We would now like to introduce Dr. Calder as the Kenneth Johnson guest speaker from our guest nation of Britain. The Kenneth Johnson International guest speaker recognizes individuals making important ongoing contributions to the field of foot and ankle surgery from outside of the United States and Canada, and it reflects Dr. Johnson's interest in education, collaborative outreach, and the option exchange of ideas. So James certainly checks all those boxes and is a remarkable surgeon. We all know him to be, and a terrific clinician scientist and educator. But beyond that, he's also a brilliant thinker and really a generally all-around nice guy. So it is our great and distinct pleasure and honor to have him here as our Kenneth Johnson lecturer, and he's very deserving, and we're all really looking forward to his talk. So James, come on up. We want to give you this plaque first, if you don't mind. Well, what I say, thank you very much indeed. And it's a great honor when Chris asked me to come and speak. It was obviously a great honor, but also very humbling. I'm not sure I entirely deserve it, but there we go. But Ken Johnson certainly had a big impact, not just within your society as a former president in, what, 1890? But he was also a big promoter. I think the matching scheme for the fellowship came in during that time, and I was the editor-in-chief of the FAI. I sadly never got to meet him. But I came to the AOFS 23 years ago was the first time I came here. And I was with Mark Glazebrook and a few of the other reprobates, the first traveling fellow. And thank you letting me come home, eventually, again, after how many years, two or three years, missing out on these things. Chris asked me to talk about athletes and Achilles. Part of the Ken Johnson thing is I looked at who has done this before. And when I say I'm humbled, because there's some really good people out there. But upsettingly, Chris, and he's not here anymore, I was also worried, because all those guys are very senior guys. And I've never realized that I've, until today, that I'm actually, officially, now an old fart. I don't know how that translates into, but thank you, Chris, for bringing that to me. So what he wants to talk about was there's been great debate about the Achilles reconstruction, whether we should, in acute ruptures, we should repair them, or whether they should be treated conservatively. And it's whether there's any science, or it's just opinion, and whether we should just get the Hogwarts hat out and look at it. My conflicts, as are disclosed on the Academy website. So my view is it's time to decide. Stop faffing around, and let's just get on with deciding whether we should treat athletes operatively or non-operatively. I'll say from the outset, I come from a very biased opinion. But I do have recognition of my bias in this. The debate has raged on for ages, but I cannot see why there's an argument in elite athletes as to whether we should treat them conservatively or operatively. I don't think it's necessary to use the Hogwarts hat. There is an awful lot of pseudoscience out there, particularly in the last two years, there's been an awful lot of pseudoscience out there suggesting, and there's a lot of bias in the papers that are out there about Achilles tendon. So what I want to do is put a little bit of science in there that is not as complicated as that blackboard would suggest. Nick Van Dyke and I did a presentation to the Academy nine years ago now, looking at the meta-analyses regarding operative versus non-operative reconstructions. And when you look at these, they were all saying that actually there's no evidence that operative repair is any better than non-operative repair, than non-operative treatment. And there's a bigger complication rate with wounds and things like this. But at the same time, when we looked at this, there was quite a lot of bias in there. There were studies included that had not been included in others. And the Sorensen one in 2012 was a big paper suggesting that we shouldn't be repairing Achilles tendons. And yet they left out other papers that perhaps should have been included. Now, that paper had significant legal implications across Europe because we then needed to justify an operation if we were going to perform an operation. So for those residents who are thinking about doing papers, just think about the implications of any recommendations you do because that made this quite difficult back in 2012. When you look at that paper, there's quite a lot of selection bias. There's no power analysis. Chris Pierce wrote a letter to the editor talking about this and saying that the stats actually did not, were inconclusive and they didn't add up. And I'm not sure that that paper would have been critiqued in the editorial department now and been published in the same way that it did. However, there are still papers out there. This is the most recent paper from the New England Journal of Medicine. And the conclusions here in patients with Achilles tendon surgery that was not associated with better outcomes than non-operative treatment at 12 months. That was the conclusion in the abstract. I'll come back to this in a minute because that suggests there's no purpose and there's no reason to do operative repair. But is that really the conclusion? So what are we trying to achieve with these athletes? Well, we return to a predictable and timely fashion, maintain the power, protect the longevity of the career, and avoid complications. But these professional athletes are extraordinary. We're not talking about Joe Bloggs. We're not talking about the diabetics, the smokers, and the rest of it, the obese patients who we get into our normal practice. We're talking about athletes. Now, these, since I'm over here, these athletes are extraordinary. Now, this is probably the top level of where you want your Achilles to have the most power. You cannot imagine an Achilles rupture with one centimetre, two centimetre lengthening. These guys actually getting back to do anything useful in their athletic career. The jumps that these guys are expected to perform are absolutely outrageous. So I understand that it's not all about the Achilles. That is, there is also an arm swing and everything else in the centre mass velocity. I understand that. But a lot of power comes from the Achilles, the gastrocilius complex. If you look at LeBron James, you know, 42-inch vertical jump. Michael Jordan had a 48-inch vertical jump. Absolutely outrageous. I don't think he's here yet, but that's almost as high as Jim Brodsky is, and probably a bit higher, a bit taller than him. Sorry, Jim, I know I got to hell for that one, but you're not here, so never mind. But, you know, these guys are absolutely outrageous. And yet, if you get an Achilles rupture and you look at the science, what happens? It's a disaster. So if you look at the post-operative games played, it's a disaster compared to any other injury. If you look at the player efficiency rating, it's a disaster. If you look at the return to play rates in players treated by surgically, it's a disaster. The Achilles is not a good injury in these players. And the survivorship post-injury, 39% never returned from the paper in 2013. And the survivorship down here from 2016 shows it's the one that just piles in early. They lose, they retire early. And in this paper more recently from two years ago, 28%, so nearly a third of patients are never playing basketball again. Is it just NBA? Well, if you take the other four major leagues, 62 athletes, 30.6 did no return to play. In a systematic review last year of 15 studies, 25% no return to play in NBA, NFL, and soccer were all the worst affected. So what happens with soccer? Obviously, being European, there's a lot of soccer that goes on and there's a lot more soccer going on over here now. Well, if you look at soccer from this paper in 2018, 22% didn't return. A paper two years ago, another 118 soccer players, 18% didn't return. So this is not a great injury. And the latest review that I can find from early this year in the British Journal of Sports Medicine, they concluded there were no studies to evaluate the non-operative management of an elite athlete population in terms of athletic performance. So although there's all that stuff out there about non-operative versus operative, no one has studied the results of non-operative treatment in elite athletes, which probably means that nobody's doing this, I would hope. So I think that perhaps with my operation, I am pretty much justified in the world opinion. But overall, worst performance was the NBA when you look at any of these other match controls. And so what's going on with these explosive sports? We need to understand what's actually happening from a scientific point of view. Well, a lot of it is the calf atrophy that we were talking about earlier on. So when Chris was talking about the calf atrophy, the shoulder surgeons have looked at it with a rotated cuff. And if there's fatty infiltration, they can have a poor outcome. The same is true with the calf atrophy following Achilles tendon rupture. And there's also the lengthening. So this paper from a few years ago looked at atrophies that is extremely common. They looked at 32 surgical and non-surgical reconstructions. The muscle atrophy, there's a difference with surgery. So 18% versus 25% if treated non-operatively. If you look at the plantar flexion strength and the AT lengthening, you get 18% greater plantar strength if you treat it operatively. But AT lengthening, Achilles tendon lengthening was 19 millimetres, which is two centimetres lengthening if you treat them non-operatively. I think that may help to explain, for those of you who treat ballet dancers, it may help to explain why... Well, first of all, they take about twice as long as any other athlete to get back to doing anything, even if they sprain their ankle. But if they have an Achilles rupture, they take ages to get that final rise towards the demi point in the ballet dancers or the on point for the ballerinas. And it's really difficult. You spend ages, they'll spend ages on the reformer trying to get that final inch heel rise. And I think that's probably because of this. You also get the tendon elongation. So two years ago, this study came out and showed that after tendon elongation, and they put these tantalum beads in, that however you mobilize them or mobilize them quickly, it didn't matter. There was no difference between the groups, whether you treated them early mobilization or otherwise. They still got a significant elongation. Another study last year looked at tendon lengthening, once again with tantalum beads, two different groups, non-weight bearing and full weight bearing with early movement. There was a mean of 16 millimeters lengthening treated conservatively and it didn't matter how you mobilize them afterwards. So I think it suggests we need to be very careful about how we rehabilitate these patients afterwards. I'll come on to that in just a minute with the rehab. So infection after re-rupture is always a concern. But in fact, 2.8% infection, re-rupture rate was 1% with surgical treatment. That's 423 patients, that's not bad. And in the 48 studies in this systematic review last year, the re-rupture rate was shown to be lower with surgery and the wound complications were lower if you had MIS. So therefore, it suggests if you're going to do this, you need to repair them because you definitely have a higher re-rupture rate. But the infection rate and the wound problems is not as high. I'll bring you back to that New England Journal of Medicine paper that was published earlier this year. The headline was that there's no difference. That was in the abstract. That was the conclusion in the abstract. But if you read the paper fully, the re-rupture rate was 10 times in the non-operative group. Now, that should have been in the abstract. And I don't understand why it wasn't. But the editorial comment at the beginning of the New England Journal of Medicine, this edition said, this editor said, surgery may also be preferred in high-level athletes because of the 10 times re-rupture rate. So when you're looking at these papers, the conclusion in the abstract for the residents out there, don't just read that box there. Read the full paper because I think that paper has been very misleading. So overall, surgical repair is considered advantageous in athletes. I hope you'll agree with my, it's not an outrageous comment given what we've seen has come before. So how can we improve and repair and minimize the risk to the patients? Well, many incision techniques do appear to have a very valid way forwards for the majority of these patients. And you can, if you've got a more proximal tear, you can still use what the aculon or the PARs or whatever to try and avoid damaging going through the area where there could be potentially poor blood supply. Although realistically, in these patients, they are very fit. They're not smokers. They're not diabetics. These are fit athletes. And you can get a reasonable repair by using this to augment an open repair more proximally. We also know that minimally invasive techniques are as strong as open. There's very good data, biomechanical data looking at this. So we know that it doesn't cheese wire out in all cases. Although I do ski, if you like, on the water ski on these, if I use an MIS technique to make sure it's not cheese wiring out. And if it is starting to pull through, certainly in the more proximal ones, then I will use an open technique. So in conclusions, MIS is preferable to open repair, probably. The meta-analyses on this, there are two meta-analyses, nine level two studies and several other level three and four studies. So I think you can say that as a grade B recommendation. I'm confident that that is a reasonable thing to say. But how else can you optimise a repair to make it super good for your expensive NBA player or your marginally expensive Premier League soccer player? Well, Mike Carmont, who did his PhD with Jon Carson in Gothenburg, wrote a very good paper looking at heel rise height in 122 patients. And basically, they stretch up, we know they stretch up. We've talked about that a few minutes ago. So you need to make it as tight as possible to reduce the elongation because you will inevitably get some form of elongation. And he's shown that very well in this study that was published two years ago in OJSM. The other thing that may be helpful, and I'm not sure how widely available it is in the US, but it's UTC scanning, ultrasound tissue characterisation. And this has revolutionised my rehabilitation programme for elite athletes in the UK. And this ultrasound is a very high definition ultrasound and it actually looks at the tissues and it looks at how they're behaving. So you can see how they're reacting to the loads being put across them, not just if you're getting any gapping at the repair site, but also how they're reacting. And you want some, as we'll talk about in a minute, you want some force going through the tendon to encourage it to heal. But actually, if you put too much through it, then it begins to react and you start to get some more degradation. So you can follow these patients through. If you do a scan every three or four weeks, you can see how it's progressing, whether you're getting inflammation, whether you're getting some deterioration in the repair site. It's great for the physio, but it's also great for the player, because they can see what's actually happening to their tendon. It gives a big reinforcement and a psychological benefit. So that has helped my practice. And there are three other areas where I think we can improve the standard repair we do. One is we know we should be using mechanical stimulation. We should mobilize them early and get some bit of tension going through it. There's some very good studies using Botox, showing that the force to failure of a repair is reduced by about a third at the two-week stage, unless you stimulate it, and that encourages the repair to heal. So we should be using calf CompEx, and I use calf CompEx under the bandages straight after the operation. They'll start twitching, getting a little bit of twitching going on. Possibly also reduces DVT, but that's my level six of theory about it. But also there is some compression as well that you get some compression across there, and intermittent compression seems to help with the healing. We don't quite understand it, but it does seem to be a neurovascular ingrowth, according to the clever scientists. We also know that, from Karen, Silver Knuckle has done some good work looking at early mobilization. And there is a significant correlation between early mobilization and its positive effect on to reduce tendon elongation and the tendon callus that forms afterwards. So early mobilization is extremely beneficial. But perhaps only after surgical repair, because this study, which was published earlier this year, shows that, in fact, non-operative treatment, with non-operative management, you actually get a poor tendon quality. So you don't get a good repair site. You get, it's more prone to elongation, and therefore it can lead to, how do you rehab them? How do you know how fast you can push them? So I think this is important, because it suggests that surgical repair is more predictable. You know you can start to push them on a little bit more and get the movement going, because you've got the ends together. You haven't got that criteria in non-operative management. The next thing is non-steroidals. It's an odd thing to give non-steroidals post-tendon repair. You'd think, well, you know, you get less collagen synthesis and everything else. But in fact, if you look at the science going back many years, there is an effect of Cox inhibitors on the strength of the tendon repairs. But if you start it later after the acute inflammatory phase is over, it has a beneficial effect for tendon healing. And the paper from 2018 showed that there's chronic inflammation in all Achilles tendon ruptures. So it's been around for a while. So I suggest that we start to look at using a non-steroidal at sort of the two-week stage post-operatively for about a month or six weeks to help the tendon remodeling, because there is some basic science out there that suggests it can help. PRP. To be honest, I don't know. To be brutally honest, I always use it in the elite athletes, but I find it difficult to justify scientifically. There is some science out there to support its use. And for these elite athletes, if it's a percentage gain thing and it's costing $200, well, you know, and it does no harm. I haven't got a problem with it. Personally, I do think it probably does have some effect. It probably has a short-lived proliferative effect, which then may aid that early rehabilitation set, may strengthen that early repair to allow you to go for early mobilization. But I can't prove that, and I apologize. It's a level six, level seven. The only thing you can say is that this Sagoti paper back in 2013 showed that there was no effect of PRP on tendinopathy, but on the data collected and looking at the meta-analysis systematic review, there was a large effect on a beneficial effect for rupture. But it's still, I think the jury's still out and we can't prove that just yet. But, hand up, yeah, I use it. The rehabilitation, respect the wound, make sure there are no wound problems. That's a disaster. This is a professional rugby player who came to me picking at his wound, and it wasn't his fault that he picked the wound. It was a bad moment. And you can see that's got misery written all over it. He did eventually heal up. It's a bit like Chris when you sort of, you keep your fingers crossed, and you watch him like a hawk, and it might come good in the end. But the rehabilitation is really important. And there's a good paper out there in the JPGS from a few years ago looking at stretching versus strength. And basically, if you get a stretching of the tendon, you lose strength. You know, it's no surprise there. But, and they certainly get, certainly everyone seems to get, even with surgical repairs, some element of stretching. So we need to be careful about that. So my key aspects are no stretching. You get early mobilization, don't stretch it. You get strength, go for strength. Every single time, go for strength. Go for isometric holds and get the strength going. Seated heel raises, getting the soleus going. So strength, strength, strength. I can't emphasize that enough to the physios. And vary the stimulus. It's not just about keeping the patient's head going in the right place, but also calf raises and the dynamic testing to ascertain whether you're beginning to get a bit of a defect. And what do we tell the athlete? Well, I go back to this paper, which Mike Carmont also co-authored in BGSM. And basically, I tell them to keep the leg up for two weeks and get bored, please. I don't want you coming back with a wound problem. Just keep your foot up in the air. Don't do upper body strength because that'll make you get sweaty wounds and it all goes pants there. And I also reassure them that 80% expected to return to play. I try to de-emphasize the 25, 28, whatever it is. Don't ever play again. But give them something positive. And I say, yes, it's an average of six months in the literature, but I actually tell them it's like six to nine months. You won't expect to go back too early. So you may miss the rest of the season. And finally, listen to the physio because you avoid any pain. If it's painful greater than three hours after your post-op, after your rehab, stop, slow down. And if there's any swelling, slow down. What do I tell the physios? Well, I break it down into four phases because I can count to four. Immobilization, controlled mobilization, late rehab, and then a return to sports paid section. I do use progression markers of progression by using ultrasound. I don't like MRI scan because it looks absolutely dreadful. They get an MRI scan for some of the Premier League players at about two months post-surgery, then four months, and it still doesn't look any better at two years. So please, I just say, please don't do that. But ultrasound can be very useful. It also reinforces the fact they're actually getting better for the player. And UTC, I found extremely helpful. Weight-bearing from two weeks, early weight-bearing, early use of calf compex, and then gradually they'll start to get on a reformer and start to do this, but no stretching. Don't stretch it up. And also occlusion training. So restricted blood flow training. I use that from four weeks post-operatively. And that seems to, the work that's come out of the military guys from this has shown that it's good growth factor release, and it certainly helps to reduce the calf atrophy. Early to late rehabilitation. There's a very good paper from Francini from four years ago, looking at the isokinetic strengthening and jogging outside, and breaking it down into different things. And I found that paper extremely useful to guide the physios of where they should be going in each particular time. And you can use certain markers of strength to get them going during that time. And also get them, there's obviously a soccer player on the left and then a heptathlete in the middle there. Getting the different coordination going before they can get out there and start doing any form of jogging. Isometric testing is important. We use the Biodex frequently. Just every week they get a Biodex reading to show what it's like compared to the other side. And gradually they'll start to get increased GPS and cardiac data. They begin to increase, move through from the moderate intensity through to a high intensity, and start to get to individual jumps in a very controlled manner. But that's like, this is four months, four or five months down the line. So it's a long time down the line. I pulled my rehab back very, very slowly. Very, very markedly now. And I slow them right down. And then there's a gradual transition through to jumps and sports specific drills. And force plate analysis has been extremely useful. I thought some of the clubs came through with all this data and I couldn't understand it. But in fact, the force plate analysis has been extremely useful and a very accurate marker of where they may expect to be in six weeks time as to when they might be back into play. And hopefully, when you get to the five months, six months down the line, this heptathlete got back to do her first jump at six months, a long time. But she got back to do, it's a pretty low jump. Jim Brodsky could probably jump that as well. But this is a low jump. But six months down the line, that's kind of what we'd expect as the earliest stage, realistically now. I no longer go for the four months back to this sort of activity. The coaches, the coaches are never happy because as soon as they see a player somewhere in the building, they'll say, they're ready, they're ready to go back. But when they go back to training, I tell the coaches, it is training. And they hate it. And they really bitch and moan about it because they expect the player to be back. They can sit on a bench. But it is training. And training may take another two to three months. They also need to respect the training load management, which some coaches are very good at. Other coaches are absolutely disastrous because they will put them back into, you know, they need to carefully keep them rehabilitating during the next six months because it'll take two years before they get to as good as they're gonna get. And there is a risk. We have got a significant, and Gino Kerkhoffs and I are looking at this at the moment, on the number of hamstring injuries you get during your return to play following an Achilles tendon rupture. And it's six to nine months. But the return to play is when the player's ready, not for whatever the stats happen to say. So I thought for a joke, we'd put this in, not joke, but I thought it'd be useful for you guys. Obviously, I didn't do this operation, so I can talk freely about it. But Kevin did it, you know, ruptured his, I think it was very well done, very well known. But the rehab that Les put out there for him was amazing. And they took a very, very pragmatic approach. And if you remember, they signed him with the Achilles rupture, having just had it repaired on a five-year deal for a lot of money. But what they looked at, their timeline was, they were looking at eight months. It reads well there, but eight to nine months is what they were looking at. And they were looking at very, very heavy loads. So you can see they're talking about three times body weight, heavy, very heavy loading going up there, but in a very, very controlled manner. And overall, they expect him to return to play at one year, not before. So they said, you can sign him for five years, but the first year, he's in the gym. A very pragmatic approach, and look what happened to him. He has got, P.E.R. is off the scale. He has had the most amazing stats last season compared to any other player in the NBA. So I think if you've got a bit of patience, that's what you should be doing. And my take home messages are really quite simple. Chris asked me to crystallize the thoughts as to whether surgery is indicated for Achilles tendon rupture in athletes. So be arrogant for a minute. I think we've hit the bullseye. I think I can safely say that the evidence suggests you must consider surgery in the elite athlete because non-operative management tends to lead to increased gapping and weakness. So I think you can prove that. I'm a bit ruthless, and I think as far as I'm concerned, it isn't really a bullseye. And the duel that's been going on, I'm afraid that bloke's been killed. So I'm afraid those cynics out there that say we must treat these conservatively because they can have very good outcomes is rubbish in my view. I think it's wrong, and I think you should consider surgery in the elite athletes. And I think it's in the science. I really don't think there's an argument to be had anymore. I think it's out there. It's in the science, it's in the literature. We don't need a sorting hat. You can have a mad scientist if you want, but I think the science would support that statement. But this does beg some questions. If you look at the repaired athlete that we've been talking about out there, that's the surgery. It's probably a little less than that actually, if I'm honest. And I think the majority comes down to the rehabilitation. And that begs a question, two questions. Are we really in control of this patient once we've done the operation? We're responsible. If it goes badly, we get to know about it. It gets in the papers. If it goes well, the club get this benefit and the physios get the benefit. And we know that the best operation in the world may have the worst possible outcome because of poor post-operative management and poor rehabilitation. So as a surgeon, I think it's crucial that we understand the rehabilitation process. And fundamentally, that comes down to how much emphasis is placed on teaching our surgeons of the future about rehabilitation during our training. I can tell you from my side, I had absolutely no rehabilitation experience or training during my training program in London. And I came to the States and did three-year rehab fellowship because I didn't understand what eccentric loading was. I didn't understand plyometrics. And I couldn't speak the same language as the physios. And I think that's a poor thing and we need to review that in our training programs across the world because we will be asked how we're gonna rehabilitate the ACL post-operatively or the Achilles tendon. And I'm not convinced that when I came off my training program, I was the best person to ask about that. So those of you on the training program directors, I put that question out there. Are we really training our fellows of the future for what they expected to do at post-op? And that's where I go sailing down in Cornwall, Chris. It's probably similar sort of temperature water. It's a bit chilly, but it's about 20 degrees this year. And we do have some decent beaches in the UK down in Cornwall. And I'd just like to thank you very much indeed for inviting me over here. I hope I've put that argument to bed, although I'm very happy taking a bit more abuse off Jim Brodsky. Thank you very much. Thank you for that great talk. One of the most amazing parts about the world of foot and ankle is that it's exactly that, it's a world, and so we're absolutely honored to welcome the British Orthopedic Foot and Ankle Society as our guest nation. They've made an amazing symposium. This will be moderated by Callum Clark, who heads their educational committee. So, hopefully you enjoy it as much as we will. So, I'm going to ask the BOFUS members to come on out. And I will say that one of the most wonderful things I think our society has done in recent years is the integration of and cultivation of a guest nation in our meetings. And I appreciate James' talk and all the talks we've had this week by our UK and BOFUS colleagues. And I don't think anybody would argue that they have truly enhanced the quality of our meeting, and I'd like to give them all a round of applause. And before we begin the symposium, I'm going to ask Paul to stand up on behalf of UK and BOFUS and ask Casey and Daniel to come on over here and just take a quick picture. We're going to, we'd like to give this to the team BOFUS and UK on behalf of a grateful AOFAS. It is not the World Cup. You're going to have to earn that a little bit differently pretty soon, but it's close. So, congratulations. Thank you. Great. Well, thank you so much to Chris and to Daniel and Casey, who've invited us here and have been so welcoming to all of us here. I think we'd all agree. And also for helping us put this program together. So we've got about an hour now, and we've put together what we hope is a series of thought-provoking talks, some things that perhaps we do slightly differently from over here. So first up, I'd like to invite Jit Mangwani, who is the chairman of our scientific committee in Bofast, who's going to talk about our approach to research. Thank you, Calum. Good morning, everyone. Thank you, everyone. And great to see so many friends. I've been coming to AFS for a number of years and make some new this time. So a big thank you to AFS for the invite. Before I start, can I just request you all to keep your smartphone handy, if you have one. There's a QR code I would like to share in the middle of the presentation, and I don't want to take too much time on that. So that'll be great if you can. Thank you very much. So I grew up in the city of Taj Mahal in India and ended in the city of diversity, which is Leicester in the East Midlands. It's about 100 miles from London, for those of you who haven't traveled there. And some years ago now, we won the premiership of football. So some of you who follow football and soccer in this country will know that. And Leicester Tigers is going pretty strong. So please do visit us. So what should we research in Ferdinand Cole? I'm seeing people here who have devoted their lifetime in Ferdinand Cole research. And I'm not here to teach how to suck eggs to those people. I'm just here to share some of our experience on behalf of the Bofast, where we've gone in terms of prioritizing our research. So what will I talk about? I'll talk about the James Lind Alliance. Some of you may have heard of it, maybe not. So we'll talk about that. Bofast JLA PSP, which is the Priority Setting Partnership. Top 10 research priorities that we've come up with in the last year. And some challenges and success factors related to the process, as well as going beyond that. And some of the reflections en route and what we're going to do in terms of next steps. So let's get started with that. So who normally decides on what gets researched in Ferdinand Cole or any other speciality for that matter? Researchers, investigators, or corporate, i.e. pharmaceuticals in medicine and industry, a lot of industry in the orthopedics. So the priorities of people with these conditions and the people who are treating them and caring for them can be very different from those who are pure academics sometimes, and there might be a disconnect. So what does JLA do? JLA brings patients, carers, and clinicians together as one voice, focuses on single conditional areas, identifies some uncertainties, and then prioritizes the one they think are the most important ones for research to address. And top 10 out of those are then looked at for funding, et cetera. So JLA process has been there. It's just not a new thing. It's almost 15 years plus now, and they've done about 100 odd of these priority setting partnerships with different specialities across the board. If you look at TNO in the UK, there are about 12 or 13 priorities that are there, and foot and ankle certainly seems to be up there, and I've just highlighted that. So what does JLA process do? Essentially, you have to form a steering group of multidisciplinary people with different skill set completely, and then you have to go on to engage with the partners that are going to be part of your organization for research in the later time, also with the patients. Then you have to look at what are you going to capture from patients, carers, and clinicians, move on to then synthesize that against the published literature, and then you move on to the final workshop, which then prioritizes the top 10 research priorities. Then you have to engage with the funders, the national bodies in the UK's NIHRs, NIH here. So both us got involved as part of the BOA initiative, and there's a wide variety of conditions that we treat, and there is lack of robust evidence, and hence why there was need to go down this route. And this variation in practice we know leads to different patient outcomes. And do we have the real outcomes that we measure? So this is a flowchart that just describes the process as I've outlined. So you have a scope of the PSP, then you have the primary survey, summary questions, and then the interim survey and workshop. I'm ever so grateful to a really motivated and lovely steering group that I had the joy of project managing for a couple of years, and it's been a privilege to do that. And you can see there's a completely different skill set of people in there. So what was the scope? Scope of the very first PSP was pretty narrow, and we focused on the surgical treatment and also injections and post-surgical rehabilitation and injection. As a result, you will have a huge amount of exclusions, particularly diabetic foot being a big one, which merits a full PSP on its own accord, which is planned in the future. So the first survey was sent out in November 2019. We were at the Bofast meeting, and we then went out to the patients, carers, and health care and social care professionals. And we got about 200 people responding to it, and about a quarter of those, reassuringly, were patients and carers. Out of those responses we got, 70% were in-scope and 30% out-of-scope, which have been parked for further work. And once you've got the primary survey results, you change them into summary questions. And with summary questions, then you look at what uncertainties are there in research. And then you do lumping and splitting of those and match them against the published literature so that you prepare, then, a long list of summary questions. That then gets cross-checked against the evidence again. And finally, you will get the interim survey, which is part two of the survey, and leads to further responses and fine-tuning of the questions that are going to be prepared. So out of that second round, we got 16 questions that were going to be considered for top 10 priorities. Now, these are priorities. These are not questions, research questions. So I'll talk about that in a second. In the final priority setting, there used to be an all-day affair of clinicians, patients, carers getting together and prioritizing research. In the COVID times, as we all know, we all went online. So they had already figured out the way, the GLA team, how to do things online. So that worked really well. In the final workshop, we had 16 questions taken. And after the whole day of work, we came out with a top 10. And this is where I want your smartphone, please. See, lots are going on. This is pretty much what we need to look at. These are top 10 priorities in foot and ankle research in the UK at the moment. If you don't get a chance to get it now, by all means, stop me anywhere, and I'll pass it on to you. So these were top 10 rank priorities. And right at the top is the outcome measures we're using. Are they the best outcome measures? And I think there's a lot of work ahead of us in terms of where we take all of this, but this is a good start. In terms of next steps, dissemination, so publications, presentations, engaging with societies other than our own society. So thank you very much for that. Engagement with the funding bodies, patient groups, and researchers so that we can create that environment for the end user, i.e. patient, who is going to be at the end of receiving change in treatment or a better treatment. And creation of some national clinical study groups. So out of these 10, we're going to focus on three and create national clinical study groups so that the message goes out to everybody that we're going to go down this route. So dissemination part one has already happened this year. We had one publication done. The second one is coming out soon. And in terms of engaging with funders, all of these reports are then sent to the NIHR, to clinical trials unit, and further engagement is done on that front. So when we budgeted this project, it was around 50K that we were going to use. We ended up doing it in one third of the cost purely because of the COVID times we went online, and that was about the only silver lining to the COVID cloud for us in that time. So some reflections, JLA process works. It's a good mix of pathologies and interventions we got in top 10. It now puts us in a stronger position to ask for big projects to be done in the country and beyond. Interestingly, when we were doing this work, there was a lack of readily available patient groups in the foot and ankle. We're not a unique kind of pathology, one pathology that we have lots of patients of. So I think it's important that we do patient and public involvement on this. And also some lack of research teams related to foot and ankle trauma. Having said that, the Trauma Society is working on that and moving that forward. So if you need any more information, give us a shout and thank you very much for having us here. Thank you, Jit. Thanks for sticking to time. So I should say, we're going to try and take questions at the end if we have enough time before the next session. So next up is Lyndon Mason from Liverpool in the UK, and Lyndon has done an enormous amount of work on ankle fractures. He's going to tell us all about it. Lyndon. Thank you very much for allowing me to stand on my soapbox, which I have done in the UK for a number of years. So ankle fracture is fixed from the back, so I do have disclosures. These are my disclosures, which are relevant now to the work that I've done. Also, I will have a disclosure that I do fix from the back. I've been given nine minutes for this. I've done 10 years worth of work, so trying to squeeze into nine minutes is very hard. So if you want to see more about this, I've got a huge amount of work on the Liverpool Foot and Ankle YouTube channel, if you have any interest. Okay, so there's a story behind this. So where do we start? We started in a very poor position. So back in 2013 in Aintree, which is our trauma centre in Liverpool, we experienced a high rate of complications of ankle fractures. Done a usual audit, mainly looking at the malreduction greater than one on a Petroni classification and was classed as malreduced. And this is where we were. So a malrediction. So if you were taking a patient to theatre, there's a one third chance that they left theatre with the ankle not in the right position. Higher rate of complication rate, higher rate of revision. This is what we're seeing. So this was everyone doing these operations. It was seen as the simple operation that was put on the end of a trauma list for anyone to do. As you can see, the malreduced fibula, medial side and the postural mal then proceeded to fail. But we weren't alone. So initially when we presented this in Bofast, we were one of the first to put our hands up and they were like, oh, you're just a bad centre. But then many centres came out and also presented their poor malreduction rates. So this was us. We got better. Initially we tried a period of education. It did not work. And then we had a full systematic change. Seeing the operations the next day, removing some implants, which are obviously difficult to use. And during this time, we became a major trauma centres. The complexity of the work we were seeing was much worse. We joined forces to look at functional outcomes with JET in Leicester. And found not only that the OMAS scores showed that the more you malreduce the ankle, the worse it got. Surprise, surprise. But these B3s, the posterior malleolar ones, got worse even if you reduced them. And this is why I termed the results prior to 2017 the time of the third. A lot of people now talk about it as the 25%, but it was the time 30% was the initial marker that people used. And it came back from this publication back in 1940s. And this is orthopedic dogma. And if anything, this presentation is me going against dogma and reflecting on our own practice. So two systematic reviews prior to 2017, both reported poor outcomes in posterior malleolar fractures. Also the importance of the article step in overall result. Percentage was never a thing. It was never part of what was the problem. So how could we improve these? So first of all, we need to know the injury. And the usual, as you would do for a fracture. Did we know the injury? We didn't. There was a classification by Haraguchi. There's a number of faults, I would say, on that. But this is what we found. There were different injuries. You had avulsion injuries. You had rotational pylons. And you had axial loaded pylons. We've done a publication back in 2017. This is our classification from this. And as I said, the rotational pylons was a new thing. And I've also sent many papers off being bounced back, saying there's no such thing as a rotational pylon. Of course it is. Your talus rotates in the mortise. The posterior malleolar hangs over the back of it. It impacts it. And it rotates off. Bartonisec, which is usually referenced all around Europe, had the same idea. And you had the rotational pylons, which is these middle two. So these rotational pylons, what it is, is a rotational impaction injury. You can see the 2A on the top there. It has an impaction fragment, a die punch fragment. This is very common with these injuries because the talus is hitting this back of the tibia. And you can see the rotational force that's applied. The posterior medial site tucks in underneath the posterior lateral. And that's important for an algorithm. So morphology is now seen to be the key. There's many papers on this. This paper, which was published two years ago, showed rotational pylons major did worse. The type 2Bs did worse. I recently done a systematic review with Prof. Dhillon's group from India, showing that rotational pylons did worse across the board of those who are being fixed. The results are better with direct fixation. Do you go through the back? There's a few papers on this. So there's level one, two, and four studies. The only level one study really in posterior malleolar treatment showed significant improvement in anatomical reduction and functional outcomes with a direct approach. And this is the problem. So this is one of the problems. This is being transferred into my unit. You can see they've gone front to back, a good length of the fibula. They've got an impaction fragment in the middle. They've hit it and pushed it off. So trying to get reduction is difficult. There's also the soft tissue entrapment. We've currently got a study of over 700 posterior malleolar fractures and pylon fractures looking at the tip post within the fracture site. And it's very, very common. So if you can't clear out this and you're doing it front to back, you will get entrapment. This is the case. It's transferred from Spain, came back from Spain on holiday. It was fixed as you can see the bottom left hand corner there. It was past the safe zone and it was overhanging, but he has not cleared out the tip post as you can see as it progresses. And we've got quite a few cases of these now where encapsulated tip post tendons. What about syndesmosis? Okay, there's five papers indicating a reduced need for syndesmotic stabilization to fix the posterior malle. And the stability of the PM fixation was much greater. However, there's a few caveats on that. So some PM fractures don't have syndesmotic instability. Back in our paper in 2017, you can see a type one fractures, the PRTFL revulsions, all of them have syndesmotic injury. Some of them only posteriorly, however. We type twos and threes have less so. And the reason for this, so it was questioned by a reviewer. Well, this is where the PRTFL inserts. Why on earth is it not unstable? So we took this to the anatomy labs. You can see on the far right there, the superficial PRTFL is massive. So you may have a fracture, but it may not damage your superficial PRTFL. So syndesmosis can still be intact. This is the average surface area for type two B fracture. The average surface area of PRTFL is much bigger. Some PM have persistent instability after PM fixation. Since the case was taken in theatre, it happened in my unit, and so you can see a high fibular fracture, obvious enzymatic instability. They've gone in the back, they fixed it, intra-op and post-op, you can still see widening. Post-op CT, they've well reduced the PITFL insertion, we can still see persistent widening. This is obvious, there's more than one ligament, so you're only treating your PITFL. This was shown recently on a biomechanical paper that you need syndromic stabilization in these high fibulars. What about incision? We've done multiple bits of work on this, so the post-lateral approach is a systematic review. Good results, but increased rate of hardware removal. This was a clockwork paper which we've done looking at, well, where's your best place to put your screw? And you can see your type 2Bs and type 3 fractures going in the post-lateral approach, you're not getting your right orientation. I took this back to the cadaver lab, and you can see that the size of your poster medial is much bigger. Outcomes wise, so this developed a treatment algorithm, type 1 didn't require any fixation from the back, but the type 2A, 2B, and 3 did through different incisions. So this is an example of your type 2B fracture. We want to fix the poster medial side first to prevent this spitting out, and you can see this is what we have, and that little screw that you can see on the medial side there is what is fixing the poster medial fragment initially, and then it's been fixed with a plate at the back. We looked at our functional outcomes from this, published in the JBS America open, and we did improve. So our study on this algorithm did improve across the board. We weren't alone, there's many papers on this now, papers coming out all the time showing increased improvement. And going back to the systematic review we've done recently, you can see that the AFS scores have improved significantly to what was published prior to 2017. What do we do to the dye punch fragments? This is the next bit. Looking back at our JBS article, I saw that those who had dye punch were much worse. You can see this with a dye punch fragment here. You can't get through these through the poster lateral approach, so doing a medial poster medial can fold this open, and you can get to these dye punches very easily. Similarly, if you've got a fracture such as this, you can see you've got dye punch at the back, but also the fibula off the front, so doing a poster lateral approach on this, you'll not be able to get that anterior aspect. And for this, you can get that dye punch down, but also fix it from the side. Lastly, so if you can go through the fibula also to get your dye punch fragments. So this one, you can see that's had a impaction fragment, and this has been brought down through osteotomy. And that's where I end. Thank you very much. Thank you, Lyndon. So next up, we are inviting Paul Halliwell. You've already heard he's our current Bofast president, and he's also done a great deal of work about ankle arthroplasty and how to do it safely as a population. So Paul. So I'd just like to say once again, thank you so much to AOFAST, to Chris, and the whole team for inviting us. It's been an absolute pleasure to be this side of the Atlantic and join you. Renewing old friendships, making new ones for sure. The content of the talks has been unbelievably educational, enlightening, and we hope we've contributed in a small way ourselves. I also publicly want to thank Callum. We've all prepared our talks, but it's Callum and Joe Millard, who will be in the audience somewhere, who organizes everything Bofast. As I said at the dinner the other night, without Joe, Bofast would rapidly, in weeks, days, hours, or seconds, fall to a complete halt. So thanks to both of them for organizing everything. Now Callum threw me this curve ball. It really is a curve ball, with a bit of a mischievous glint in his eye, which he often has. Can anyone do total anchor replacement? So I called him and I said, is that really exactly the title you want me to talk about? And he said, well, maybe it should be something slightly different. Just a couple of disclosures. My only disclosure, I teach for DJO, anchor replacement. And I said to him, is it really... Can anyone do anchor replacement? And he said, well, maybe should anyone do anchor replacement? Well, that's an interesting one, but even then, it's still, well, in whose opinion? So it's an interesting idea, and let's see if we can open it up a bit and pick it apart. So I thought maybe separate into two parts. There's the surgical ability side of things, aptitude maybe, the individual, difficult. But also there's the other aspects of it, is providing a service to all the patients who have anchor arthritis. In other words, providing a service to the whole population, the surgical community, if you like. So let's start off with the first bit, the ability bit. Well, that's it for me. If you can do a complicated ankle fracture and do a good total knee replacement, you can, with very little training, do a total anchor replacement. So that's it. Thank you. Any questions? Okay. Okay. Let's explore it a bit further. I say that when I'm teaching, say, in mainland Europe, and I've said that for a long time, and I occasionally see some blank faces in the audience of the tutorials. And I gradually realized that because the training pattern can be so different in different countries, whereas we're very used to coming through the orthopedic training, learning to do these operations, particularly the knee replacement, that doesn't happen everywhere. But anyway, what does it really take to do a total ankle replacement? Well, there are the technical skills, as I say. If you can do a complicated ankle fracture, you can do a total knee replacement. You're bringing together all the ideas and the technical skills. But there's the diagnostics, hugely important. This is anything but a technical exercise. Patient assessment, crucial, and selection with respect to the indications for the operation. And then there's the patient preparation, assessing the patient for suitability for the operation, medical optimization, counseling, again, counseling the patient with respect to the indications and the outcomes that we know about. And then there's the management of the post-op care, of course. Crucial to an operation like this, a high-stakes operation where things can go wrong, and when they go wrong, they can be very significant. One needs to anticipate those complications by knowing that they exist and knowing what you will do if they occur, even before they occur. Hopefully, they don't, but they always do from time to time. Recognition of them early, of course, because recognizing your complication early and addressing it is much more likely to ultimately result in an outcome that's fine than otherwise. And treatment of those complications. And I'd argue that the best person to treat the complications is the person who did the operation at the beginning. It usually is. Now, just on how do you get to that point? How do you get to this situation where you are somebody who's able to do those things? Well, you start with your medical training at the beginning, and then understanding the biology of the human being, the pathologies of the human being in every way, and then your surgical training, learning the surgical skills, the surgical pathologies, the surgical complications, and moving on to apply that to the musculoskeletal system, becoming an orthopedic surgeon, and then specializing in the foot and ankle. So you've got your MD, your FRCS being examined in each one as you go forward, and then you can only exit once you've got your FRCS, trauma, and orth in the UK. That's a long time, and quite apart from the hurdle that you have to pass at the beginning to make sure you're the sort of person that can go into medical school using whatever parameters are being used to assess that. That's 15 years. That's a long time, but that's what you accumulate in that time, and you can bring to something like total ankle replacement. So concluding that first bit, I would say a person doing a total ankle replacement should be well-trained in the generality of medicine, surgery, and orthopedics for all those reasons, and also be the person who makes the decision to offer it by knowing the indications and being able to assess the patient to match that person sat in front of you with their symptoms and everything that comes with them to everything you know about whether this operation is the right one for them, matching the two. We have the medical knowledge, you have the person in front of you, and I'd argue that being a doctor in the general sense is all about matching those two, bringing that scientific knowledge to the real world and the pathology and the person that comes to you, and managing the complications. And then also be well-practiced by doing it on a regular basis, bringing us this concept of volumes. And that brings us on to the second part, which is about providing service to the population as a whole. Now, in the UK, we have this body called GIRFT, Get It Right First Time, is what that stands for, headed by this gentleman, Professor Tim Briggs, who is actually a hip surgeon and a tumor surgeon working in the Royal National Orthopaedic, Stanmore, where our colleague Nick Cullen, who you heard from earlier in the week, works, and Andrew Goldberg, also at POST. And this is their remit, a national program designed to improve medical care within the NHS by reducing unwarranted variations. And it started off just with orthopaedics, with hips, but it expanded a lot. So if I can open up that side, you can see that now GIRFT is trying to rationalize and even out the outcomes in stroke, pathways for children with abdominal pain. The general practitioners now have heard of GIRFT. It's really expanded. But obviously, I'm just focusing on where it started and where it is at the moment with respect to ankles. And this is really what Tim, Professor Briggs, is saying. He's asking us for a minimum number of total ankle replacements, which is appropriate for a surgeon or a unit to do each year. And really, he's pushing us, and it also applies to total ankle replacement, revision knees. And he's really pushing us to say, what's the number? What's the number? Give me a number. And if you can't come up with a sensible number, I'll tell you what the number is. And I'll say, anybody doing less than that, you're not going to do any at all. And I know that pretty much is the vibe about it. So where are we? So just to give you a quick idea, this is data from the National Joint Risk Registry in the UK. And the last year that really makes any sense is 2019, pre-COVID. So just a few figures there, 993 total ankles by 155 surgeons in 2019. The median was 5 per surgeon, which had improved from 3.5, the median, of course, 3.5 from the previous year. 23% of surgeons performing units performing greater than 10, and 3.2% performing greater than 20. So not many high volume surgeons. So this is just to give you a quick idea of what we're looking at. Now GIRFT is promoting very much a hub and spoke model, with hubs where the operations occur and spokes where the operations don't occur, but patients coming in. And this applying to lots of joint replacements, elbows, revision total knees, as I say. So GIRFT's asking for a minimum number. What should that be? So we looked at that. We are to continue to try to engage, and we're looking at what our colleagues in the upper limb are doing. The elbows are sort of similar to us, perhaps. So elbow replacement networks, they were being sort of pressurized a little bit by GIRFT as well, and responded by producing this paper. As you can see, GIRFT logo on there. So Tim Briggs approved of this paper, and we had to do something similar. So we sat down as a group, myself and colleagues, and how does this work for the ankle? The ankle is different. It's different from all the other joints in many ways. First of all, ankle arthritis has several effective treatments. We know that some patients can do very well with fusion. It all depends on the indications and the circumstances. The status and the treatment of the rest of the foot is absolutely crucial. Supplementary procedures with total ankle replacement are really, really important in many cases. And they don't necessarily have to be done by the same surgeon, even, who does the total ankle replacement. And patients maybe don't need every surgeon to do TAR, because within a population, if you do your maths about the percentage of the ankle arthritis with patients who might be really, really exactly right for total ankle replacement, it isn't likely to be every one, and you end up thinning, the ankle replacements are thinned out too much amongst the surgeons, and therefore the role of surgeons who choose not to do replacement but everything else is absolutely crucial. And the evidence for which treatment is the most appropriate of the various treatments available is always evolving. So there's a bit of a light bulb moment for us. When we were being pressurized to make ankle replacement networks, actually, we realized these should be ankle arthritis networks. And that's the concept. It's subtly different, but it's really important, and that's what we've pretty much convinced Gerft and Tim Briggs about now. And where the ankle replacements are done, they're not sort of hubs and spokes. They're more nodes within a web. That's what works for the patient. So myself, Stephen Bendel, a colleague, and Andrew Goldberg, Andrew Robinson, Fred Robinson, both here, of course, we produced this paper, and about ankle arthritis networks. Because it takes a lot of thought when you have a patient with ankle arthritis as to what's appropriate. And when you're thinking about it, and you're trying to think about that patient, surgeons who do and don't do ankle replacement mustn't drift apart. The patients need us not to drift apart. If you just decide not to do ankle replacement, you're not even going to take a great interest in the evolving indications for it, and your patient isn't necessarily going to get exactly the right, the best operation for them. It's all about indications, patient selection. So we produced this paper to try and put across this point, so that any patient who sits in front of a foot and ankle orthopedic surgeon has potential access to all those treatments, including ankle replacement, whether that surgeon chooses to do ankle replacement or not. It's all about networking. And the key thing in the acknowledgments there is Professor Briggs approved of this paper as well. So it was a bit of a milestone for us. So we also set up a Bofas Ankle Arthritis Network Steering Group, and several members of that are here with us today. And the remits for this group that we set up were, first of all, data collection, finding out where are we at the moment, and trying to develop maps of where ankle replacement is occurring, where across the country, whether it's evenly distributed or not, where effusion is. And also data on what networks already exist, because we know from our colleagues, there are lots of networks around the UK where patients are flowing from surgeon to surgeon, and groups are getting together to talk what exists. And also the second remit of that group is to provide guidance and advice to colleagues on consolidating or setting up a network, if necessary. So working with the NJR, we've managed to start developing these maps, all on that map, all ankle replacements, 7,951, as you can see, over a long period of time on the NJR, all located by zip code, by postcode, and then that converted into heat maps. So we're really starting to understand what's going on in the UK. And then the next task, which is being done at the moment, is to try to superimpose on that ankle fusion, and then see how they match, and try and make sense of it, and see what it means, and how we can improve access for patients. So these are the networks, which obviously I've taken all the names out. The networks that we were working out already exist by sending out questionnaires, and that's the key thing, non-ankle replacement surgeons, heavily involved in every network, to keep everybody talking together. And supporting colleagues, share existing models where the networks are working, where the multidisciplinary meetings are working well, and actually just sending out the questionnaires to colleagues and saying, you know, what's happening in your area? They often email back and say, you know what, ourselves and our network just next door across the county line, we've been trying to get around to having a discussion about working out where the patients were going to flow, and this has sort of precipitated our discussions. Actually, we've nailed it down now after procrastinating for five, ten years and things. And advising colleagues on how to set regular meetings up, and helping colleagues whose numbers are low to buddy up with other colleagues, pressurize the hospitals into allowing dual operating, which they don't like, because they don't like the way it affects the resources, and thereby increasing the volume, so helping get experience and increasing those numbers. And the aim is actually get the right treatment to the right patient first time, very much mirroring what Tim Briggs set his GIRFT movement up for in the first place. So to conclude, can anyone do ankle replacement? Well, yes, but probably not everyone should because of the way the numbers work, and that should be done by well-trained, committed orthopaedic surgeons who do ankle replacement regularly. And what's crucial is surgeons network with colleagues who choose not to do ankle replacement. Thank you Paul. Next up is my colleague Tim Clough from Manchester in the UK who's got a particular perspective on a type of arthroplasty you may not have heard of. Okay, thank you very much for OFS to invite me here. So, this is probably the most controversial talk you will hear at this meeting. The reason for it is, is I am going to try and resurrect an implant that has been stuck in your trash can for the last 40 years, which you have never used. So, where do I work? I work at a tiny little cottage hospital stuck just outside Manchester, surrounded by farmer's fields, called Ritington, which most people won't have heard of. Those who have heard of know their orthopaedic history because this is where the joint replacement was first invented in the whole world. It came from a tiny little cottage hospital, Sir John Charnley, and he wrote it up in 1961 in the Lancet. If you want to pull that paper, it's called A New Operation for Hip Arthritis, the total hip replacement. So, from this cottage hospital, we do the most hip and knee joint replacements in the UK. We push out 3,000 hip and knee replacements in the UK, and we're pushing out 85 to 90 ankle replacements, which is the most in the UK. So, I'm not going to talk about any of that. I'm going to talk about the Silastic Joint Replacement. Those are my disclosures, nothing relevant to this talk. So, first MTPJ, End Stage Arthritis. Fusion versus replacement. Fusion is an excellent operation. Excellent, gets rid of the pain, but why have stiffness when you can have movement? So, this is what the ladies want, and this is what the ladies come and ask you because they want back in their high heels and they want rid of the joint pain, and they cannot get that successfully with a fusion, and this is what you can get with a Silastic at four months. Okay. So, why are we not all doing it? So, like you, I was brought up that this is the device of the devil, okay, and none of us do it because our mentors say it's useless, and we're in blissful ignorance. So, why did I start using it? Well, I inherited a practice where the guy before me for 30 years had been banging them in, and my first clinic, I saw three, and they were 10 years old, 10 years in, and I thought, well, this is going to be great because this is my practice now for the next, it's just revising them all, and I asked them how they were doing, and they were all doing well, and the pain had gone. So, I thought, well, I'm just going to x-ray them because they're all going to be falling out, and they're going to be non-functional. So, I x-rayed them, and they weren't too bad. They were like a hip replacement at 10 years. So, I thought, well, that's just, you know, beginner's luck, and then the next clinic, there was another two, and they were all the same. So, I thought there may be some mileage in this, so I started collecting them, and then I looked at the literature, and the literature, historical reports of Silastic Sinusitis, progressive cyst formation, and loosening and failure. So, where did that literature come from? Well, the literature is historical, and it came, I'm afraid, mostly from North America, and there are eight studies in the world literature in the late 70s, early 80s, and early 90s, and all but one of those negative studies were on a different implant, with this implant, which was the original implant, which was a single stem Silastic implant, and they do not do well, and the implant was pulled quickly after five years, and those were on a mixture of Halox valgus and Halox rigidus, and this is not an operation for Halox valgus with OA. Halox valgus with OA needs a fusion. This is not that. This is primary Halox rigidus. So, since then, there have been 17 subsequent studies in the world literature, but it cannot displace its original bad reputation, between 1990 and 2000, and there is, predominantly for Halox rigidus, but the odd paper in there for Halox valgus, and all but one of those report good to excellent results, and on those papers, you've got 1,300 patients with a follow-up of over 1,400 months, so the average paper is reporting 81 patients with an 86-month follow-up and an 87% satisfaction rate. So, there is something out there in the literature. So, what did I do? So, I started putting them in, carefully, and then following them up, and there's nothing that ruins good results like proper follow-up, okay? But, I followed them up, and I put in 108 over about a 12-month, 12-year period, and then reviewed them, minimum follow-up two years, 14-year follow-up. The mean age was 61, with an average follow-up of 5.3 years, and the VASC score went down from 7 to 1.3, and the MOX FQ is the reverse of your AOFAS, and it went down, which means that's good, so it went down from 78 to 11, and there's a 97% mean survival rate at five years, and a 91% satisfaction rate. So, we've already heard about an ankle replacement. Those who are putting ankle replacements in would love these figures. It's a great operation, okay? So, are there other studies that match them? Well, yes, there are. Here's another case published in 2011, 59 cases, nine-year average follow-up, 95% survivorship. Here's another one published, you know, 2013, 43 cases, 19-year follow-up, 97% survival, 90% satisfaction rate. So, there is evidence out there. So, this is a controversial slide, and I know I am in the country of Carteva. So, we're going to just have a look at it. So, I'm not going to dish Carteva, because Carteva may have a place, but I'm just going to run you through their study, and I know the authors are here in the audience, so I'm going to have to be very careful what I say. So, their original paper, two-year follow-up, had a 91% survivorship and an 87% satisfaction rate, and there will be many people in this audience that put in Carteva, and there will be many people in this audience that worry about pain and stiffness, and then they followed their paper up for longer follow-up, 5.8 years, with an 85% survivorship. So, that is from the originators of the implant. So, you then go to non-originators of the implant, and unfortunately, the non-originators cannot replicate the originators' results. So, at one-year follow-up, you've got an 8% failure rate. So, we're talking about a joint replacement here, and any joint replacement that has an eight-year failure rate in one year is worrying. There's another paper, different study. So, we've got three papers out there that worry a little bit with results on the Carteva, and yet you go to Silastic, and I'm a non-originator. I'm just a user who got converted in real-life medicine, and I've got an average five-year follow-up with a 97% survivorship, which is much better than the ankle replacement, and then there are others out there. So, in summary, what are the indications? You've got to put it in the right patient, and here you are. Indication is a spectrum, and you've got a line at one end, which is the ideal patient, and you've got a line at the other end, which is somebody who you should never put it in, and in real life, you'll be somewhere on that line, and if you're nearer the line that you want to put it in, they will do well. So, who is the ideal patient? So, the ideal patient is a lady, 55 years or more, who has neutral osteoarthritis, who wants movement and is concerned for shoe wear, and you can be active in the gym, and the person you should not put it in is a hallux valgus with OA, and you should have a bit of caution in the rheumatoid, because they often drift into valgus, and they have soft bone. The male, who does really well with effusion, are a young, active person. So this bottom person is your ideal patient that's coming into your clinic, a lady, 61, hallux rigidus, painful, she wants the joint flexible, and she wants to wear heels afterwards. So I put it to you that the Silastic Joint Replacement offers excellent pain relief quickly, predictable, rapid recovery, preserves the arc of movement, has a 93% 10-year survival, is an extremely reproducible operation, offers excellent cosmetic results with high patient satisfaction. This is the easiest operation you will ever do. Thank you very much. Thanks, Tim. That was typically clear from Tim. Next, I'd like to invite Fred, who has been past president of our society, and for many years has been a thought leader on the management of diabetes across the population. So, Fred. Thank you very much. Thank you, Callum. Thank you, everybody. So I'm going to talk about that glamorous thing, diabetic feet, and whose problem are they? I'm a paid consultant of solutions, but that has no relevant disclosures. So I trained in Texas with Jim Brodsky and John Early, and indeed we are a country separated by two languages, but I hope I learned a little bit from them, and we did, I think, talk and understand each other to some degree. So we are different, and our societies are very different, but we have got a lot in common. These marvelous advocates for democracy, I suppose it almost drives you to republicanism, but that's got an eight-hour wait and a five-mile queue, so there is no answer, but we certainly do have very different health systems. We've got a really socialized, free-at-the-point-of-delivery health care system, and you have something very different, but I think for this sort of problem, the diabetic problem, this does give us maybe an advantage over a non-nationalized society, a system that you have here in North America. This allows us to look at the cost of diabetes, which is a huge, huge problem. These figures are really alarming. They are for a few years ago, but essentially in the British health care system, diabetes as a whole costs nine percent of the total budget, of which one percent of our whole budget is spent on the diabetic foot. I'm sure it's no different in the United States and in Canada. So these are huge problems, and I don't think we all appreciate and understand the importance of what we do and what a massive influence we can have on the total cost of health care as well as delivery for these patients. These are what we're looking at. In the UK, which has a population of approximately 60 million, there's 8,000 major amputations, 22,000 minor amputations, and numerous hospital admissions for the diabetic foot, the main person being a male from a deprived area, age greater than 65. White ethnicity has the highest risk factors. So I came to this, having chained with Jim Brodsky and Bernard Meggett, who was my predecessor in Cambridge. We've worked through many of the problems, and we've looked at the issues. We showed that diabetic control is very important, both as a long-term prognosticator. Here, if your HbA1c is higher, we show that you do have a higher rate of amputation, and also in the recovery of our patients from disease. So I'm very aware that I'm very dependent on my diabetologist, just who I work with, and the team, and become aware of that. We also became aware of the difference in the way we're amputating toes. So I amputate and close the wound, whereas the vascular surgeons tend to do more of a guillotine-type amputation and leave the wounds open. We've published a couple of times on closing wounds. So this is the sort of thing we're looking at at the top, the wounds that I do, whereas underneath we've got really largely non-functional feet, where the wounds have been left open, they've been hard. And it does make a huge difference if we can get the patient healed quickly, but also with a functional foot. And I think we're better at thinking about the functionality following surgery than maybe the vascular surgeons. Our results were very good. Interestingly, one of the major problems, once the arterial disease had been corrected, was venous disease. And I don't think we always appreciate that. So be careful of venous disease. Transmetatarsal amputation, it gets patients back to good function. This was 25 patients. Most were walking unaided with just one wheelchair bound. There was obviously a high death rate, but that's the nature of the patient group. So to talk about organisation, it became apparent about 10, 15 years ago that arterial surgery, and you're hearing as much as Paul was saying, was being moved to central areas. So we in Cambridge have about five or six hospitals around, and the vascular surgeons are based in one unit, where they have all the kit and facilities that they need. And they go out and visit the outlying hospitals, and then bring any surgical cases with any complexity back to us. Now, this has changed the structure of diabetic foot care hugely within the UK, because the vascular surgeons used to do very much of the surgery in the district general hospitals, where they were providing not only a service for aneurysms, that was all being done on site. But now those surgeons have come back centrally. There is not the facility. And when you come down to it, the only people these days operating on the limb are ourselves, the orthopedic surgeons. It used to be general surgeons would do much of the work. That is no longer the case. So that vascular reconfiguration gave us an opportunity to really structure diabetic foot care, and we need to get organised. We know that, for example, trauma centres reduce the mortality by 25%. And the hope is that by centralising vascular services, we'll see a similar improvement. So BOFAS got together with these other organisations, particularly the Vascular Society and the various diabetic groups, and the British Association of Plastic Surgeons, and we tried to come up with some structures. We have NICE. You get all these eponyms in the UK, but the National Institute for Clinical Excellence, and they have mandated how we do this. So in the community, you have a foot protection service, and that's run by non-surgical podiatrists who look after simple ulcers and do foot monitoring and care for simple ulcers. Within the hospital, you have a multidisciplinary foot care service, which we need to work out how to structure. And the patients have to be seen within 24 hours. At this stage in 2015, despite these mandated central government targets, only 71% of the hospitals actually fulfilled them. So this leaves us with the problem of who admits the patient. Is it under the surgical or the medical team? We have the problem of the care of the acute patients. I'm finding our orthopaedic colleagues are much less willing to drain abscesses than they were several years ago. Then we've got the complex area, the reconstruction of the Charcot foot. And we've also got, if we have vascular centralization, which patients do we transfer in? So we've moved on, and we've actually studied recently and got data from about two or three years ago. And it's become apparent that the way we're structuring it now is improved. Every hospital had a diabetic foot service. The majority of the patients were admitted strictly under medicine, which I think helps. It contains the infection, so you haven't got a diabetic foot sitting next to a patient having a hip replacement. And also, in my opinion, these patients are probably better looked after because their medical comorbidities are so complex. They're much better looked after by our general medical colleagues. Some of them are mixed generally, but we are now beginning to see that orthopaedic surgeons are beginning to drain abscesses and provide acute care more than the vascular surgeons, which is a huge progress. So I think we're beginning to progress on. And actually, Bofast has driven this improvement in diabetic foot care. So this is the model I just happened to have. We have a daily clinic with a diabetologist and a non-surgical podiatrist. We have a weekly ward round with podiatry, diabetes, vascular orthopaedic surgery. So all the patients are reviewed weekly, and big decisions are taken at that stage about the difficult problems. And we have a monthly clinic to follow up the patients. And these structures are now being, with various permutations, are now being built up around the country. And I think this really has been helped both by the document that we put together and by the NICE guidelines. So that's the team that I did work with. Some of them have retired. And you can see I've got a lot more brown hair there, but that's the passage of time. But we have a large team. But actually, the structures allow us to do that. So what can you do? And I think we can engage in the care of this group of vulnerable patients. We can start to come up with structures and organisations. And that's probably easier within a socialised medicine system. Our problem in the UK is that we've got about one in ten people following COVID are now waiting for treatment of some sort. So there are some aspects which, frankly, we're not doing very well. And elective care has been very badly damaged. But this sort of problem can maybe be better treated with socialised style of medicine. And we can also support and educate our colleagues, and hopefully improve the care, both of the acute patients. So diabetic feet, whose problem are they? Well, there's no doubt they do belong to the individual clinician. But hopefully, the central structures of organisations such as BOFAS, and I'm sure AFS as well, can actually help us. And we need to take collective responsibility for these patients. Thank you very much indeed. Thank you very much, Fred. Well, I'm conscious that I think we've run up to 10 o'clock. I'm looking around for Daniel or Casey to see if we've got time for questions. But I think the answer is no. So I'd just like to thank all of our speakers very much for some excellent presentations, and we hope we've stimulated some thought. Good morning, everyone. Hi, my name is John Backus. I'm a member at large of the AFS, and I work at Washington University in St. Louis. I'm joined today by Tom Clanton, one of our past presidents who needs a little introduction. I'd also like to welcome Jason Kim, the vice president of osteoarthritis research at the Arthritis Foundation. After coming to our meeting in Charlotte last year, Jason approached AFS and offered to collaborate with our society to create a joint arthritis foundation and AFS program to create an ankle arthritis think tank. This think tank has been formed and was tasked with identifying ankle arthritis research and targets to raise awareness about the prevalence and impact that this disease has on our communities. Tom Clanton has volunteered to lead this think tank and represent the AFS in partnership with Don Anderson, who you will all be hearing from shortly as the AFS guest speaker. Furthermore, this collaboration will also form a joint funded $600,000 seed program for novel ankle arthritis research proposals that will help improve our understanding of this disease and the lives of the many people who suffer from it. This program is the result of many efforts and great effort from Dr. Kim, our president Dr. DG Avani, Elaine, and the AFS staff. Dr. Kim, we are honored that the Arthritis Foundation have joined us here today in Quebec City. And on behalf of the AFS, I would like to thank you for forming this collaboration with our society and your commitment to helping us improve ankle arthritis knowledge and treatment. I'd like to invite both Dr. Clanton and Dr. Kim to tell us more about this think tank and grant seed program. So it's well known to this society that ankle arthritis is a disease that results in significant morbidity for our patients. Older patients have been addressed to some degree with advances in arthroplasty, as we've heard. However, our younger patients with disease continue to struggle, having few effective treatment options. Our members Charlie Saltzman and Ned Amendola published on this in 2005, showing that 70% of their 639 patients with Kellgren grade 3 or 4 ankle arthritis were post-traumatic in origin. Yet in terms of ankle arthritis research, little has been done to mitigate these post-traumatic changes within the past 17 years. That is why this collaboration between the Arthritis Foundation and our society is so meaningful and impactful. It is the culmination of a year of negotiations and collaborative development of an ankle arthritis think tank. Two online conferences were held in February and April this year, providing an overview of foot and ankle arthritis that included presentations by AOFS past presidents Judy Baumhauer and Jim Brodsky, as well as presentations by society members Carolyn Sofka, Tyler Gonzalez, Dennis Janacy, and the late Alex Breg. From this, a two-part summary has been accepted for publication in FAO. The next step will be a grant review process for this program, which will award substantial funding for the most meaningful research studies targeting Charlie Saltzman, Jody Buckwalter, Elaine. those with all forms of arthritis and we hear about their aches, pains, and burdens and surprisingly we hear quite a lot from those with ankle problems and this is troubling because we at the foundation don't have many good answers for them but also because this is supposed to be a rare disease and if you look at the prevalence, the prevalence is near rheumatoid arthritis and rheumatoid arthritis gets a lot of attention by the NIH. have more disability, get the disease earlier, live with the disease longer, and then are at greater risk for adjacent joint arthritis than other osteoarthritis. So that's why we're really excited. but also we hope that more research will. Good morning. I'm Mike Anardi from the Research Committee. It's my pleasure to introduce our research speaker for the morning, Dr. Anderson from the University of Iowa. He serves as the Richard and Jan Johnson Chair in Orthopedic Biomechanics, as well as the Vice Chair of Research for the department. He has over 120 publications, multiple DOD grants, NIH grants and he's going to be challenging us today, this morning, to up our game in foot and ankle research. Please join me in giving a warm welcome, Dr. Don Anderson. Holy cow, I've never had music at my introduction. Thank you very much. I'm looking forward to this presentation. I appreciate the invitation from the Research Committee and AOFAS to come and present some of our research committed at the University of Iowa, as long as some of our colleagues. As my introduction said, I'm really challenging the community to up our game in foot and ankle research. The good thing is there's going to be no test here and there won't be a lot of details, so hopefully you'll bear with me. Here's my disclosures. A little bit of a roadmap. On the right there's a nice highway that takes you on a clear corner here. Unfortunately, more often it's something like this where you have to coordinate your way through a riddled path with cleared downed trees. We're going to talk about some case studies, some research of some other people I brought along whose work I really respect and I hopefully then conclude. Just motivation wise, I think it's fair to say that present day orthopedic foot and ankle practice is built on over a century of research, much of it involving anatomical and cadaveric studies that are subject to historical limitations. State of the art mechanical testing, biology, imaging, modeling capabilities have really greatly expanded the rigor with which research can be done. These new capabilities really afford opportunities to better understand the complex interplay of biology, mechanics in the foot and ankle, which can lead to evidence based practice improvements. I'd love to start with imaging studies like this because it's just really amazing the amount of information that's in an image set like this, this 3D volumetric reconstruction. We've often turned to the words of Lord Kelvin, who said back in 1883 that when you cannot measure what you are speaking about and express it in numbers, your knowledge is of a meager and unsatisfactory kind, whatever the matter may be. Admittedly, a little bit of a scientist's perspective, but let's work our way through this first case study. I'm going to speak a little bit about the path of mechanics of ankle OA, some work we've done in this area over the last 20 years. You all well know that ankle osteoarthritis is generally rare, but it's very high incidence after fractures such as those of the tibial pilum, which are by definition post-traumatic OA. They can occur early, as soon as two years after injury. The etiology is unclear, but there's clearly mechanical factors implicated, but these factors are really pretty difficult to quantify. It's a disabling major economic burden, of course. The predisposing joint injuries we mentioned, and I'm just going to talk today about two pathomechanical risk factors, the intensity of the acute fracture severity and the chronic contact stress elevation left after this joint is put back together again. We'll talk a little bit about how that might influence orthopedic treatment. Surgeons have long known that fractures occur over a severity, and we often hear people speak of low-energy or high-energy fractures. In fact, some of the subjective fracture classification systems try to indicate fracture severity, but they suffer from poor inter-observer reliability. Of course, the great thing is there's a whole branch of science called fracture mechanics, and I'm an engineer by training, but here we have a structure where energy is stored in the structure until the load is exceeded, and then you have failure, and the energy is liberated in this fracturing process. Fracture energy, the quantitative objective measure, is proportional to the fracture-liberated surface area in brittle solids such as bone under the high rates of loading associated with fracture. We've spent 20 years coming up with ways in which to use preoperative CT data routinely acquired for these studies to quantify the fracture energy. Here's an interesting slide. I just want to introduce the basic idea. These are 20 patients whose data I've colored. Two years after their intra-articular fracture, they either did not develop OA, they're green columns if they didn't, yellow if they were kind of on the borderline, and red they clearly developed OA. We asked a series of three surgeons to rank order these from the least severe to the most severe by looking at the preoperative CT scans. They agreed pretty well. There's about a 72 percent concordance between them, and here's one individual's rankings. You can see it's more or less green to the left, their lower severity ones, and red to the right, the higher severity ones, but there's some notable outliers here. I just want to show you then when we use fracture severity in contrast, now the Y axis is no longer an arbitrary number. It's the fracture energy based measure, and here you can see there's an 88 percent concordance with whether somebody developed OA or not, and a perfect agreement with whether they had a KL grade of two or higher in their fracture energy, and there appears to be a threshold here, and that threshold may well be a point of intervention. So we've taken this methodology outside of the ankle and used it in a variety of other joints, and I think it's kind of fascinating to think people have long said that different joints respond to fracture, inter-articular fractures differently, and their risk of developing post-traumatic OA vary accordingly. Well it turns out if you take this fracture energy metric, which I've here normalized to the local area, because you have an impact over an area, and sometimes the contact area is smaller, other times it's larger, that's the X axis, and I'm showing here five different parts of the body, five different articular joints, and then the historical PTOA rates, and you get this really high correlation. This is wonderful work of Kevin Dibberin, a PhD student in my lab who's since moved on. So those are all based on PTOA being classified by the KL grade. I think we could all agree that a grading scheme from 1957 may be a little long in the tooth, but it's still routinely used. I will say this about the KL grade. It's stamina. It's withstood the test of time, but it's a subjective grading scheme that's strictly categorical. It's weight-bearing radiographs, but they're 2D in nature. They're projection of a 3D structure, and they poorly capture early changes, and they're not as useful in joints of the foot and ankle because it's just hard to visualize those articular surfaces. So this is an area where we've explored weight-bearing CT, which is an emerging means to analyze the 3D joint structure under a loaded weight-bearing configuration. In the 3D joint space width, a key element of the traditional KL grade is able to be characterized with this. And just as a quick aside, of course, there's also interesting information about the bone, and we just recently, Cesar de Cesar Neto and our group just recently published a paper in FAO showing how you may well be able to characterize changes in the bone density in the vicinity of that surface as well. But turning back to the 3D joint space width measure, we did a study here of, I'm showing you, of 40 patients. This was originally funded by the Orthopedic Trauma Association and then the Arthritis Foundation. We evaluate changes in the tibial tailor joint using weight-bearing CT after tibial pilon fracture. Eighteen-month follow-up time period at six-month intervals, we have weight-bearing CT. And I'll just draw your attention, of course, here's a series of radiographs of the same ankle, but there's a CT slice on the bottom. And if you look at those radiographs, it's awfully hard to see any kind of incongruity, but clearly on that CT scan, there's a substantial posterior step-off. So we use these measures, the intact contralateral provides a basis to assume what the joint space width was prior to the injury. Then if we kind of overlay them, we can develop these maps of the joint space width, the distance between those bones. And we can look at how that changes over time using something like the talus as a fiducial. So here we have four different groups among these cases. These were the first 26 cases here. And I'm just showing you that some of them see pretty substantial change in joint space width. This at the 12 month, that'd be the far right for you. But some of the others really look indistinguishable from the intact. And that's consistent with our experience that kind of different people have a more higher or lower likelihood of developing post-traumatic OA. And this is just some data to show that the fractured ankles averaged greater joint space narrowing, but it really varied among the fractured ankles. And this is then taking that fracture severity idea I introduced to you earlier and looking at the joint space narrowing at 12 months. And we have this correlation here between the fracture severity metric and the joint space narrowing. So now I'm going to shift gears slightly and talk a little bit about what we all understand. The reason people try to reduce these fractures is there's chronic contact stress elevation afterwards. And we're trying to minimize that to reduce the like or increase the likelihood that they don't develop post-traumatic OA. Well, patient-specific computational modeling is here to help. It enables prospective evaluation of surgically obtained fracture reductions. Here again, I've got CT volumetric renderings of those same 20 ankles after the surgeon put them together. And they did not do a perfect job in all those cases. But the modeling we do allows us to look at, this is a simplified methodology called discrete element analysis. With the bone and the cartilage identified, we're able to look in a weight-bearing apposition and see what kind of contact stress develops. This simplification allows us to be able to do quick measures and to simulate loading across an entire gait cycle. So we're not just looking at a maximum contact stress at one loading point. We're actually looking at how the habitual loading accumulates. In fact, just take it a step further, we all know that contact stress is not on its own harmful. That there are probably reasonable levels of contact stress that are healthy for cartilage. But when we exceed a damage threshold, here we've put it together as a summation over the gait cycle. And we look at the time at which those elevated contact stresses are exposed. We can come up with what we call a contact stress time overexposure. So this is a per gait cycle exposure of potentially harmful contact stress to the ankle joint. And when we take that on the x-axis here as an overexposed area, which percentage of the area has this elevated contact stress. And on your right, I guess it would be your left, you'd see that the intact contralaterals look relatively green, the low contact stress over time exposure. But the reds show up on the fractured cases. In fact, it appears to be a tolerance threshold that delineates between those that developed arthritis and those that did not. So that obviously offers an opportunity. If there are other ways beyond just doing a great job of putting this back together where we can reduce the contact stress exposure, we may be able to decrease the risk of PTOA. And in fact, we've developed methodologies then to be able to take a post-op CT scan all the way through to contact stress predictions. Of course, we all know that post-op CT scans are not exactly the standard of care. So one of the challenges in the post-op CT scan is actually the ankle is not in a loaded position when it's scanned. So the modeling has to come up with a way to put it in a load-bearing pose. Well, enter a weight-bearing CT scan. Of course, that automatically is in a weight-bearing pose, and we're able to move much more quickly to contact stress predictions based on something like a six-month post-op weight-bearing CT scan, which might be comparable to roughly three radiographs that you might obtain at six months to see how the ankle is doing. So then here's a metric then of that overexposed area. We're still early in this series, but overexposed area versus changes in the joint space width over time. So moving forward with mechanical concepts developed that help us to understand and predict PTOA risk and development, how might that information be used? Well, clearly it's useful in terms of if you're trying to do a clinical study, you kind of have a basis to say what risk each ankle had to develop post-traumatic OA. But what about providing perhaps intraoperative feedback to surgeons or alternative treatment strategies? And I'll just touch on a couple of those ideas. This is a system we developed courtesy of NIH funding that we call a biomechanical guidance system. You're all familiar with intraoperative navigation systems. Well this goes a step further and tries to give you an idea of the contact stress in the middle of a fracture reduction. So when you're trying to decide if you have done a good enough job, you're able to use this information to make that kind of a decision. And this is based on fluoroscopy. So if you're doing this in some kind of a limited approach for fluoroscopy, on the fly we can perhaps help you understand how good of a job you've done. And after developing that technology, here's a kind of an idea. This is an intermediate stage in the procedure and based off of that fluoroscopy, we're able to superimpose that 3D geometry in a nice aligned pose and tell you where those fracture fragments are at an intermediate stage. And that then allows you, here we did a proof of concept study to essentially the top row on your right, shows ankles that were reduced using the guidance system. The bottom row shows you fractures that were reduced without the guidance system. I think you can get the appreciation that you may well be able to reduce the contact stress using an assist like this in the operating room. A second alternative might be to use some kind of a bracing strategy. And I tip my hat here to the military, in particular a good colleague Jason Wilkin who worked at the Center for the Intrepid developing these fancy custom carbon fiber braces. If you watch this video, one of the things that really strikes you is that strut behind the tibia is flexing. So it's storing energy, returning energy, so it actually bypasses some of the load at the ankle and reduces some of the moments at the ankle. So this may well be a strategy, but how would you predict what brace might work well or not? So we've developed a methodology here. OpenSim is a product that allows you to do musculoskeletal dynamic modeling based on gait lab data. And then you can take that all the way through to being able to introduce a brace, vary some of the properties of the brace, and see if you might well be able to reduce the contact stress using our discrete element analysis methodology. And just to show you, here's a one case where we show on your far left would be no CDO, no brace. And on the far right you can see under the right configuration with the right stiffness of the brace, you can actually reduce the contact stress. This is a prediction that needs to be validated in the laboratory, but we were very encouraged by this result. And it's fundamentally because the brace is able to reduce, bear part of the moments across the ankle, thereby reducing the joint reaction for us. So I'm going to talk now, shift gears slightly now, and talk about some of the work Paragon has funded in our lab looking at total ankle replacement. And this is really a computational modeling approach to look at press fit fixation design features. And you all know about uncemented fixation considerations. There's a variety of design features that are intended to provide early stability while supporting later in growth. We're going to be trying obviously to reduce micro motion so we can get bone to go across interfaces, since micro motion is a known contributor to implant loosening and influences survivorship. We also need adequate load transfers to the surrounding bone to avoid either bone under or overloading. So some strategies might be to develop a model that looks at putting this implant in, whatever the implant might be here, a pegged design, without sidewalls, with sidewalls, with some kind of an interference fit. Here we've modeled an interference fit both on the pegs as well at the edge of the implant. This is modern finite element analysis capabilities for bone are pretty impressive and formed off of CT scan data. So we can certainly model the stiffness of the bone appropriately to look at the CT scan data. But we can also use that to predict elastic plastic bone behavior, which means as you implant that peg implant, you're going to cause some plastic irrecoverable deformation of the bone. And that rebound of that is going to be what holds that implant in. So we've modeled that off of the CT scan data. And this is just a way to show you. So on your left, you'll see the displacement of this implant. It goes in the stress that develops at the interface. And on the far right, anywhere you're seeing red, you're seeing high plastic strain. So you see bone deformation. In fact, maybe you'll see if I can run that a second time because you might appreciate watching rebound. So as we bottom out and we relieve the load, we're going to see a little rebound or recoil as you might expect. So then what does this do? We've leaned on some data from Hospital for Special Surgery where they implanted and had a cadaveric robotic simulation to come up with these force and moment distributions across the gait cycle and implanted those. So again, I'd say a simple finite element model, I could apply a single load. I might get some information. If I don't include the plastic strain of the bone, I'm not really going to be able to represent very well how the bone holds the implant. And these are all important factors. But of the right considerations, hopefully you'll be able to see this on the video. Your far left, of course, without any sidewalls, without any interference fit, these implants are actually pretty unstable, right? Kind of makes sense. They really rely on that interference fit early. Introducing sidewalls helps some, but really the press fit is where you see the real benefit here. And just to show you that data, here's for the apex implant is one pegged design. You can see how when I don't have sidewalls or press fit, there's pretty high micro motion actually early in the stance phase of gait. But as you start to introduce press fit and sidewalls, you can see that you greatly reduce. So whether you model this accurately or not is really going to change the result. In fact, this puts you in a position to be able to look at different implant design strategies. I will caution you, I'm showing here the Infinity and Salto, but we have not yet introduced the press fit in those models. But anyway, it's really interesting data to look at the ability of these implants to hold themselves in place. And here's a look at the micro motion. Again, now we've got the ability to look at the motion between that plate and the bone behind it throughout the gait cycle. You see relatively high micro motions without any press fit, and as you move from left to right in the apex and add more press fit, you see a great reduction in the amount of micro motion. And in fact, the far right, if you really want to look at the variation, you've got to zoom in quite a bit on a scale to have 0 to 20 microns instead of 0 to 40. So let me shift gears a little bit out of my work now, and I'm going to ask you to bear with me a little bit because some of this work you'd need to talk to the actual scientists who did it. But I just want to give you an idea of some work that's out there. And Amy Lenz, who I think is in the audience, was kind enough to share some of her really wonderful work she's doing at the University of Utah using statistical shape modeling. And I just want to say we've long known that there are measurements that can be made off a radiograph that tell you about changes in bone, changes in the relative position of bone, and traditionally those measurements have been made off a radiograph. Maybe they've been made with calipers, maybe they've been made with some kind of software. But we now have capabilities using methods called statistical shape modeling to look at this in a different way. And here's a case on the top row you've got a healthy ankle, on the bottom you've got one with ankle OA. And clearly there are signs here that you could easily see, you'd see off of your radiographs to be able to help you. But measuring those is a little difficult. Here's one strategy you might be able to use some kind of a tomographic approach where you try to make some measurements of compensated or uncompensated joints dealing with ankle osteoarthritis. Here the calcaneus and its relative position under the load. Or you might use DZR's radiographic measurements where you're looking at the degree of tailored tilt, the hind foot alignment angles. These are the traditional methodologies. They're kind of prone a little bit to some user bias and they're kind of difficult measures sometimes to make. One statistical shape modeling is a methodology whereby you can describe in mathematical sense the shape of an object. This is an automated process here you're looking at two different tali. These dots are finding, these balls are finding their positions landmark wise on the joint in a way that's able to define subtle differences in the geometry. And those can be tracked over time and studied. In fact those are looking at a single bone. You may want to look at the relative position of different bones as you have collapse of the foot and ankle. And Amy and her group have developed this capability to put the dots, the balls on different bones and look at the relative position between them. So if you will think about the shape of the whole structure and these articulated bones and how they deviate in their positions. So this then allows you to do things like look at a population, a statistical population of variation. This is fundamentally for those of you who don't know this is how you do things like morph faces, morph structures into different population based metrics. And she's been able to show some of the early work has shown some of these differences between compensated, non-compensated ankles looking at the range of variation within those groups. So for instance then you're able to do things like identify and measure some of these variables that historically have been identified as important indicators of progress in treatment or advancement of disease. And I just want to say again Amy thank you very much for sharing these data with us. The last work I'm going to do is show you some stuff I had a good friend Bill Ledoux who works with Dr. St. George and out at the University of Washington in the VA Center there. They have a Center for Limb Loss and Mobility that over the last decade has really ramped up the great work that they had done there. And this is just one location and I just kind of this is even a little faster run through their data than Amy's because I don't understand it as well. But they've concerted effort VA funding has supported this NIH funding. They've been able to take work where they better understand through mechanical measurement of tissue properties the properties of the diabetic plantar soft tissues. You're able to develop potentially non-invasive methodologies to be able to characterize using ultrasound the soft tissue properties and then developing mechanical systems to be able to look at 3D scans of plantar soft tissues in live subjects. And this is kind of really wonderful work that I think has potential to really change the way we understand those tissues and evaluate them. They've also done work with cadaveric gait simulation. They're not the only lab in the country that's done this with the world. But I've got to zoom in a little bit so you can see it of course but there's somewhere in the middle of that structure there's a little poor little foot and ankle that's being taken through a range of motion that would simulate gait or other input waveforms. And this robotic gait simulator can take cadaveric feet through a walking cycle. They can use that to compare different implants for different treating different conditions and see how that changes the motion of that joint. And then of course if you haven't seen the biplane video fluoroscopy or radiography methodologies that are out there now you can now using these video fluoroscopy techniques quantify the motion of the bone as a person walks through a space here on a treadmill. And they've developed a biplane system out there that allows them to have people walk across the treadmill and they can track the motion of those bones. And again that's kind of a really interesting way in this human setting. I think one of the things I hope you can understand is we've moved away from relying as heavily on cadaveric studies. And in fact if you're looking for NIH or Department of Defense funding it's harder and harder to get projects funded that involve cadaveric tissues. But fortunately the technologies give us capabilities to study these in live subjects. So I'd like to thank the Arthritis Foundation, the AOFAS, and Paragon 28 for supporting the ankle away think tank. And I think you'll be hearing more about this you've already heard a little bit but this is really an opportunity to marshal some research forces along with some clinical forces to look at some really lingering problems that haven't been studied as rigorously as say knee OA. I'd like to acknowledge my other funding sources. Thank you for your attention. I'd be happy to take any questions if that's allowed.

ankle replacement surgery

ethical considerations

age

activity level

overall health

ankle arthritis

limitations

complications

alternative treatment options

patient safety

patient well-being

patient goals

patient expectations

advancements in foot and ankle research

ankle osteoarthritis