did much poorer. Conversions with patients that had surgery within the same year did much poorer. So he came up with actually some contraindications based on his study. Any non-manageable hind foot deformity, and I think this speaks to Steve's talk, is a contraindication, unless you can manage the hind foot deformity first. Highly compromised soft tissues, which makes sense. Demands for physical and sports activities, which demonstrates a lack of reality on the part of the patient who's undergoing the procedure. And then chronic pain. He adds in more than three centimeters of shortening, and we've already addressed the prior fibulectomy. Pellegrini in 2015 looked at 23 ankles, and I want you to look at these carefully. The conversion demonstrated an improvement in range of motion, which is actually pretty substantial. However, again, fibulectomy identified failures, right? But in addition to that, malleolar fractures, which is not uncommon in these because of the soft bone that I already mentioned, and 14 of these patients underwent, or had subtalar, I'm sorry, talar subsidence. So two-thirds of these patients had talar subsidence after the takedown, and that's thought to be due to the repetitive vascular insult to the talus. A third of these patients required reoperation, so important numbers. And then most recently, again, study out of Duke 2019, the only diagnosis related to higher revision rates in a five-year follow-up on total ankle, on failure of total ankle arthroplasty was previous fusion takedowns of surgery. And with that, 21% failed. No indication as to what was done with these, but again, prior fusions lead to questionable results. So should you do them? Should you not do them? Is it wrong to do? Well, here's a couple patients that I looked at of my own, and just some representative cases. So 50-ish-year-old lady, 3B open tibia, underwent repair, it didn't do well. She got this fusion. We looked at that. To me, it looks like a pretty reasonable fusion. I did this, so I can say that subjectively that it looks pretty good. Realistically, though, I think you have to be critical about this and look at it. So she had a fusion, she did okay for five years. Over time, she started to really not like it. And if you look critically and look at the weight-bearing views, you can see here that she's standing in varus. She does not like this. She walks awkwardly, and it's painful for her. She's got decent dorsiflexion, but she's walking on the side of her foot, and she hates it. She comes in, she's saying she wants her leg cut off. And I figure, well, I can offer her better than that. So I get this fancy study with a lot of different colors, and it points me to the subtalar joint and the syndesmosis. So this is a SPECT CT scan, and it identifies that there are some problems potentially there. So what do I do? I'm gonna make her stiffer. Instead of making her better, I'm gonna make her stiffer. I go across the subtalar joint and the syndesmosis and fuse both of those, because that's what the SPECT scan told me to do. And so then she comes back and she tells me she really wants me to cut it off. She hates it. It's awful. So I said, look, I think we can do you one better. Let's try this. Because if you look at that weight-bearing view, you can see she's standing in varus. She's dorsiflexed a little bit, but she's definitely in varus. So we take her down, and I'm not gonna go through all the details, but in this particular case, I chose a stem implant. I think the critical thing here is looking at the gutter cleanout, which I think is really critical. You make your cuts, but you have to spend a lot of time in the gutters to clean this out, do a lot of soft tissue releasing. You can see my prophylactic pinning of the malleoli, because we learned from studies that that's important, that there are fractures in a number of those. We get the ankle in, and now you can see that with this, a relatively straightforward procedure, it's not perfect, but there's reasonable dorsiflexion and plantar flexion. There's her ankle with good gutter cleanout. She still stands in a little bit of varus, but she's corrected a little bit. And you can see my implants actually put in a slight bit of valgus to combat that and try and adjust that. And so she's better. She's not perfect, but she's much happier in this situation. I think the best indication for this is gonna be this kind of situation, where this fellow developed a tailored body fracture, underwent open reduction internal fixation. It went on to a dorsal avascular necrosis. It didn't do well. He's got this joint line problem. And so he underwent a percutaneous arthroscopic arthrodesis. And I think we can all agree that this was done to the point where he did not have compression across the joint. There's a CT scan. He's still got pain. He hates it. It was stiff, but not completely fused. So I think these are great indications for a conversion from an attempted ankle arthrodesis to an ankle arthroplasty. These are patients that don't have arthrodesis, but have a functionally stiff ankle. They have pain, and they have pain very specifically at the area of the non-union site. So you could certainly go in and bone graft him and actually make it a fusion. Or under the circumstances, he hated the stiffness, and he had a reasonable opportunity to get better. So this, and you can see from top left to bottom right, that he has reasonable dorsiflexion, plantar flexion through the range. So tips to promote success in this direction from arthrodesis to fusion. Use liberally injection of contiguous joints. See if there's actually a joint that actually contributes to the existing pain. Obtain a detailed quality imaging. I made fun of the SPECT scan, but I think it is useful, and it does identify an area of increased uptake that you could focus on to see if you're barking up the right tree. Require that they ask you the procedure. Don't necessarily suggest it to them because then it becomes your problem. You're taking down a perfectly good operation that they had, and you're installing something that may or may not work. Use the words amputation and significant complications liberally because those are reality risks for these things. Document your vascularity. I can't emphasize that enough. I have a great case of that if anybody's interested. It's a lot of slides. I'm not gonna show it, but it's a really compelling case for how you can get into trouble with vascularity. Lay a lot of crepe. Do good surgery. Be precise. Think twice. Cut once. I mean, plan these out quite a bit, just like Steve said. Redoing the steps is technically a lot harder, and don't gamble. If you can't do it or you don't feel like you can do it, there are people that can help you with this, and you can refer. So that's the first half, and I know that's relatively long to try and go through the second half. The salvage options after total ankle are gonna be considered to be these. Ankle arthrodesis, PTC fusion, revision arthroplasty, which actually is my preference to do for a failed total ankle arthroplasty, revision arthroplasty including arthrodesis, and amputation. Interestingly, the FDA actually only supports a few of these, and so we're gonna talk about the top two because the FDA actually doesn't still endorse revision ankle arthroplasty. They're getting closer, but when this information came out, the FDA actually suggested that the only treatment for a failed ankle arthroplasty is fusion. So I implanted my first ankle in 1996, 25 years ago, and published reports since that time with newer designs suggest 75 to 90% success rates at 12 to 14 years. But at some point, it's going to fail. We know that. Depending on when you put it in, you're going to have failures because these are mechanical devices that won't last forever. So failure's inevitable at some point, and the question is, what do you do? So I'm not gonna talk about revision, but we're gonna talk about why it failed and then what to do with it. And these are factors that contribute to the failure. Bone loss, subsidence, we've already seen, fracture, poly wear, lytic lesions, deltoid insufficiency is a huge one that is underrepresented, aseptic loosening and septic loosening. So the management of failures remains difficult because we have to identify why it failed. That's your first step. And so it may be something simple like this, instability that was not addressed in the index procedure and leads to edge loading, which leads to poly wear, which leads to lysis, which leads to failure. And that can be ultimately catastrophic. But you can also have component malfunction, and there are several older designs out on the market that actually have been identified to have polyethylene wear and failure problems. And these things will periodically show up in your practice. In addition, every once in a while, you'll see an actual component break. Trauma is not uncommon, and sometimes late malleolar fractures are actually things that you see that can contribute to a loss of stability of the stem or may represent a loss of stability or a lack of in-growth that occurred. So if you see malleolar fractures, start thinking, did this ever really have purchase in the bone? Systemic disease, particularly inflammatory arthropathies are things that can lead to late term subsidence of the tibia in particular on the talus. That's where you'll see it most often. Sometimes you see tibial subsidence in the tibia. It's usually not terribly symptomatic. Consideration of medications also here. And then sepsis is gonna be a source of failure. So the generally accepted traditional solutions are gonna be these, it's gonna be fusion. And the question becomes, how do you do it and what do you consider? What do you choose for your fixation? Well, this study from Berkowitz in 2012, I thought was really helpful in terms of helping delineate what you do. And it breaks it down by basically limb length and bone loss. So if you have a marginal amount of bone loss, if you've done a minimally resection type of arthroplasty and you have less than two centimeters of bone loss, you can consider an in situ fusion. And that tends to work very well. The mechanics are preserved, the Blix curve on the tendons is maintained. And so you actually have a functional foot and ankle that you can fuse in situ. If it's greater than two centimeters, and oftentimes they are, particularly with some of the newer designs, particularly with stems, and then some of the older designs, like the agility. You take out a lot of bone with these or they've subsided and lost a lot of bone, then you have to really consider restoration of limb length. And that may be done with autograft, allograft, or maybe even synthetics. Fixation is your choice. And there are a number of them. We'll go through some of them. The choices of how to choose an intercalary graft is really, again, a level of comfort, but we're gonna address these. The most commonly done is some sort of femoral head, femoral neck allograft. You can also use autograft from the Iliac crest in a storybook kind of fashion, where you stack the books, a bookshelf kind of fashion. Mesh cages and tantalum are also addressed. So this is just an example of what would be considered to be traditionally done. A mechanical collapse of what appears to be a reasonably positioned total ankle arthroplasty that leads to this tailor subsidence all the way down to and into the subtailor joint. So this patient is actually fractured through the tailor body, and this is, at the time, considered to be unsalvageable. So this is what was done with a femoral neck allograft, femoral head and neck allograft. So very simply, you cut the femoral neck, you take a piece. I like the neck as opposed to the head fragment because you get hoop stress. You get actually cortical bone, and then you get that metaphyseal bone in the central portion that can communicate with your talus, with your tibia, and actually gain some fixation, but you also can drill through it, and you get a circular ring that can support the entire construct, and then support it with a nail device. You can see that here. Brian Den Hartog, Chris Cotcia, came up with this alternative. Brian popularized this years ago with femoral or estabular reamers, and then making an interference fit with a circular graft, and they had 90% success rate with this. So taking an estabular reamer, you're creating your defect and matching it with an allograft femoral head, and then you just basically put that in, cut off the rest, and you can use, again, a large amount of fixation. In this particular case, inter-frag screws, posterior plate, lateral plate, put a lot of fixation around it. You'll never be able to tell whether it healed or not because there's so much metal in it. It doesn't matter. You basically get a metallic fusion. But the concerns over bulk allograft persist because these are very suspicious for late subsidence, cracking, fragmentation, graft collapse, and so with that in mind, there have been some newer techniques that have been proposed using other forms of fixation. So this is a patient, similar case, with subsidence and failure. Take the implant out, but in this case, I was having my own problems with graft collapse, and so chose to go with a more synthetic approach and a more biologic approach. So reaming with a reamer, irrigator, aspirator system, you can ream the tibial canal. You don't necessarily have to violate the femur. You can actually go up through the heel of the same patient, which you potentially will do anyway because of your intramedullary rod device, and then use a spine cage. It's an off-label use, but you can use a spinal cage, or now there are devices that are actually made for this. Put that in. It generates a tremendous amount of support, and you can actually early weight-bear these. Then you put your morselized bone graft in and around the cage, and you can use your bone substitutes as you feel are appropriate, and this thing will provide tremendous support. Similarly, you can use tantalum mesh. So in this particular case, you can still bone graft, but you can provide a tantalum mesh support system with a rod, and this will, again, provide you with a tremendous construct that you can early weight-bear these patients because there's no fear that your allograft is actually going to collapse and you're gonna start loosening your nail. This thing will actually support full body weight. As we transition into sepsis, we'll take a page from our total joint colleagues, and those patients are gonna use those same criteria. We don't have specific criteria for ankle joints compared to knees, hips, shoulders. So we borrow the criteria that we use for septic joint and any other specialty and apply those to the ankle. And then, similarly, treatment protocols are also applied. So in a patient that's less than three weeks out, you can certainly go in, wash out, if the patient's identified to have an infection, do a washout and a poly exchange, and I think you're perfectly appropriate to miss that glycocalyx sticking to the implant. After three weeks, all bets are off. You may be able to get by with it, and it may be okay, but generally speaking, you're looking at a staged implant with cement spacer. So this is just an example in a rheumatoid patient who had that exact scenario. After three weeks, we chose to explant. You can see here with the cement spacer, so staged arthroplasty, took the cement spacer out, and in this particular case, chose a frame for early weight-bearing. This patient couldn't be non-weight-bearing, and so we chose to squeeze her down. That implant was a minimal resection arthroplasty, and so we got a good, solid fusion in a neutral position with a post-operative protocol that allowed for early weight-bearing. So how do these patients do? Well, if you look at these patients and look critically and pair these, if you have matched patient populations and you look at patients who have had primary fusions versus patients who have had secondary fusions after ankle arthroplasty, the salvage fusions clearly do not do as well. They are significantly worse in both their subjective scores as well as their complication rates, so that's something to keep in mind. A failed ankle arthroplasty fusion is theoretically not going to do as well, or not theoretically, it's not going to do as well as an ankle arthrodesis in a patient who's not had a previous joint sparing or salvage surgery. Gross supported these results with an overall union rate of 84%, but a high complication rate of 22%, and then these busy slides consecutively demonstrate that basically you can support whatever you want to do and whatever fusion rate from zero to 100% you can find. There's actually quite a bit of literature, but if we dumb it down and look at this as a meta-analysis and cull that information down into one or two slides, what we find is that ankle fusion after total ankle is more difficult and has higher complication rates than does primary fusions. Ankle fusions for failed total ankle does better than hindfoot fusions, so if you include the subtalar joint, intuitively you're gonna find that, yes, these patients do not do as well. Non-union rates can be anywhere from 10 to 40%, particularly for allograft patients, and the most common site for a non-union is actually the subtalar joint and a TTC fusion after a failed ankle arthroplasty. This is just supported with this literature as well, and so in summary, in modes of failure, what do you do when they fail? You take it out, you assess the level of deformity, you use these principles and the literature that's available to consider what your best supporting system is and what you can get to fuse based on what's available to you, and then you do it in whatever way you feel most comfortable because there is not a right answer, but doing something within your comfort zone is probably the best choice, but with these principles in mind, if the patient has a low resection type arthroplasty, an in-situ fusion is probably gonna give you a better alternative because you'll have fresher surfaces and you're fusing fewer joints so you'll have better functional outcomes. In a patient that has a large resection as a result of the failed ankle arthroplasty, you will have to be creative, you will have to consider your allografts, your synthetics, your rods, your frames, combined rods and plates and frames. 75 to 90% fusion rates and maybe lower if reviewed by CT with allografts, so consider those synthetics like cages or possibly these panel and metal devices that are now available. I know that's a lot, I know it was fast, and I'm available for questions before and after. Thank you very much for your attention. Thank you. Thanks, Bill. Lou, you gonna come up and join us? That's awesome. Hodges, we got it worked out? Yeah. Awesome. Does anybody have a question while Hodges is getting ready? Yeah, oh, yes, please. You have to stand up though and talk loudly. Those are cases that I, thank you. Those are cases that early on I sought out because I thought that that would be a really cool thing to do. It just introduces a whole level of problems in terms of trying to get that to heal, not only at the level of the end-to-end anastomosis, or whatever you want to call it, the osteotomy site, but also the syndesmosis stability. And it's just, to me, it's not a reliable way to do that. And so I have not done it. I've seen some that have tried and failed and have converted to fusion. Steve's got some thoughts on it. I'm gonna prove to you that I can sit calmly and answer your question. I think that's a pretty good thought. So I've also tried that. And besides what Bill's saying, just to add to it, a lot of the problems are with the soft tissues because often the soft tissues have sunken in with that absinthe, especially for a certain period of time. So if you're gonna play that game, you may want to consider doing a free flap or something at the same time, at least a rotation flap, a gastroc flap or something. See, I can do it. Awesome. You've really grown in just the few minutes that you've been up here. All right, Hodges. I'm so glad that I'm following Bill and not Steve. Not for the reasons that you would think, but because the concepts that I'm gonna talk about mirror Steve so equally, just I'm gonna present them in a much slower, more controlled fashion. So I was given the topic of a failed total ankle is not a failure, dot, dot, dot. And I'm gonna tell you that a failed total ankle is not a failure, but an opportunity. I also have some conflicts that you will see. So, I really think revision toll ankle in many ways is the final frontier. As one of the older guys, and it's beautiful that I'm not the oldest guy on this panel, in my opinion, when we finally figure out the true concepts in revision is when we're going to tip the scale. If you do enough total ankles, you will see failures, and there is no doubt about it. The knee guys will tell you that, the hip guys will tell you that, the shoulder guys will tell you that, and if they don't tell you that, they will tell you that if they tell you that they don't have any failures with their total knees, then they're liars. Most failed total ankles are revisable, in my opinion. I have not done a fusion for a failed total ankle in almost a decade, and I really believe that most are revisable. The present comprehensive revision systems available make revision much more doable and make most situations revisable, and the fundamental principles of primaries, which Steve put out very nicely, are the same fundamental principles that make total ankles revisable. The first is native bone stock, the second is get them to neutral alignment, third, balance the soft tissues, and the fourth is well-aligned, stable, plantar grade foot is essential to long-term salvation of these, and staging may be required. Let's talk about native bone stock, 76-year-old, four years, status post a star, with severe pain, did pretty well for about six months, and then things started going south. Why this happens, that's a whole different conversation because I'm not real sure I have an idea about why these fail early. So the plan is a two-stage. I removed the implant. I did a TN fusion. I did what's left of the subtalar joint fusion. I put a cement block to keep him out to length and to stabilize his soft tissues. And then did a CT, confirmed my subtalar joint was healed. And then did a revision at four and a half months. He's now three years. I created native bone stock. 76-year-old healthy male, did an agility in 99, did okay for nine years. He was skiing and really pretty pleased with it. Had a revision polyethylene and did a talus to breed mild in 2012 and did just okay with that. Now he's got progressive collapse and things are going bad quickly here. He had been offered an amputation that you might suggest. The osteolysis is massive and it's all the way out into his midfoot. So clearly there is an inflammatory process going on in this gentleman. So back to fundamentals. We can revise him. I think it's this is a really hard fusion. I think an amputation probably is the easiest option. So on stage one, a tail and a vicular subtalar fusion and I filled the cyst with both autograft and with a variety of implants. took out the screws, curetted all of the cysts, all the way to the calcaneus and into the midfoot, filled that with calcium sulfate, calcium phosphate, and filled the rest out with autograft, fused what was left, multiple screws from the top down, it makes it much easier to revise these, and then waited. Four months, did a CT, confirmed healing, came back, took out the cement, and then did a stemmed implant with a thick tibia and a thick talus on his bone. Still had a little area to curette, and I fixed that with cement, which works very well as an axial loading device. I got him out of varus, and this is him at two years, he's now six years out. Native bone, seven years, buccal pappus, he was never great. Because he's a buccal pappus, you know that he was done on the east coast somewhere. The talus is gone, stage one, talus intervicular, CC, sub-talus effusion, and then came back and did a revision on native bone. We were able to recreate a joint space. Sixty-seven year old, degenerative disease, bilateral ankles, had a sub-talus effusion at the same time as his primary. This is an in-bone one with the saddle talus, which didn't work particularly well. Revision, redid his sub-talus effusion, and then came back and did a stage revision on his bone. This is one and a half year after revision. He said, I don't want a total ankle anymore. He had a fusion, which he hated. At four years after his revision, he came back and we took down his fusion for a replacement. Native bone, very key to revisions, and in my opinion, native bone is very key to primaries. Correct residual deformities and get them to neutral. If you do not get them to neutral, there is no opportunity here. Fifty-nine year old, varus degenerative disease, did an agility. Those of us who did agilities knew varus was really hard in agilities. Varus has become much easier in our practices, mainly because we're not doing agilities anymore. One and a half years, she's still in varus. In fact, got a Jones fracture. I was at the sports symposium early. Now I know how to fix these. Two years later, still in varus. The pain's worse, right? The talus is starting to go. Of course, she's still in varus. Sixty-two now had a revision using one of these custom implants. The problem was she's still in varus. Three years out now from her second operation, painful and presents to our facility. The options, again, fusion, revision. The first thing we have to do is get her alignment right. In my opinion, because she's now had two failures, I needed to do that as a stage procedure to make sure that the soft tissues were balanced and the gutters were open. So I did that. Fused her tail and auricular joint. I got her out of varus. Once I had her out of varus, then I was able to convert her to a primary. This is prior to having some of the revision components we have now. But again, she's seven years out now, and she's out of varus. Hindfoot pain with the triple placed in varus. He never was great because he was in varus. And we know that this just doesn't work. And not in a lot of varus, but varus. I thought he might have been infected. I ruled that out. And then we went over all the options and was able to revise him in one stage and get him out of varus. The third opportunity, balance the soft tissues. This is a lady, 45-year-old, had a triple with degenerative disease, had this procedure. And honestly, the implant looks pretty good. The problem was the heel was still in varus. And she did pretty well for a couple of years and then felt something tear. And she had lateral ligament instability. So I went back. I did a heel slide and did a crisp and snook procedure that Steve talked about. And now she's up and around with her ligament reconstruction. So sometimes it's just balancing the soft tissue. And finally, with revision, you get him out, you get him neutral, but the foot ends up being what kills you. So valgus degenerative disease with a normal foot. It's often, and Steve showed you a few of those, had infinity with an MDCO. One and a half years post-op, increasing pain with valgus collapse. Went back, redid the MDCO, revised it, and did a flat foot procedure. And ultimately, the foot now is there. So what I would tell you is that if you're doing total ankles, you will see failures. The key is to go back and figure out what the reason is. And if you revise them, and most, if not all, are revisable, don't be scared to take two stages. And be sure to follow your principles. Native bone stock, neutral alignment, balanced soft tissues with well-aligned plantar grade foot. And sometimes that takes staging. The results are coming out. Our results are mirroring our experience. The more experience we have with these, the better off we do. And so ultimately, it comes down to these fundamentals, and the opportunities are there, and it is changing people's lives, and we've got to continue going. Thanks. Thank you, Hodges. That's a good segue, too. So Craig, tell us about balancing, and how it is important in total ankle replacement. All right, good afternoon. Thanks for having me on the panel. I'm definitely a little tough to follow these talks about the complexities, and this may seem a lot like an ankle 101 talk, but I think that there are a lot of important points here in terms of soft tissue balancing, that as you try and do more total ankles, and potentially attack more complex total ankles, you really need to follow these procedures to get the best results, as the people up here on the panel have mentioned. These are my disclosures. They don't affect the talk. So historically, patients that had end-stage arthritis with severe deformity, that was a relative contraindication to do a total ankle. And while there was no consensus on the amount of deformity that we could tackle, we saw universally that you got poor results in patients who either remained in deformity post-op, or they never had that deformity of the foot corrected at the time of the ankle replacement. And so malalignment, malposition can cause a number of things, including pain, gutter impingement. You get edge loading, which increases the stresses at the bone implant surface, the poly, and can affect loosening, and eventually impact your survivorship. We know that if you leave the deformity more than 10 degrees, your implant survivorship will decrease by half after eight years. And so we've learned over the years, as we've heard, that you need to do additional procedures to help correct soft tissue imbalance, osseous imbalance, and malalignment. And so there are a number of procedures that have been discussed, and we'll go into further. I'll focus more on the soft tissue procedures. But we have to be very comfortable with this, because we know that only about a third of the patients that we're going to see are going to have normal alignment, and not infrequently we're going to see patients with more significant malalignment. And so we're required to use a lot of these procedures in many of the cases we're doing. And I did a fellowship in knee surgery, like Mark did, and I still do a knee reconstructive surgery, and this is rarely ever required in the knee or the hip. And so unfortunately for us, the cases are much more challenging for us. But the goal, again, is to achieve neutral stability and alignment, and we've seen over time that that's how you're going to achieve the best clinical outcomes in the short and long term. And the recent literature really reflects what we've heard so far from the other speakers, that we're able to extend our indications for ankle replacement in increasing severe chronic deformities as long as we can correct the alignment of the ankle and the foot, independent of what the preoperative alignment is. So it's very important when you're attempting to plan these cases out and tackle these cases and potentially stage these cases, you have to understand certainly the origin of deformity, you need to do what you have to do to address the deformity, understand what you have to do for the soft tissues to balance them, the osseous abnormalities as well as the malalignment. So it starts out preoperatively, obviously, you have to look at the patient, look at their skin, the previous incisions, the contractures, that'll help you plan your surgery, look at the gait, how they're swinging, the alignment. Neurovascular status is really important, especially with multiple surgeries, so routinely I send all my patients for vascular evaluation, non-invasive flow studies preoperatively. You want to look at the range of motion, and you really want to look at the whole limbs, you want to look at the knee, see how that contributes, is there a thrust, is there instability, look at the ankle, and look at the deformity, is it rigid, is it flexible. A lot of your radiographic analysis, as Steve was saying, in terms of get the most data you can, so look at the bone, look at their erosions here, is there adjacent arthritis, do you retain hardware, what's the congruity of the joint. We know that incongruent joints can typically be much more difficult to treat, historically over 10 times more likely to develop progressive edge loading, so you're going to need more procedures to help balance that ankle. Stress x-rays can sometimes help you with the decision, can determine laxity, especially with the deltoids, you can see if your deformities are correctable, which can sometimes affect if you're going to stage this ankle or not. Multiple, you want to see the hind foot alignment view to give you an idea of what's going on in the foot. Again, with more severe deformities, especially more proximate, you want to get a three joint standing film. MRI, I don't think you necessarily need to get routinely, I think it can help you sometimes with your tendons, your ligament, your necrosis, but I don't necessarily get that routinely. I think CAT scans are very helpful, including the weight-bearing CT now, which is really a very good dynamic study, which can help assess your deformity and your laxity, can also help you see if there's any kind of compensatory alignment throughout the foot. I think SPECT scan is helpful if your x-rays are normal, I think it's much more helpful in the revision type setting. We know that PSI has been very helpful and has a lot of benefits in terms of OR efficiency and cost and time. We know that it can help us increase our accuracy and reproducibility, but I would say that you have to be very careful when you interpret the PSI in terms of patients with deformity. So the more severe the deformity, I think you really have to understand that the PSI is based on a non-weight-bearing study. So a lot of times, number one, you have to really decide to maybe minimize your bone cuts, and you have to understand that this study is based on a non-weight-bearing evaluation, so it may be very different when you're actually treating this patient. So regardless of deformity, I use an anterior approach, so I use an anterior incision. I'll debride the osteophytes anterior, I think it's really important to spend time in your gutters, so you need to do a lot of bony debridement, excise the stenoidal capsule. You have a lot of instruments that can help you assess the balance intraoperatively, so you can use a laminar sprayer, you can use an osteotome, you can do a pin distractor. If you happen to use an instrument system with a jig, I think that's very helpful. You can place the foot and ankle in there, and extreme deformity, you pin it, and you can use the jig to help reduce it. And in general, when I look at a varus, this is kind of the things that I'm doing step by step. So I'm debriding the osteophytes, especially posterior lateral, you will not be able to reduce the tails if you don't do that debridement. In certain patients with more of an adduction deformity, you may need to do additional releases, you may need to do transfers. We'll talk about these as well as the deltoid release, which is really the go-to release in the varus ankle. Eventually you do your bony cuts, you have to do an extensive capsule release, and once you put the implants in, I think that that's a really important time for you to assess both how much the hind foot and the forefoot contribute to deformity, but you also have to understand that once you put the ankle in, a lot of times you've corrected a lot of the mal-rotation of the talus, and so then this may also change how much of the foot deformity you need to correct. And so I think it's important to, with your experience, understand when you definitely need to stage it, but at the same time, a lot of times, that deformity may correct a lot intraoperatively, and may be very doable in one stage. When you take your congruent deformity, I think it's in the varus, you can usually just adjust that with your tibial cuts, take a little bit more laterally, maybe do a small release. Again, you can recheck it with the trials to see if you need to fine-tune it, and then you also check the hind foot to see if there's any foot deformity, but most of the time it's pretty straightforward, and just correct it with your implant. I think the incongruent varus, when you have this increased tail or tilt, you're going to have more of the soft tissue imbalance, and so that's typically not corrected by bony cuts alone, you usually need some additional soft tissue corrective procedures. Again, you really want to debride the gutters, especially posterior-laterally, and you want to correct that tilt, so the deltoid release immediately, you can do this in a graduated fashion, you can use it at different points in the case. I tend to do it initially, once I've debrided the gutters, it's been described, I do it approximately. I like to elevate the superficial deltoid with the subpariosteoid section, I like to keep that sleeve intact, and then I'll titrate my release of the deep deltoid from anterior-posterior, and sometimes you may need to leave it bare and just go all the way back posterior, just to protect your tendon. Throughout this, though, I monitor with my LAMR spreader, so I can see exactly how much I need, and again, you can check this again, once you've had the implants in place, you may need to do a little bit more. In cases of more severe vascular deformity, it's been described with vertical sliding osteotomy, that can be fixed or not fixed, it tends to be put in after the implants, so you can avoid the medial edge of your implant. Fortunately, I have not had to do this osteotomy, it's also been described to couple that with a lateral malar shorting, that's another osteotomy I've not had to use. But in general, as you get more toward a moderate deformity, again, you have this deformity, you can reduce this with a deltoid release and gastroc, and get an excellent result. Some of the things, once you've done your cuts, you have your implants in place, again, you want to assess the motion, you want to have at least 10 degrees of dorsiflexion, so this is a point in case where you can go to either a gastroc or tendon-caves lengthening, you want to assess your laxity, your lateral laxity, you might need a reconstruction, is there a persistent anterior lateral extrusion, so you may need a transfer, and then you also want to look at the hind foot and the forefoot and see if any other corrections are needed. Most of the time, I can use an anatomic reconstruction for my lateral ligaments, this is still my go-to, I find most often there's good tissue in place and I can still incorporate the retinaculum. I tend to do this, I remove the poly, I perform a reconstruction, and then usually I can put in a smaller size poly afterwards. Sometimes, in certain cases they listed here, you may need a non-atomic reconstruction because the lateral ligaments and the lateral tissues are incompetent and you need to provide more of a check grain to inversion and to a translation. So a modified Evans is an excellent procedure, we can take a whole or a split perineus brevis and bring it up. This is a case of Hodges, we're a 63-year-old gentleman with a history of ankle instability and fractures, and you can see this lateral ossification, varus deformity, anterior lateral extrusion, so you do your ankle and then you assess and you do this non-atomic reconstruction. You can also do a little dynamic repair by transferring the perineus longus to the brevis and you do your tendochiles lengthening, this is intra-op films and again the post-op. As you get further along toward more of a cao-varus deformity, so you've done your ankle, you've done your lateral ligament instability, now you're checking your foot and you can see how much deformity is there and what needs to be corrected there. So this was a case I did last week, you can see this varus, 25 degrees, anterior extrusion, so I do the deltoid release through the same approach, I do a tail and a vicar release, I do a gastroc, you can see a touch of lateral laxity here that's more impressive intra-operatively, so I do a brostrum. Once I do that, then I check the hind foot, I do my lining few, you can see it's in the touch of varus and so I do a percutaneous osteotomy, which has been really nice addition for me, it really makes me feel more comfortable doing a lot of these procedures in one stage because I have a very small incision, I don't have to worry about extending that lateral incision and working anterior and posterior due to my lateral ligaments and my osteotomies, I can do this really quickly and so it really allows me to move a lot of these patients on to one stage and this is the final correction. And so these osteotomies that I do, I do a lateralizing closing leg and a little superiorizing osteotomy. And then as we get much more complex, there are other soft tissue procedures you can use, again we talked about the dynamic transfer, the longus and the brevis, you do a plantar fascia release, if it's severe deformity, I'll do this at the beginning of the case, you can also do more extensive release immediately if there's more of an adductor contracture, so you can do a separate incision, you can release the tail ligature joint capsule, if needed you can come all the way plantar and get the spring ligament. You can see here this is a caovarus malalignment, you can see here the severe deformity, anterior lat extrusion and I do the releases and the osteotomies and this is the correction, you can see him at three years, that's his left foot. So I would say in general, and I'm not going to go into the staging, but one of my concerns is with the varus ankle that's severely unstable with perineal insufficiency. And so if you have more of a mild to moderate caovarus, I think that you can address insufficiency with a longus transfer to the base of the fifth, which appears as brevis. But I think if it's more severe and it's grossly unstable, I think that's when you need to think about doing something more. So I think that's where the posterior tibial tendon comes in, it's a dynamic stabilizer. I use this a lot if it's more mild to moderate, I may make a small incision immediately just in the size of the sheath, especially in post-traumatic cases, sometimes the tendon's just adhering, and so literally just opening the sheath and debriding it can improve significantly. Sometimes I do a fractional lengthening, but sometimes rucous is defined during a recession, so you do a little bit loosely more proximal at the middle distal third. But if it's a more severe caovarus, especially with the perineal insufficiency where it's unstable, I think you need to consider transferring. For this procedure in my hands, this would be a staged procedure, and you bring it around lateral for your classic four incision technique, and dock it depending on how weak the inversion is. So this is the case where I think in my hands the severe varus unstable with perineal insufficiency is the case that I would stage, where you do a bunch of the procedures first, you correct the alignment of the foot, and then you come back later and do the ankle. So moving on to valgus, I think in general, I think valgus is more of a difficult challenge compared to the neutrally aligned ankle or the varus ankle. The preoperative valgus deformity has been shown historically to have a higher revision rate, as well as a negative influence on implant survival compared to if it's a preoperative neutral or varus malalignment. Dimitri Coppolis also showed that in patients with a flap deformity, they also have a much higher incidence of associated procedures at the time, and so I think when you're thinking about tackling a moderate to moderate severe valgus ankle, you should really be very comfortable with a lot of these techniques, but also with your experience in terms of taking these cases on. So you have to think about where the valgus is coming from. We know that 70 to 80 percent of arthritis in the ankle is post-traumatic, so a lot of times this will be something that's more focal and sometimes easier to address. But 20 to 30 percent of the time, it could be something from pesiquenal valgus with much more of a progressive deformity, and so those I think are very difficult to tackle. In general, I still do an anterior approach. I still approach it the same way. I remove my osteophytes. I debride the gutters this time more immediately. I think a jig system is helpful because you can pin it in extreme deformity and help use the jig to reduce it. Certainly a mild valgus I think is pretty straightforward. You go in and use your laminar spreader. You correct it. Fortunately, in the bulk of our valgus cases, the deltoid will be intact, and so that's excellent because once you balance it and you do your corrections, you can realign it. You can re-tension that deltoid. I think when you're planning these cases, you need to plan much like in a valgus knee. In a valgus ankle, you need to plan on doing minimal bone cuts, so these are typically cases that I'll plan on under-resecting my tibia. So in this case, you can see a mild varus, mild sag, and so I'm able to get a good reduction here with just the ankle replacement and the TAL. I think it's important to assess the confidence of your deltoid when you're planning these preoperatively because complete deltoid disruption can be a problem. So historically, this was a relative contraindication. I think that if you're going to take these on, it's at the very least a two-stage procedure, and so this is another instance where I two-stage my ankle. So if I have a pretty significant valgus deformity that has deltoid incompetence, this is another two-stage for me. So I do the appropriate radiographic workup. I try and do stress x-rays to see is it reducible or not, and you want to go into the operating room and place the laminar sputter, and you want to make sure that the talus is pivoting along the deltoid because then you know that there's enough support there, but the last thing you want to do is to go into one of these cases and put in your laminar sputter laterally. The entire joint distracts, and then you know it's compromised, and so then you're looking at either effusion, which I still can sell my patients for, or you're looking at a reconstruction, which is probably one stage. Historically, it's been described with autograft, posterior tibia, which Dr. McGarvey described. I tend to use a technique similar to what Dr. Haddad described. I use a semi-tendonous allograft. I like to recreate the deep and the superficial parts of the deltoid. I create the graft. I loop it. I place it through the tibia, and then I have two strands which go into the talus and calcaneus, and I can tension it and dial in my tension and suture button in the tibia. This is a case right here. I was able to do that in one stage. Most of the time with the valgus ankle, we think of the medial insufficiency, but you also have to consider lateral laxity. In general, lateral ligament release is rarely needed, so it doesn't get contracted. Every now and then, I may see a little bit of contraction, so I usually would just take a blunt, smooth acetone. I may rub it into the lateral gutter or subfibular subperioste to loosen up a little bit, but sometimes it can require reconstruction, so if this happens, and I'm not surprised that it's happening at this point, I still use the Brostrom. I think that's my go-to. I think you see this a lot of times, though, in post-traumatic cases where you've had chronic valgus impingement, so sometimes you do have to consider a non-atomic reconstruction if the tissue is poor. You can also consider a dynamic transfer, and sometimes you can accept up to one to two millimeters of laxative in the valgus, which you can do, then, is upsize your poly, and that'll create symmetrical laxity and actually probably be better for the stability of the deltoid. In post-traumatic cases, you can also sometimes have a malunion or nonunion or syndesmosis that can be associated with a fibular fracture that's shortened, and that's going to rotate. I think we'll probably see a lot of this as we're revising some of the agilities, and so in these particular cases, I think these you probably have to take down. So these are cases in the valgus where you have to restore that lateral buttress, so you do your osteotomy, you debride the syndesmosis, you bone graft, and fixate the fibula, and then you fuse your syndesmosis. So this is a case that did not have shortening, but it's a post-traumatic case, similar to what I've shown before. So again, you can see the cystic changes here. You can see it on the CAT scan. On the sagittal, you can see that it's less than 50 percent of the height of the tail is compromised, and so I feel comfortable going ahead and doing an ankle, but you can see the cystic changes in the distal tibia, and so this is a case where I prefer to do a stem implant to bypass the defects in bone graft. Again, it's important, so not just to balance the ankle, but you have to balance the foot, and certainly as these deformities are more and more significant, you need to make sure that you do what you have to do to balance that foot before you leave the operating room. This is where, as Steve was saying before, you have to think this out beforehand to see what's going to happen step by step, and that'll help guide you if you can do this in one stage or two stage. So in general, if I'm going to do a severe valgus that's unstable, if the deltoid's insufficient, that's a two-stage case for me. So in the first stage, I'll go in. I will do a small arthrotomy. I'll debride the osteopaths. I'll try and reduce the ankle. Maybe I'm placing it just like Varus. I'll hold it either with pinning, or I can put a little cement in the lateral gutter. Then I'll do my deltoid, and then I'll do whatever selective realignment procedures I need to do for the foot. Sometimes I will do a fusion, but again, if you're going to do it in one stage, you want to make sure you protect the blood supply, but also in two stage, you want to make sure you come back, you have good blood supply to do that total ankle above it. And then a lot of times I can come back within six to eight weeks, depending on what I'm doing, because then I can tell the patient I'm basically piggybacking recovery. So I can do the foot correction, and normally they'd be non-weight-bearing for about three months. This way, about halfway through the recovery, as long as they're healing well, their wounds are healing well, we're getting good x-rays, I can come back, I can take out hardware if I need to, I can do the ankle, and that way they're still not weight-bearing for a total of around three, three and a half months, and that can work out really well. There's a more significant process, and obviously I can stage it longer. In general, again, when you come back with a valgus ankle, you want to minimize your resections, and then once you have your total ankle in place, then you have to reassess the ankle. So even though you've done your first stage procedure, it doesn't mean that the ankles will be balanced automatically once you've done the ankle. So reassess the stability of the ankle joint, reassess the hind foot alignment, and then tinker and do what you have to do to touch it up. So this is a case of a patient with a valgus with a rigid hind foot and midfoot. So this was stage one, they had a repositioned fusion, extended the medial column of gastroc, and eight weeks later they came back, took out the hind foot hardware, and did the total ankle. Some other deformities that are less common, I think these are important just to know and be prepared. These are deformities that typically require a stage procedure just because a lot of times the deformity is super malleable or will require extensive recovery, and you want to stage these. But I think you have to be aware that these are typically cases that when you're doing them, you want to make sure you get a really thorough posterior capsule release. You want to make sure that you do either gastroc or TA as needed. I think it's important to really plan out your bone cuts for these, because again, the non-wafering study from a PSI can mislead you. As you can see here, if you have recurve bottom, it's going to be eroding anteriorly, so that anterior leading edge needs to be where the superior aspect of your cut is. So you can see here, if you follow that proxy, that's going to mislead you. And similarly, the procurve bottom is going to be the posterior leading edge that you have to make the superior aspect of your cut. Posterior contracture is important, too. I think you need extensive release because you want to minimize this anterior extrusion, as you can see here. So one of my mentors, Dr. Sanders, submitted this technique for publication where you make this small posterior medial incision. I think it just takes an extra few minutes. You protect your structures. You can do your release with a smooth, osteotome posteriorly. You can see it intraoperatively that you're all the way bluntly, so you've done a release back there. You can put a malleable there, protecting the appropriate structures. And that allows you to really debride the capsule, do a very thorough capsuleectomy. You don't have to worry about the posterior structures. You remove the osteophytes, which can minimize your chances for HO postoperatively. And you can see here the difference on the right, what an extensive debriding you can get. And the added benefit of this is that, because you've debrided the complete posterior, that you have no problems getting the tibial cuts out, so you don't have to spend 10, 20 minutes fishing out the piece of the bone. Again, at the end of these procedures, you want to make sure you have at least 10 degrees of dorsiflexion. So historically, we do our cervical test, and you decide what you need to do to treat it. Do you do a gastroc recession? Do you do a TAL? But we see now some studies now that have shown that the gastroc recession, regardless of what the cervical test has shown, can provide a reproducible increase in dorsiflexion, but you can avoid the potential downsides of push-off and plantar flexion weakness with the TAL. So now we do that almost exclusively. Sometimes it may be more complicated. Maybe you have a chronic deformity, more of a contracture, so you may need to do an extensive open approach, posterior mealy, with a cap selecting, Achilles lengthening. And sometimes if they have a really significant aquinas, you may even stage a seduce and tailor a spatial frame, bring the patient out of aquinas to neutral. Once you let that settle and heal, then you can go and continue with your other procedures. So here you can see a patient valgus enters subluxation, and I do my releases and get a good reduction. So in conclusions, I think that if you're going to do these surgeries, you're going to encounter coronal malalignment. It's going to happen, but this does not necessarily have to be a contraindication to your replacement. However, it's extremely important you have to correct that deformity during the surgery, and it requires multiple procedures. As we heard, it requires a lot of patience, but proper alignment and stability of the ankle and the foot is going to be essential for successful long-term outcomes to prevent complications. So I think, everyone, you have to really understand your competency and your comfort and your understanding of these deformities, but I think that if you can develop a systematic algorithm in your head and you go through and check the boxes, that each time, then you won't leave the operating until it's balanced. And so you assess it preoperatively. As we heard from Steve, you make a plan. You assess it intraoperatively at multiple points, but you have to make sure you do not leave the operating until the ankle is balanced. Just a few thoughts on the deformity. If I put a total ankle and a patient has moderate ankle arthritis with minimal foot pain deformity, then I will just replace the ankle itself. So I'll now do also subtalar fusion. I think the ankle replacement has been shown to provide good pain relief and function. It also usually markedly improves the foot alignment, so I feel I don't have to do that, and that's been borne out in some studies recently as well. I think also from my knee experience, it's well documented in the knee literature that when you correct the deformity at the knee, you can correct as much as 50% of the deformity at the hind foot. And so if you see a patient come in your office that's walking like this, obviously you're not going to jump into doing a total ankle, right? So this is an extreme example, but a lot of times you may want to have that total knee replaced first, and then you can build back to that knee. In general, soft tissue balancing procedures that can be formed through the same incision, I'll do at the same time. If I can do concurrent procedures that can be completed quickly through minimal incisions with good skin bridges, I'll do that at the same time as well. And again, with experience, you're able to do more of this at the same time. For me, when I'm thinking about staging this, retained hardware for me, it gives me a lot of angst. And so especially when I see a lot of broken hardware, especially areas where I'm going to need to put my implants, these I will stage. So I'll do whatever I have to do to remove it. I might require coring the bone, bone grafting, and I'll probably wait three months to do my definitive procedures. The other thing is that if I'm concerned about my ability to obtain a plantigrade foot in one stage, so for me, that's either severe varus or valgus rigid deformity, or severe valgus flexible deformity with the deltoid insufficiency, or severe varus deformity that's flexible with perineal insufficiency. thank you for joining us. So you are going to teach us some good stuff. While you're getting ready, I think I see Chris could see you in the audience. Your head keeps dropping lower and lower and lower. So either you're falling asleep here or in your phone. Can you come up to the mic? I want you to lead something for us and clear something up for us. I've heard from Steve and from Craig about staging. So what is the right answer? You're a very to-the-point kind of surgeon. Do you fix the foot first or do you do the ankle first and fix what you need to, what you see after the ankle is in? I'm a little bit more efficient surgeon than Steve. I usually do stuff in one stage. So depending upon the deformity, if it's a foot and ankle, I'll do the ankle because I know where I want to put it and then we'll put the foot where it should be in the same setting if I can. But there are situations we have to stage. Craig, what do you think? You gave us two different paths to take. Do you think it's mostly you do the ankle first or do you often do the foot first and then come back? So I would agree for most of the time I'm doing the ankle first and I'm assessing the foot. I think a lot of times when I'm planning these cases out, once I put the ankle in, that corrects a lot of the foot deforming. So at the time then I either don't have to do associated procedures on the foot or I'm doing fewer procedures except for those select cases that I mentioned. Steve? Accuracy over efficiency. That was the shortest answer I've ever heard you give. That's amazing. Ryan, thank you for joining us. I appreciate it. Thanks so much for everyone's attention. As the only non-foot and ankle surgeon in the room, I'll try to give you my perspective on foot and ankle surgery. Here's some of my disclosures, none related to this talk necessarily. I always have to give honor and thanks to the guys in my field who have led me, both Scott Hollenbeck at Duke, which you know well, and Scott Levin who was at Duke for a long time now at Penn, as one of few plastic surgeons who's also done a residency in orthopedic surgery. So the outline for this talk, we'll talk a little bit about the unique anatomy as it relates to the challenges with total ankle replacement. Talk briefly about the reconstructive ladder, soft tissue considerations and why I feel probably a lot of these problems are more urgent than not. A couple of difficult case scenarios and some helpful plastic surgery solutions. So just briefly, here's the foot and ankle anatomy. Most total ankles, as I understand it, go through the anterior surface of the ankle and this soft tissue is thin and pliable but it's extremely unforgiving. The dermis is pretty thin and it has a very poor lymphatic outflow so it gets swollen very easily. So this is where the wound problems happen. Some surgical tips from a plastic surgeon. If you can, turn the bogey down. I tell our fellows who are interested in reconstruction, whenever possible, sharp dissection rather than burnt dissection. Approach it, if at all possible, without violation of the intertibialis tendon sheath as this can be a reconstructive option later. Careful retractor placement. Here's an example of a gelpy that's really put on extreme tension and it's left in there for quite a bit of time. Meticulous hemostasis, I don't know if drains are used, but whenever possible, that's an option. So the reconstructive ladder, it's really just a systematic approach to how to manage complex wounds, right? It emphasizes things simple to complex really based on the clinical need. Options to consider are based on viability, complications and optimizing both function and cosmesis. So for the reconstructive ladder, in my practice, really things in the middle of the ladder don't work. If you can get to the ankle problem early, sometimes primary intention closure or tissue biologics can work. Other times it's really at the higher rung or, as Scott Levin would say, take the reconstructive elevator instead of the ladder and go right to a free flap. So why is it so important? Why is there urgency? So here's a study, 613 totaling replacements, 19 infections, 15 chronic, four acute. All four acute failed implant retention with a polyswap and washout. Of the final outcomes, only three were successful reimplantations. Seven went on to permanent cement arthroplasty, six fusions and three bologna implantations. There's another one of the esteemed author on this panel. Fourteen acute total ankle infections. Implant retention and polyswap was only possible in 46% and failures were deemed to be secondary to both time to irrigation at the time the infection was witnessed and bacterial species such as MRSA was a poor prognostic factor. So here's a couple of obvious cases when to call your plastic surgery colleague. But maybe there are some little less obvious times to call your plastic surgery colleague such as these cases. And I always caution this so-called biologic dressing. There's really nothing biologic with dead necrotic tissue sitting on your ankle. Here's a couple examples when maybe it's not so obvious, right? So total ankle's pretty fresh out of the gate. And what do you do with these scenarios, pinpoint drainage? So if you learn nothing from this talk, find a plastic surgeon and become their friend. I think you take him or her out for a beer. I know Hodges did this for me when I first came here. So I am forever indebted to him no matter when he calls. Send pictures via cell phone. I think it's very helpful because, again, going back to urgency of these implants and trying to retain them and avoid an infection. So here's an example of about 70-year-old male, two and a half weeks post-op, total ankle replacement, has a mild woundy hyssop. So I was called. I said send the guy to my clinic right away. I took him to the OR the following day. Most of it looked clean. We took some cultures. They were all negative. I used part of the aspect of the tendon sheath to close the defect over the total ankle to get a capsular closure and then just did a really meticulous primary closure. He went on to heal without infection. So this was really a save that if it wasn't addressed urgently, it may have been a much bigger problem. But if we start to climb the reconstructive ladder, here are some other case examples. So here is another article, again, of our esteemed colleague on this panel from Duke, 19 patients from a cohort of 1,001. Thirteen went on. All of them had two-thirds had stage reconstructions, and I think it's really important. You've got to assess whether or not the implant is loose or not. I think it's a very good idea to wash it out first, get an assessment of how big the wound is as you start to prepare whether or not a pedicle flap or a free flap is going to be necessary. Of these, 12 of 19 were treated with rotational flaps. This is less common in my practice. I tend to do more free flaps. Carol Jones will tell you if she calls me with a total ankle, they're going to get a free flap no matter what. No deep infections following flap coverage unless they were positive before. So here's an example. Urgent debridement, deep capsule appeared to be vascular. I used a spy. It was all vascular, so we just did it in a xenograft application and went on to heal without infection. Here's another more difficult case. Scott Hollenbeck shared this one with me. 65-year-old female, wound dehiscence, has elements of devitalized fascia. Fortunately, cultures were negative, so she had a sural flap as a pedicle flap from the back of the leg, which is possible only because she didn't have much lateral incision, so the perforators from the perineal vessel are still intact. Here's one of my cases, a 70-year-old patient, exposed intertibial tendon. You can see it's pretty necrotic and shredded. The TAR is threatened, so she goes on to the reconstructive elevator and gets a free flap from a radial form free flap and does well. Here's a guy, a little more difficult case, 80-year-old male, a heavy smoker, peripheral astral disease, threatened TAR. So this picture comes my way. I take him to surgery the following day just to assess, take these ischemic trauma sutures out, and it just pops right open. So I know this is a soft tissue loss that's going to have to be replaced, so he gets a radial form free flap. This is a more difficult case. He had to tie into the intertibial vessel in between calcific areas, so you actually press on the artery and find a soft spot, and that's where you do your anastomosis. So, very difficult case, but fortunately was able to salvage that implant. Here's another one, 63-year-old, revitalized tendon, and she threatened TAR. Little larger wound, so when they get larger, you have to start thinking beyond just a radial form, which is my go-to on most applications. So this patient gets an ALT, anterolateral thigh free flap, larger flap to cover the large soft tissue defect, and goes on to salvage the implant without complications. So here's another concept that was sort of new to me when I was doing my fellowship at Duke, and this is the question that can be posed to your plastic surgery colleague. Can I go ahead and do my total ankle through this skin envelope? And so this was one of the first cases that I'd even thought about this from Scott Hollenbeck. So we did a prophylactic free flap. So patient comes in, has four soft tissue on the anterior surface of the ankle, gets a free flap, does well, then gets it re-staged three to four months later when the flap matures. And so I would think it was in practice maybe a year, and this shows up on my doorstep. So the question is the same one. Am I safe to do an anterior exposure to the ankle? This is a 60-year-old female, multiple prior ankle procedures, including skin grafts on the front of the ankle, very unstable soft tissue envelope. It's going to take a hit when you go to do your approach. So she gets just that. She gets a radial forearm prophylactic free flap. Here she is at three months healing well. The donor site's minimal. And here she is at six months, was able to go into the OR with the foot and ankle surgeons and learn a little bit about the foot and ankle anatomy there, and lifted the flap, gave access to the exposure, the implant is put in, and here she is long-term without any complications. So this is always an option as well, although a staged approach. So in conclusion, anterior soft tissue can be relatively unforgiving. I think that your total ankle replacements, if they get infected, it's a devastating problem. Wound complications, in my opinion, are urgent. So when in doubt, send a picture. Become a friend to a plastic surgeon, buy him a beer, make him indebted to you, and let him buy into your problems. And whenever possible, get a preoperative consultation. Let them look at the wound beforehand and maybe consider a prophylactic free flap. Thanks. Mark, I know you all have orthopedic surgeons who are also plastic surgeons. Well, when Ryan came to Charlotte, I was trying to determine how many of my junior partners I would give up to make him stay. And it was around two or three, and then I have the list of things that would make me retire, and one would, he would come up and go, you know, I'm moving, and then I would retire tomorrow. So if you don't have someone like Ryan, which I know very few places do, I know Duke does, because it's changed our practices in Charlotte, in foot and ankle, mainly because he's so available and speaks our language. So Ryan, absolutely excellent talk. Thank you so much. Hey, Ryan, what is your practice? Is it mostly plastics, or what else do you do? I want to do more breast augmentation, but that hasn't become a part of OrthoCarolina. I want to, tits and tunnels, but that's not, I do mostly hand surgery, so 70% of my practice is hand surgery, but limb reconstruction, both upper and lower. Yeah, just at our place, you know Sue Hill, who does a great job. So for a while we had an issue on this, I mean, he's very responsive, very helpful, so we're very fortunate as well. And, you know, Celene can speak to it too, Jim can speak to it, so we've been very lucky. But there were instances where on the same day I wanted to have him see a patient, but because he has an orthopedic background as well, there were some issues seeing, you know, being paid for a visit with two orthopedic surgeons the same day. But I guess you can compartmentalize that. Yeah, no, I mean, I, because I'm, I guess I have board certification in both, I just switched the hat. Yeah. Okay. That's good. Well, thank you very much. Yeah. Great lecture. I'm sorry we don't have a chair. Oh, no, no, you're fine, you're fine. Here. All right, Lou, take us home. Okay. Let's go. All right. It's okay for me to take the mask off here. Steve, avert your eyes. You can take the gloves off too. Okay, so I'm going to do a little case stuff. So in Mark's true to form, he sends us a text like three days before. That's not true. It was three weeks. Three weeks. Okay. He says, I want to do more case-based talk. So anyway, so this is, these are my partners, my disclosures, and I'm going to talk about some complex cases that involve possibility of infection. So here's case one. This is a guy, he's 75. He owns his own gymnastics equipment company. He was an Olympic gymnast, and he had post-traumatic ankle DJD. And you can see a valgus deformity. And he undergoes a star replacement or a replacement. This is what he looked like post-op. And he had some persistent pain. So let's just start it there. Steve Haddad, you love to look at things and find the beauty within them. Positive. Be positive. Go ahead, Steve. So this guy, he's got some valgus still. Okay. He had some valgus before. He's got some valgus still. The surgeon, I didn't do this one. So what was the thoughts here? I know it wasn't your case. And what would you do to work up the persistent pain? It's not terrible pain, but it's annoying, Tim. So you said you were going to talk about infection. So I'm kind of waiting for that to come out. Oh, wait for that. Yeah, but I'm going to start without that. Let's start with the mechanical stuff. Let's start with the basics. Right. So the one thing you don't know is if the tibial tray was put in Inveris or if it just eroded Inveris over time. So you can't really blame the surgeon for that. That's an older implant. Okay, wait. So along that line, if you had a valgus case, might you overcorrect him by cutting the tibia into some Inveris? Technically, you're not supposed to do that. But you can do that, I guess, as an option. Okay. Any of the other guys on the panel except for Mr. Augmentation? Dr. Augmentation. In the U.K., okay, he'd be a mister. William McGarvey? Would you cut your tibia in some Inveris? No. No? No. Audience? DeOrio? Anybody else? Okay. I didn't do it. Okay. So you don't know if he did cut it that way or if it subsided that way. Our guess is he cut it that way. It looked like it was cut that way. Sure. Okay. Well, first of all, this is a little more than slight. And secondly, the only issue in a mobile bearing prosthesis is you don't have the ability for a sulcus in a fixed bearing implant to capture a talus and maintain its neutral alignment or close to neutral. So unfortunately, in mobile bearing, that is the one negative is that it would move medially if it's Inveris and impinge against the medium lewis and cause pain in that direction. So that's what's. So if this guy was valgus before, as we saw, your strategy would have been to do an anatomic alignment and then do other procedures to correct his deformity. Yeah. Okay. I know you missed my lecture, but I did go. I was there. Just two eyes were not open. I think I'm done. I've got the one. I've got the one over here. So I've done all I can here. Okay. All right. So so he has some persistent pain. And what about Mark Easley? What do you think about the gutter there? The lateral gutter? Is that does that concern you? I mean, from what I can tell me, it's definitely what to Steve's points, a mobile bearing prosthesis. That worries me. There could be some bones still in the gut. I mean, I've been completely cleaned out. I can't quite see it from this angle, but that looks what it looks like to me. But I don't think that's the main problem. I agree with Steve that just the prosthesis can't maintain its mechanical stability. So it's more of an impingement immediately, most likely. Right. And with this tendency towards valgus, might you be worried that the fibula is not going to contribute to some stability there with the fibula being so spaced away from the talus? Is that is that an issue? He keeps saying valgus. I think we're embarrassed now. No, we're embarrassed now, but he was valgus. Yeah. So that's been cleared up. But now he's starting to tilt into clinical valgus. He looks like he's embarrassed here, but he's actually going by like he's compensating through a subtalar joint. Yeah, he could be. He could be. Fair enough. OK. All right. So he has persistent pain. It's getting worse. And he starts to show some signs of osteolysis and more convincing signs of posterior tip tendon dysfunction, medium allelis pain. So this is what his films look like. Unfortunately, I didn't the lateral didn't come through. This is where he is now with his more persistent pain. What would you want to do here? Hodges? Well, things are happening. More valgus of the hind foot. Right. And now the medium allelis looks a little weird. Yeah. I mean, things are happening quickly with with that erosion. I would I would absolutely want to rule out infection here. First, second and third in the first year, in particular with the low virulent organisms, you you see this. And the compensatory valgus of the hind foot, I think, is more related to the the various collapse at the ankle joint. OK, so how, Craig, what would you do at this point? Besides ruling out infection one, two, three, you're thinking about maybe number four would be some sort of revision option, perhaps. Let's say we have no infection here. And I want to discuss that in a second. But what's your next thought in terms of a reconstruction? I mean, I think you would have to rule out the infection. And that's going to cause one, two, three. And then you want to get some more data. See how much erosion there is. And so how much losing subsides osteolysis and how much bone destruction before you go further in terms of ruling out infection. What's your go to study? You mentioned several things in your talk. What would you? So I would do an ESR, which is usually would be elevated now. It's been a year. C-reactive protein. I would do an ultrasound guided aspiration. And if it's approved in your state, I would get an alpha defense. OK. Anybody else want to do other things to rule out infection here? No. CAT scan? MAR CAT scan? MAR MRI? Anybody? OK. OK. All right. So the surgeon did some basic workup. The studies were normal, supposedly. And he thought it was more of a failure of the medial tissues, the posterior tip tendon. So he did a reconstruction of his medial side of his malleolus with an allograft posterior calcaneus and achilles. And he put that in on the medial malleolus, attached it in, and then used the piece of the achilles to rebuild some medial structures to pull him out of the valgus of the hind foot. Get your mic on. We can't hear the hate. There's no hate, Lou. I'm all about being nice now. I know. I know. So did he obtain biopsy specimens at the time of this? Biopsies were supposedly normal. Yeah. So the patient was possibly given preoperative antibiotics. So that was... But that wouldn't influence pathology, right? Should not influence pathology, right. But it should influence your cultures. Anyway, so he had this done. And then post-op, the wound started to break down. Had IV antibiotics and some cultures. They called in the augmentation guy. He had a flap medially. And things looked like they were doing okay. They did not take out the hardware, right. I knew it, Steve. Yeah. Right. We probably would have taken out the hardware. We would have taken out the allograft, right. So the allograft piece was left in. The hardware was left in. And this is where he is now. Not now, but currently in this presentation. So the foot had been balanced with the calcaneal osteotomy and a lapidus procedure. And the flap is now over the medial malleolus. Anybody want to say something good about the case? Okay. His toes are perfectly aligned, by the way. No clawed toes. Okay. So now we have three months later. And he seems to be getting more swollen. Okay. Now, would you have insisted that they take out the hardware, the allograft, at the time of your flap? I think that's always a difficult question. I think you have to have a plan. If the cultures are positive, then, yeah, I think the allograft and hardware ideally can come out. Fortunately, I've learned to take these implants out myself. So even after the beer and the phone calls and all those pictures they send you, it's like, I'm doing this the way I think we need to do it. It's a call at 10 o'clock. Are you telling me you don't have a fellow who can come take this out? I said, you got fellows? I mean, let them take it out. I did like the way Ryan, when you presented the case, he said, and this is one of my cases. That was like music to everybody's ears in here. Okay, so at this point now, so we have the flap three months out, matured over the medial malleolus. We have a foot that is a balanced foot now because of the calc osteotomy and the lapidus and the allograft deltoid with the medial malleolus made out of calcaneus of a dead person. So there were not a lot of great things that were going with this case. So then he had a stage two implant exchange, removed hardware, six weeks antibiotics, and X-Fix. So basically, this was an attempt to salvage the situation and that ultimately crashed and burned big time. I don't have all those pictures, but then that's when he knocked on my door. So here's where I am now. So I took out everything. So this was after two total ankles and the flap procedure and all that stuff. So I put in some antibiotic beads medially. These are pure calcium sulfate antibiotic beads. I put in a cement spacer. I debrided everything, of course, before I did that. I got good cultures. And this is where I am. And then I'm going to put on a frame. So how many people would use a frame in this situation? How many people would use a frame in this situation versus letting it go? Frames? No frame? Raise your hand. No frame? Okay, in the audience, frame people? No frame? Pass it to someone you hate? Okay. So I put him in a frame. Then I came back. And then I did an exchange of the block with a femoral allograft, as you can see there, with more beads after six weeks of antibiotics. And then I've got this, which looks pretty good. But you can see there are spots that didn't heal up. So we got rid of infection. That was good. Now what to do with this situation. I've got my allograft femoral head, no infection. I've got some healing, but I also have zones of incomplete healing. Steve, do you want to start with what you would do at this point? I'm trying to understand where you are with this, Lou. First, I think we should take a step back. I mean, we're all this, quote, erudite panel and sit up here and make judgments on other people's stuff. This is the kind of case that gets people angry for a reason, right? I mean, the judgment stuff earlier, you can make the first mistakes, right? And that's okay. And we all do that. Nobody here would say they're above any of the law there. When you get to a point where you retain an implant over a free flap, when the implant highly looks like some infectious process, then everyone starts getting angry, right? Because now you've made an error in judgment that really shouldn't have been done. Now you're spiraling into this disaster case, which you've left me with trying to solve, thank you. And go, so you're telling me you put this allograft femoral head in here? Yeah, I took over and removed... It's not healing. I removed the second replacement. I removed the allograft. I removed the old hardware. Right. Put in cement, spacer, antibiotic beads, six weeks antibiotics. Sure. Things settled down. Everything's clean. Got some biopsy, and then put in a femoral head allograft with the frame. Right. So your problems, so you define the problems, right? And I don't see plane radiographs working just by CT, right? So you have very little to no medium allelis, so you probably have no medium support structures here in this case, correct? Right. So that's my game of revision to ankle replacement now would be psychotic. It's possible, but it's psychotic. And I try to stay away from that now that I'm under a lot of therapy. You're not going to draw me down that path. So in the end, I'm going to have to find a way to diffuse this or stabilize it or amputate it. And I think it just depends on the patient who's had seven operations now, which five of them have been major, to try to figure out what they would like to do at this point. He wants his motion back. Oh, yeah. That's all. Is that a lot to ask for? I like that. Okay. Mark Easley, are you going to bite this revision case or what? Absolutely not. But I do want to ask a question. So, Ryan, you've already been, you know, hypothetically been here with this medial soft tissue reconstruction. One thing that would get this to heal is a vascularized bone graft, you know, maybe the medial femoral condyle, maybe coming completely a different angle, maybe coming from posterior. Is it still possible or is most likely that bridge burned? Yeah, it's absolutely possible. I think I was just thinking the other one would be a pre-fibula from up through the heel. Ryan, would you consider that another step up? So the pre-fibula option, Steve is challenging that given the history of staph epi. Yeah. Ryan, speak into the mic, sorry. Yeah, I think you can. I mean, if it's vascular and the bone stays alive, it's got some chance more so than that. So, chronic suppression if you did the free fibula. are all negative, multiple cultures on it. So the experiment that I did. He's been without infection now for a couple of years. He's just having pain, or maybe some pain, from the non-union, or incomplete union. So how long since the last surgery you've done on him to get this non-union? It's about two years now. Two years. Yeah. And hadn't had any further erosion, just as a non-union? No, no. So what are you thinking? Well, those are the ones that at least you can have a consideration of it. The difficulty is, as Steve said, the malali, though I would suspect, based on what you've done already, that the soft tissues on the medial side are reasonably stable. They've had a flap, but they are stable. Yeah. And so I think this is one that, if you come back to your fundamentals, I think you could make, I would refer to Bill's talk, and you really can make a conversation that's saying, OK, we'll go for motion, but this is going to be the last gasp. And then I think patient-specific instrumentation really does help with this. I think you can do a big tibial component that's fairly high up in the tibia. and mainly because the soft tissue envelope is intact. Again, not knowing what it looks like anteriorly. Skin, tissues look good. Yeah, Bill? So I don't disagree, but I mean, you don't have. You're going to have to cut up into the tibia a fairly significant amount, which is not unreasonable. nubbin of medial malleolus. I think the talus is actually not that challenging. The other thing that it provides you with is that it will leave you with one more option, which would be, the question is, I think you need to determine bone viability at the distal end, not just your graft, but the distal end of it. not the allograft. The other option would be, if you want to cut your losses... Okay good so I did I considered all those things but basically what I did was percutaneous addition of some bone and some percutaneous addition of some screws and got him to heal up and right now he is about five years out from that he's doing okay but he wants his motion back so I figured I'd bring him to you guys and discuss whether it's he's healed enough but he still has some questionable subtalar incomplete union so I might now revise him but I would just argue that you can't rely on a medial free flap as a medial support structure so you're gonna play that game you're going to have to make a new yeah you're gonna have to make I've done this made a new medium wheels with allograft and done a deltoid using the medium wheels as a vehicle for stabilizing the deltoid allograft is fine as an allograft but you can't rely on it as a support structure and it's dangerous with all the other stuff he's been out long enough you need a new plastic surgeon I mean you see took that from the thigh that is better than any deltoid you get get from allograft I mean that's live tissue just we have one more minute I just want to throw this out there just for perhaps the some quick feelings from the audience about what to use for decreasing infection intraoperatively so there are all these washes iricept is one we've got surgery for we have other washes using beads post operatively using vacs big vacs small vacs different beads let me just have a show of hands how many people would use some form of intraoperative wash in their primary total ankles okay how many people use the iricept just how many people use surgery for betadine okay how many people use back to shore okay any other chlor any other washes people use no how about antibiotic powder you anyone use vancomycin vancomycin that's a tracing wash in the DC area don't you use we're too busy drinking it yeah yeah I was just trying to figure out whether that was a wash the last you mixer my last periorectal UV light that I removed you know it seemed to be good enough that I don't need to do any more Lysol drinks yeah okay so and how about beads people using the beads intraoperative okay stew of course vacs post-op the incisional vacs post-op interesting so I'd be I'm kind of curious about this stuff and obviously for a bad wound regular vacs some okay all right I just did my survey I'm looking forward to discussing this further in the Ken Johnson symposium tomorrow so this was kind of a prelude to that thank you all for that lively discussion and I enjoyed it yes I did that I didn't have to do it I got your usurped you want my next case no we do but not now all right good well thank you everybody round of applause for the team

total ankle replacement

revision surgery

failed total ankle

complications

deformity

infection

post-traumatic ankle deformity

ongoing pain

antibiotic beads

cement spacer

wound healing

preoperative planning

surgical techniques

implant designs

native bone stock